CMS ACCESS Program: Key Considerations for Physician Practices

By: Elena Dicus and Scott Wilkerson

CMS announced the ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) program in December 2025 which is a program designed to improve outcomes for specific chronic health conditions of traditional MEDICARE enrollees only. Medicare advantage enrollees are not eligible. CMS has released program updates and specific details in recent weeks that clarify how the program will work, while also raising many questions about who is likely to participate in the program (either providers or enrollees who are required to opt-in) and under what conditions participants will be best aligned for success in the program.

For physician practices, participation in this program must be evaluated from a strategic, financial, and operational standpoint. Further, physician practices may need to partner with new health technology companies or improve the use of technology they have already invested in.

CMS reportedly reviewed around 100 technology company business models in setting annual payment rates, a move that appears to signal the agency’s intended focus on digital-first models with low requirements for clinician involvement.  (A federal experiment opens up a new market for digital health — if it works).

Nurse Education

Basics

The ACCESS model’s goal is to test an outcome-aligned payment approach in traditional Medicare to expand access to new technology-supported care options focused on conditions affecting more than two-thirds of MEDICARE beneficiaries, including high blood pressure (eCKM), diabetes (CKM), chronic musculoskeletal pain (MSK), and depression (BH). Participating organizations (read: healthcare providers or digital companies that can bill Medicare) will receive recurring payments for managing patients’ qualifying conditions less performance withholds, with full payment tied to achieving measurable health outcomes. (ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model | CMS) 

The first ACCESS program providers will start their performance period on July 5, 2026.  Applications from providers for this first period are due by April 1, 2026, to CMS.  The second performance period will start January 1, 2027.  For interested physician practices who think some of the above considerations may outweigh the challenges, now is a good time to do in-depth analysis and watch as CMS continues to provide updates and clarifications. 

Maximum Annual Payment Amounts

(50% of the rates are paid monthly, the remaining 50% is paid at reconciliation)

Track	Initial Period (Total)	Initial Period (Medicare 80%)	Follow-On Subsequent Year (Total)	Follow-On Subsequent Year (Medicare 80%)
eCKM	$360	$288	$180	$144
CKM	$420	$336	$210	$168
MSK	$180	$144	N/A	N/A
BH	$180	$144	$90	$72
eCKM + Rural Add-on ($15 for BPM)	$375	$300	$195	$156

Note: Practice can additionally collect 20% beneficiary coinsurance or elect to waive it. Amounts shown in Medicare column represent only Medicare's 80% payment. Providers caring for rural health enrollees could receive an additional $15. Further, for enrollees enrolled in multiple tracks, the annual payments for additional tracks are discounted by 5%.

Financial and Operational Considerations

For physician practices considering whether to participate in ACCESS, there are some significant challenges that require detailed analysis and review of your practice’s specific patient population and revenue streams.

Financial Model

Interested groups should develop a financial model that estimates the financial impact of participating in the program.  This should include the revenue related to participation, reduced FFS billing, investments required in technology, decision regarding collection of copays, and other staffing costs.  Further, a sensitivity analysis will need to be conducted to consider the revenue impact of achieving various levels of outcomes. To compound the analysis, groups need to also consider the potential benefit of these same members being in an ACO that the group participates in.

Impact to FFS Billing

Under ACCESS program requirements, FFS Part B claims will not be paid to prevent duplicative services during active participation periods. That means no FFS revenue to your practice during the enrollment period. This includes no reimbursement from E&M codes, RTM codes, CCM codes, and APCM codes. This exclusion applies only to the ACCESS provider or group the beneficiary is aligned with; restrictions do not limit beneficiary choice in seeking care from other health care providers–so your patients can receive care from other Part B providers unaffiliated with the same TIN that you bill under. CMS’ stated intent is to reduce duplicative Medicare spending and encourage comprehensive care delivery through ACCESS supported services. This could create undue financial risks for primary care or multispecialty groups that see patients for conditions beyond the four tracks.

Required Technology Investment

The program sets significant technology demands on participants, demands that may exceed the capabilities of small-to-medium physician practices. Requirements include:

• All outcome measure data (baseline, quarterly, and end-of-period) must be submitted via a CMS FHIR-based Reporting API using standardized data elements.

• Prior to enrollment, providers must query CMS Eligibility and Alignment APIs.

• Regular care coordination updates must be submitted via established bidirectional HIE connectivity.

These requirements are non-negotiable: without meeting them, a practice cannot submit data, receive payments, or remain in compliance.

Complexity of Timelines, Reporting, and Data Management

The ACCESS program has some very complex and significant reporting requirements that will need reliable methods for tracking and submitting. For example, there is no single “program year” with pre-defined start and end dates for all your beneficiaries. Instead, reporting requirements are based on individual beneficiary enrollment dates and associated downstream timelines. This includes deadlines for initial baseline measurements and quarterly measurements. Additionally, there are validity periods for clinical measures that are important to track — for example, for a beneficiary in the eCKM track without prediabetes, an HbA1c collected within two years satisfies the baseline requirement; however, for PROMIS measure requirements for the MSK track, or blood pressure readings for the Early Cardio-Kidney-Metabolic track, data must not be older than 15 days.

Adding to this complexity is that some tracks include a follow-on period for subsequent years (notably not MSK). A previously submitted measure does not need to be re-collected at the start of a follow-on period, provided it still falls within its clinical validity window. Tracking these many collection and submission deadlines could be managed with customized dashboard tracking tools that can be relatively easily built and customized.  However, unless your practice’s EMR integrates with the dashboard or has these capabilities internally, you will need a team member to manage these deadlines, validate the currency of the data, and ensure data is entered into or available in a system that can submit the data via the mandatory FHIR APIs. Any missed data submission (baseline, quarterly, or end-of-period) counts as non-attainment — an administrative failure is as costly as a clinical failure.

Strategic Considerations

Groups need to consider how participating or not participating in the ACCESS program supports their overall mission. Groups should think through how participation will impact their patients, their community, and their reputation.  Further, groups should consider how participation now can set themselves up for future success as technology and clinical care continue to get more integrated. Should your group be an early adopter, moving rapidly into the next wave of value-based care, or should your group hold off until more is known about the program?

ACO Participation

If your practice is part of an ACO and members are in both the ACO and ACCESS, there could be additional benefits assuming that your practice follows the same care pathways with all patients. Although you will lose FFS revenue billing during the enrollment period for ACCESS enrollees, ACCESS-related support may contribute to a lower total cost of care for ACO enrolles through:

• Reduced Part B services from your practice, which your practice will likely develop alternative means of communicating or coordinating with patients through the digital platforms deployed for ACCESS (unless your patients seek care from other providers) or

• Reduced overall utilization through improved health outcomes driven by ACCESS initiatives which may be returned to your practice as part of ACO shared savings. It is important to consider that reduced FFS billing with your practice may affect beneficiaries’ attribution to your practice under the Medicare MSSP, where attribution is based on a plurality of Part B services.

Underserved Patients

If your practice has financial or quality accountability for a significant number of patients from underserved populations, ACCESS participation may help reduce disparities. The impact of lost FFS revenue from these patients is likely lower, as data shows that underserved patients already receive fewer services due to challenges accessing care.

MSK and Behavioral Health Tracks

Although annual payment for these tracks is significantly lower ($180 vs. $360 for eCKM and $420 for CKM), there is more evidence to support the impact of digital interventions with lower levels of clinician engagement in these two categories.

Paving the way for other payers

Although the ACCESS program is currently a Medicare innovation initiative, in February 2026, major health payers representing 165 million Americans with Medicare Advantage, Medicaid and private health insurance plans pledged to adopt an outcomes-based payment structure aligned to the Medicare-focused ACCESS. These payers have agreed to start adopting “core principles” of the model by January 1, 2028. Given this broad reach, it could be strategically beneficial for your practice to start testing an approach to technology-driven coordinated care with Medicare beneficiaries.

Next Steps

If the ACCESS program is an important consideration for your practice, you need to be conducting due diligence on the program and building a business model now. If you are interested in receiving a sample financial model, please reach out to us.