CMS ACCESS Model Update: Payment Rates and Performance Targets Released for 2026–2027

The guidance provides operational clarity on how the Medicare Part B payment model will function in practice, including how much participating organizations will be paid and how success will be measured.

ACCESS Model Overview and Purpose

As we discussed in a prior alert, ACCESS is a Medicare Innovation Center model designed to support management of chronic conditions — particularly cardio-metabolic, musculoskeletal, and behavioral health conditions. Rather than paying for individual visits or discrete services, CMS will pay participants a per-beneficiary annual amount tied to clinical outcomes. The model emphasizes remote monitoring, coordinated care management, and sustained beneficiary engagement, while testing whether prospective, outcomes-based payments can improve outcomes and reduce downstream Medicare spending.

Under the model, an aligned beneficiary is a Medicare beneficiary who has been attributed to an ACCESS participant for management of a qualifying condition within one of the model’s clinical tracks and who has consented to participate in the model. Alignment begins a defined 12-month care period during which the ACCESS participant is responsible for managing the beneficiary’s condition under the model’s requirements. That first 12-month span constitutes the “initial period.” Some tracks allow an additional 12-month “follow-on period” at a reduced payment level if the beneficiary remains aligned and eligible.

Participation in ACCESS entails an application and selection process. CMS has not yet announced the application window.

Payment Rates

CMS will pay ACCESS participants a fixed annual amount for each aligned beneficiary, issued monthly and subject to reconciliation at the end of the care period. CMS refers to these annual figures as the “allowed amounts” for each clinical track, meaning the total annual payment associated with managing an aligned beneficiary’s condition under the model. The allowed amount includes both the Medicare program share (80%) and beneficiary coinsurance (20%).

For 2026–2027, the annual allowed amounts are:

Payments are made monthly at one-twelfth of the applicable annual allowed amount. CMS will withhold 50% of the Medicare portion of each monthly payment and reconcile that withheld amount after performance is assessed at the end of the 12-month care period.

Payment is intended to cover the participant’s care management activities for the aligned condition. During months when ACCESS payments are made, participants generally may not bill Medicare separately for overlapping care management services for that same condition for the beneficiary, although participants may continue to bill unrelated services under traditional Medicare rules. The model also includes modest adjustments, such as a small rural add-on for certain CKM beneficiaries and a discount when a single organization manages multiple tracks for the same beneficiary during overlapping months.

Example

Assume a participant medical group aligns a beneficiary into the CKM track on August 1. The annual allowed amount for the initial period is $420, yielding monthly payments of approximately $35 (one-twelfth of $420). Of that $35, roughly $14 (50% of the 80% Medicare share) is withheld pending reconciliation, with the remainder paid monthly. At the end of the 12-month care period, CMS will assess whether the group reported required outcome measures and met applicable targets. If the group meets the performance thresholds, CMS will pay the withheld portion; if not, CMS may reduce some or all of the withheld amount. If the beneficiary remains aligned and eligible, payments would proceed into the follow-on period at the lower annual rate.

Performance Targets and Payment Adjustments

CMS has established track-specific outcome measures that determine whether the withheld portion of payment will be retained at reconciliation. A beneficiary counts toward payment if the participant reports all required measures for that track on time and the beneficiary achieves either a defined control threshold or a clinically meaningful improvement threshold by the end of the 12-month care period. Measures vary by track but generally include blood pressure, weight and BMI, A1c, LDL cholesterol, validated pain and function scores, and standardized behavioral health symptom measures.

At the participant level, CMS applies an “outcome attainment threshold.” For the 2026–2027 performance period, at least 50% of aligned beneficiaries must meet all required outcome targets for the participant to receive full payment. If performance falls below that threshold, CMS may reduce the withheld payments. CMS also applies a “substitute spend adjustment,” which reduces payment if aligned beneficiaries receive defined substitute services from other Medicare providers above specified thresholds.

Data Sources and Reporting Timelines

Participation in ACCESS requires ongoing submission of clinical and patient-reported data. Participants must submit baseline measures within 60 days of a beneficiary’s alignment date, provide quarterly updates during the 12-month care period, and submit final outcome data no later than 425 days after alignment. The 425-day outer deadline reflects the 12-month care period plus additional time for reporting and reconciliation.

Measure data may be drawn from electronic health records, laboratory systems, connected clinical monitoring devices (such as blood pressure monitors, weight scales, or continuous glucose monitors), validated outputs from digital health interventions, health information exchanges, and other validated sources. CMS’ guidance specifies clinical validity windows for particular measures and requires that submitted data meet CMS formatting and timing standards. Additional technical guidance is expected as CMS finalizes reporting infrastructure and submission processes.

The Role of Remote Monitoring and Digital Health Tools

The ACCESS framework contemplates two distinct but complementary categories of technology. The first encompasses clinically validated remote-monitoring tools — such as connected blood pressure monitors, weight scales, and continuous glucose monitors — that capture and transmit the outcome data participants must report to CMS within specified validity windows. These tools serve primarily as an evidentiary function: they generate the measure data that supports payment and demonstrates performance against outcome thresholds.

The second category encompasses digital health interventions to drive the clinical improvements ACCESS is designed to achieve. These may include digital therapeutics targeting behavioral health conditions, technology-enabled musculoskeletal rehabilitation programs, and care management platforms supporting medication adherence, lifestyle modification, or chronic disease self-management. Unlike passive monitoring devices, these tools function as active components of the care pathway, and their clinical effectiveness bears directly on whether aligned beneficiaries meet the outcome targets that determine payment.

Both categories raise regulatory considerations worth monitoring. For connected monitoring devices, the primary considerations involve data formatting, transmission standards, and clinical validity windows. For digital therapeutics and intervention tools making clinical claims, US Food and Drug Administration (FDA) oversight is more prominent. Organizations in either category should be aware of the FDA’s Technology-Enabled Meaningful Patient Outcomes for Digital Health Devices Pilot (TEMPO), which accelerates development and evidence generation for digital and connected technologies through iterative engagement across the product lifecycle. TEMPO participation may support device-level evidence development and regulatory strategy while CMS evaluates outcomes under ACCESS. The FDA is accepting statements of interest through early March.

Fraud and Abuse Considerations

Fraud and abuse considerations arise in ACCESS because the model involves prospective payments tied to beneficiary alignment, coordination with referring providers, and potential provision of devices, digital health tools, or other supports to beneficiaries. As CMS notes in the guidance, these activities may implicate federal fraud and abuse laws, including the Anti-Kickback Statute (AKS) and the Stark Law.

Notably, arrangements undertaken pursuant to Innovation Center models like ACCESS may qualify for protection under the AKS safe harbor for CMS-sponsored model arrangements and patient incentives. That safe harbor may protect certain financial relationships and activities carried out in accordance with CMS model requirements, though compliance with model requirements is necessary but not always sufficient to satisfy all safe harbor elements. Participants should evaluate their financial arrangements with referring providers, technology vendors, and other collaborators accordingly. Similarly, participants should ensure that anything of value provided to ACCESS aligned beneficiaries, including free devices, digital health tools, or coinsurance waivers, meets all applicable safe harbor requirements.

Key Takeaways

The release of ACCESS payment amounts and performance targets provides a detailed view of how the model will operate. It offers prospective per-beneficiary payments while placing a meaningful portion of revenue at risk pending performance against defined outcome thresholds and reporting requirements. Participation necessitates developing workflows for identifying and aligning eligible beneficiaries, capturing required measures within CMS’ validity windows, and submitting data in accordance with CMS’ timelines, while avoiding duplicative billing for services covered by ACCESS payments. 

The CMS guidance underscores the importance of clinically validated remote-monitoring tools, digital health interventions, and coordinated care pathways in achieving the outcomes that determine payment. At the same time, the model’s structure — prospective payments tied to beneficiary alignment, coordination with referring providers, and potential provision of devices, digital health tools, or other supports — creates familiar fraud and abuse considerations that stakeholders should address through careful structuring of financial relationships and outreach strategies. Experienced legal counsel can be a valuable resource in developing participation strategies, structuring compliant arrangements, and staying ahead of evolving CMS requirements.