Understanding the ACCESS Model: Key Components

The ACCESS Model is designed for healthcare organizations, such as physician groups, already enrolled in Medicare Part B. Participants will assume responsibility for delivering comprehensive, coordinated services – whether in-person, virtual, asynchronous, or through innovative technology – to Medicare patients for a continuous twelve-month period. A designated, Medicare-enrolled Medical Director will oversee care quality and ensure full compliance with program guidelines.

Four Clinical Tracks for Targeted Care

The initial phase of the ACCESS Model will focus on four distinct, yet non-mutually exclusive, clinical tracks:

1. Early Cardio-Kidney-Metabolic (eCKM): Addressing early-stage risk factors including hypertension, dyslipidemia, obesity, and prediabetes.
2. Cardio-Kidney-Metabolic (CKM): Focused on managing established conditions like diabetes, chronic kidney disease, and atherosclerotic cardiovascular disease.
3. Musculoskeletal: Providing integrated care for chronic musculoskeletal pain.
4. Behavioral Health: Targeting depression and anxiety through coordinated interventions.

Voluntary Alignment and Patient Choice

Unlike many previous CMS Innovation Center initiatives, ACCESS emphasizes patient autonomy. Individuals with Original Medicare or fee-for-service plans can proactively enroll in the Model directly through an ACCESS Participant or be referred by their existing healthcare provider. This voluntary alignment is a key differentiator, fostering greater patient engagement and shared decision-making.

Outcome-Aligned Payments: Rewarding Results

The core of the ACCESS Model lies in its Outcome-Aligned Payments (OAPs). These fixed, recurring payments are awarded for successfully managing patients’ chronic conditions and achieving pre-defined clinical outcomes. This represents a departure from traditional fee-for-service, where payment is tied to each individual service rendered. While CMS has not yet specified the exact OAP amounts, the structure is designed to incentivize proactive, preventative care.

Clinical Outcome Adjustments: Accountability and Quality

Receiving full OAP payments is contingent upon achieving specific clinical outcome targets (OAP Measures) for enrolled patients. Baseline measurements will be established, and annual performance targets will be individualized based on each beneficiary’s starting point. However, participants aren’t penalized for every patient who doesn’t meet their goals. CMS will establish a minimum Outcome Attainment Threshold (OAT) – initially set at 50% for the first performance year – to qualify for full payment. An Outcome Attainment Rate (OAR) equal to or exceeding the OAT will secure the full OAP, while lower rates will result in a Clinical Outcome Adjustment, capped at a 50% reduction.

Addressing Potential Duplication: The Substitute Spend Adjustment

To prevent redundant care and optimize resource allocation, the ACCESS Model incorporates a Substitute Spend Adjustment. OAP payments will be reduced if a significant percentage of patients receive similar services from other Medicare providers outside the ACCESS program. For the first performance year, a 90% threshold is set, with adjustments capped at a 25% reduction. This policy aims to ensure comprehensive care delivery both within and outside the Model.

Streamlined Billing and Data Sharing

ACCESS participants will utilize model-specific G-codes for billing and are prohibited from submitting traditional Medicare fee-for-service claims for aligned beneficiaries during active care periods. This applies not only to the participating organization but also to any affiliated entities with a 5% or greater ownership stake. Furthermore, participants are required to electronically share clinical updates with patients’ primary care physicians and can request relevant Medicare claims data through APIs to facilitate coordinated care.

Co-Management and the Role of Digital Health

Recognizing the importance of collaborative care, clinicians co-managing ACCESS beneficiaries will be eligible for a new co-management payment – approximately $30 per service, billable once every four months per beneficiary per track, up to $100 annually – for documented review of ACCESS care updates and coordination activities.

The TEMPO Pilot: FDA’s Support for Digital Innovation

Complementing the ACCESS Model, the FDA has launched the Technology-Enabled Meaningful Patient Outcomes (TEMPO) pilot program. This initiative will explore a risk-based enforcement approach for digital health devices designed to improve patient outcomes within the ACCESS Model’s four clinical areas. The TEMPO pilot aims to accelerate the adoption of innovative technologies by providing manufacturers with greater flexibility in demonstrating the effectiveness of their devices.

Applying to the ACCESS Model: Timeline and Eligibility

Applications for the ACCESS Model will be accepted beginning January 12, 2026, with the first cohort commencing on July 5, 2026. The application deadline for the initial cohort is April 1, 2026. Rolling applications will be accepted through April 1, 2033, allowing organizations to participate for at least a two-year period. Eligible participants must be enrolled in Medicare Part B under a single Tax Identification Number (TIN) as providers or suppliers. DMEPOS and laboratory suppliers are not eligible to participate.

What impact will this shift to outcome-based payments have on smaller, rural healthcare practices? And how will the integration of digital health technologies be facilitated to ensure equitable access for all Medicare beneficiaries?

Frequently Asked Questions About the ACCESS Model

1. What is the primary goal of the ACCESS Model? The ACCESS Model aims to improve the management of chronic conditions for Medicare beneficiaries by incentivizing healthcare organizations to focus on patient outcomes rather than the volume of services provided.
2. Who is eligible to participate in the ACCESS Model? Healthcare organizations, such as physician groups, currently enrolled in Medicare Part B are eligible to participate, provided they meet the program’s requirements.
3. How are payments determined under the ACCESS Model? Payments are based on Outcome-Aligned Payments (OAPs), which are fixed recurring payments awarded for achieving pre-defined clinical outcomes for enrolled patients.
4. What is the Outcome Attainment Threshold (OAT)? The OAT is the minimum percentage of patients who must achieve their clinical outcome targets for a participant to receive full OAP payments. It is initially set at 50% for the first performance year.
5. How does the Substitute Spend Adjustment work? The Substitute Spend Adjustment reduces OAP payments if a significant percentage of patients receive similar services from other Medicare providers outside the ACCESS program, preventing duplicative care.
6. What role does technology play in the ACCESS Model? The ACCESS Model encourages the use of technology-enabled care, such as telehealth and wearable devices, and is complemented by the TEMPO pilot program for digital health devices.
7. What is the application timeline for the ACCESS Model? Applications will be accepted starting January 12, 2026, with a deadline of April 1, 2026, for the first cohort.