The Centers for Medicare & Medicaid Services (CMS), through the CMS Innovation Center, has introduced the ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model as a decisive shift in how Medicare intends to pay for chronic condition management. The ACCESS Model will be a voluntary model designed to focus on chronic conditions that affect more than two-thirds of the Medicare population. This model will start its trial period on July 5, 2026, and run for 10 years. While it may be tempting to view ACCESS as a reiteration of Chronic Care Management (CCM), the structure of the model makes clear that it is designed to replace, not simply revise, the current CCM framework. The difference is foundational: payment is no longer anchored primarily in time, documentation volume, or service thresholds, but in measurable clinical and patient-reported outcomes.
From Time-Based Care to Outcome-Based Payment
Under CCM, revenue has historically depended on documenting time-based care coordination activities. ACCESS replaces that construct with Outcome Aligned Payments (OAPs), annual track specific payments that are tied directly to performance within a defined 12-month Care Period. Participants receive monthly payments equal to one-twelfth of the Medicare portion of the annual allowed amount, but only half of the total payment is released prospectively. The remaining 50 percent is withheld and reconciled after the Care Period through a Clinical Outcome Adjustment and a Substitute Spend Adjustment. An organization must meet its Outcome Attainment Threshold, set at 50 percent during the Effective Period, to earn full payment. In practical terms, at least half of aligned beneficiaries must complete the Care Period and meet all required OAP measure targets. Partial completion does not count. Missing or invalid data results in non-attainment for that beneficiary.
ACCESS is intended to complement traditional primary care by having an established relationship with the beneficiaries’ primary care provider (PCP). Interoperability between the ACCESS provider and the PCP will strengthen the management of chronic conditions. The established partnership will allow both the ACCESS provider and the PCP to be compensated. A co-management payment structure has been conceptualized to allow for reimbursement when the PCP reviews care-coordination documents from the ACCESS provider and performs tasks such as adjusting medications or updating the patient’s problem list.
Clinical Tracks & How Performance is Measured and Reported
There are 4 areas of focus for the ACCESS Model:
- Early cardio-kidney-metabolic (eCKM) conditions; hypertension, dyslipidemia (high or abnormal lipids, including cholesterol), obesity or overweight with marker of central obesity, and prediabetes
- Cardio-kidney-metabolic (CKM) conditions: diabetes, chronic kidney disease stage 3a or 3b, atherosclerotic cardiovascular disease (including heart disease)
- Musculoskeletal (MSK) conditions: chronic musculoskeletal pain
- Behavioral Health (BH) conditions: depression and anxiety
Each area of focus is considered to be an individual track. Each track has its own set of condition specific measures and outcome goals driven by clinical guidelines. If a patient qualifies, they may be enrolled in more than one track at a time.
What stands out across all four clinical tracks is the consistent emphasis on measurable improvement in blood pressure, weight, HbA1c, LDL-C, depression and anxiety scores, and functional outcomes. The pattern is unmistakable. These are the same domains long emphasized in MIPS reporting, but under ACCESS they are no longer peripheral quality metrics. They are embedded into payment methodology. Quality measures now “drive the boat.”
The OAP measure framework introduces strict clinical validity windows and reporting requirements that demand operational precision. Blood pressure, weight and BMI, and patient-reported outcome measures often require collection within 15 days of submission. HbA1c and LDL-C values must fall within one- or two-year validity windows depending on diagnosis. Baseline measures must be submitted within 60 days of alignment, or the beneficiary is unaligned, and services under the model cannot proceed. Quarterly reporting is required to maintain compliance and demonstrate active care delivery, even though quarterly values are not used directly for payment reconciliation. End-of-period reporting ultimately determines outcome attainment. Documentation is therefore not diminished in importance under ACCESS; it is intensified. Documentation must now establish an accurate baseline and substantiate clinically meaningful improvement within defined timeframes.
The model design raises a critical question for organizations that have relied heavily on automated MIPS extraction, templated reporting, or AI-supported documentation tools. ACCESS depends on valid data, documented collection dates, traceable sources, and adherence to clinical validity windows. Over-reporting or software-generated abstraction that is not grounded in authentic, timely clinical measurement will not withstand reconciliation. If risk-adjustment outcomes have been reported primarily to support quality optics rather than to reflect true clinical change, the financial impact under ACCESS could be significant. The model tests whether organizations are generating real improvement or simply sustaining documentation processes that keep them financially afloat.
Financial, Technology & Strategic Implications
Financially, ACCESS replaces CCM by shifting payment logic. Time-based billing gives way to outcome-based reconciliation. A 15 mm Hg reduction in systolic blood pressure, a 1 percentage point drop in HbA1c for a beneficiary with diabetes, a 30 mg/dL reduction in LDL-C, or a clinically meaningful improvement in PHQ-9, GAD-7, or PROMIS scores directly influence payment retention. The structure is intentionally designed to avoid penalizing providers who care for beneficiaries far from control at baseline; minimum improvement thresholds allow success through meaningful progress, not perfection. At the same time, failure to submit valid measures or achieve defined targets places withheld payment at risk.
Technology becomes integral rather than optional under this framework. CMS explicitly anticipates use of connected blood pressure devices, remote monitoring tools, and digital platforms to support data collection and care delivery. Rural beneficiaries in the eCKM and CKM tracks receive additional payment to offset operational costs associated with device distribution and support. Yet the practical obstacle of internet access, particularly in rural or underserved areas, cannot be ignored. If connected devices cannot be reliably deployed, organizations must design alternative workflows that preserve data validity without over-relying on digital infrastructure that patients cannot access.
The Substitute Spend Adjustment introduces another layer of accountability. If aligned beneficiaries receive defined substitute services from other Medicare-enrolled providers for the same qualifying diagnosis above a set threshold, OAP payments are reduced. This discourages fragmentation and reinforces the expectation that ACCESS Participants will deliver integrated, coordinated care. In contrast to CCM, where parallel service utilization did not directly erode payment, ACCESS financially incentivizes tighter clinical ownership.
The implications for risk adjustment are nuanced. Improved chronic disease control may reduce acute exacerbations, emergency room utilization, and hospitalizations. In the short term, fewer acute events could translate into lower episodic diagnostic intensity. Organizations that have historically depended on reactive high-acuity coding to sustain risk scores may observe a shift in risk profile as beneficiaries stabilize. However, longitudinal control of hypertension, diabetes, dyslipidemia, kidney disease, behavioral health conditions, and musculoskeletal impairment aligns more closely with the intent of value-based payment. ACCESS reframes risk adjustment around sustained chronic management rather than episodic destabilization.
Conclusion
Ultimately, the model hinges on valid and true data integrated with claims-driven analytics. Success requires timely baseline capture, disciplined quarterly reporting, accurate diagnosis alignment, and audit-ready documentation. It also requires cultural alignment within clinical teams. Improvement relative to baseline must be understood as meaningful and achievable. Failure to report valid data counts the same as failure to improve.
The ACCESS Model signals a broader trajectory in Medicare payment policy. It reflects movement toward interoperable reporting infrastructures, standardized billing codes, multi-payer alignment, and public reporting of risk-adjusted outcomes. Organizations now face a strategic decision. They can attempt to maintain legacy CCM workflows and hope incremental adjustments will suffice, or they can proactively redesign chronic care operations around measurable clinical and functional improvement.
Staying afloat through documentation alone will not be enough. ACCESS requires providers to get into the canoe and paddle intentionally, measurably, and consistently toward better chronic disease control.
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