The ACCESS payment model is a new program that reimburses physicians and technology vendors for technology-supported chronic care management under Medicare. Learn how the model works and what physicians should do now.
What is the ACCESS Model?
ACCESS[1] (Advancing Chronic Care with Effective, Scalable Solutions) is an optional federal program to test a new payment model that provides reimbursement for technology-supported care management for chronic diseases such as high blood pressure, diabetes, chronic musculoskeletal pain, and depression. It also reimburses primary care and referring providers (PCPs) for documented review and co-management services. The model/pilot will run for 10 years beginning July 5, 2026, and is for beneficiaries of Original Medicare. The ultimate goal is to help people improve their health and prevent and manage chronic disease.
How is the ACCESS Payment Model Different?
Traditionally, Medicare pays physicians for direct patient care, such as patient visits or services provided, but ACCESS pays physicians based on health results and encourages the use of digital health tools to manage care. The model is designed to complement the care from PCPs through technology-supported care management. Additionally, it is the first time that CMS will directly pay technology-based care management organizations for offering integrated, technology-supported care to beneficiaries.
The ACCESS model does not
- change the fee-for-service payment in Original Medicare for providers
- change Medicare benefits, coverage, or rights
The ACCESS model does
- provide ongoing, technology-supported care through lifestyle support, remote monitoring, wearables, coaching, and medication management
Some healthcare professionals may remember that the Centers for Medicare & Medicaid Services (CMS) and the Centers for Medicare and Medicaid Innovation (CMMI) have attempted to implement similar models in the past, but the models have not delivered the expected results. There is hope that new technology, multi-channel outreach methods, and acceptance of technology products by seniors will help this program have a better opportunity for success. This is also the first time PCPs have been able to receive reimbursement for the care coordination activities they perform.
Are Physicians Required to Enroll in ACCESS?
No, PCPs and referring clinicians do not enroll; however, ACCESS Coordination Organizations are required to enroll with CMS.
What is an ACCESS Coordination Organization?
ACCESS Coordination Organizations are CMS-approved third-party entities that will supply the healthcare technology to patients, coordinate the technology use, and help facilitate tracking the collected health data. They will also send structured clinical updates to PCPs and give PCPs an opportunity to bill a new co-management payment for the time spent reviewing the clinical updates and performing care coordination activities. The ACCESS organization is primarily paid based on whether patients’ health improves.
Have ACCESS Coordination Organizations Been Identified?
CMS recently announced that it has approved approximately 150 digital health companies to be the first cohort of ACCESS organizations and indicated it will use a rolling application period for these organizations going forward.
Additionally, CMS has secured the commitment of numerous commercial payers that have agreed to align with the ACCESS model’s approach. Payers include Blue Shield of California, Centene, Cigna, CVS Health, Horizon Blue Cross Blue Shield of NC, Humana, United, and several other organizations[2]. These companies have committed to offering payment arrangements to providers to provide outcome-aligned payments when using healthcare technology by January 1, 2028.
How Does the ACCESS Model Work?
The ACCESS payment process is designed to work through several steps:
- PCP recommends a patient with one of the targeted chronic conditions to an ACCESS Coordination Organization; patients can also self-select.
- ACCESS organization enrolls the patient and establishes care initiation by developing a care plan, taking baseline measurements, and providing technology
- PCP will receive information from the ACCESS organization through secure electronic transactions for the baseline and if a care escalation is needed
- PCP reviews the updated clinical information and takes an action that represents a care coordination activity
- PCP can bill for the co-management of the beneficiary up to three times during a 12-month period
- ACCESS organization receives an outcome-aligned payment at the end of the care period
Primary care providers can submit a claim to Medicare for a co-management payment of $30 up to three times during a 12-month period plus an additional $10 if they assist the patient with onboarding, for a maximum of approximately $100. To bill, the PCP must spend more than five minutes reviewing clinical information from the ACCESS Coordination Organization and take a documented care coordination action in response. There is no cost-sharing for the separate co-management payment billed by primary care or referring clinicians when they review and coordinate care with ACCESS participants.
What are the ACCESS Qualifying Conditions?
Four tracks are defined as ACCESS qualifying conditions:
- Early Cardio-Kidney-Metabolic (eCKM) has qualifying conditions of hypertension or two or more of dyslipidemia, obesity/overweight with central obesity, prediabetes
- Cardio-Kidney-Metabolic (CKM) has qualifying conditions of diabetes mellitus, chronic kidney disease (Stage 3a/3b), atherosclerotic cardiovascular disease (ASCVD)
- Behavioral Health (BH) has qualifying conditions of depression or anxiety
- Musculoskeletal (MSK) has qualifying conditions of chronic musculoskeletal pain
How PYA Supports ACCESS Model Planning
PYA’s Managed Care and Reimbursement team helps physicians and health systems understand and navigate complex federal and state programs, including the ACCESS payment model, to support informed decision-making. Our team can help you implement the model’s co-management billing guidelines, program compliance, and other aspects of the model.
We expect to see additional details from CMS and CMMI in the upcoming months. Questions still exist about data requirements from the ACCESS organizations and reporting requirements for providers. We will continue to provide updates as more information becomes available.
[1] ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model | CMS
[2] Innovation Insight: Major Health Plans Join ACCESS Payer Pledge | CMS
