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ACCESS Model Resource

Clinical Tracks Quick Reference

ACCESS launched with four clinical tracks addressing common chronic conditions. Five more tracks start April 1, 2027.

Early Cardio-Kidney-Metabolic (eCKM)

Continuation: Yes

Qualifying Conditions

  • •Hypertension (high blood pressure), OR
  • •Two or more of: dyslipidemia, obesity/overweight with central obesity marker, prediabetes

Outcome Measures

  • •Control or minimum improvement in blood pressure
  • •Control or minimum improvement in lipids
  • •Control or minimum improvement in weight
  • •Control or minimum improvement in HbA1c

Key Definitions

  • Obesity: BMI ≥ 30
  • Overweight with central obesity: BMI 25-29.99 with waist circumference >40" (men) or >35" (women)

Cardio-Kidney-Metabolic (CKM)

Continuation: Yes

Qualifying Conditions

  • •Diabetes mellitus
  • •Chronic kidney disease (Stage 3a or 3b)
  • •Atherosclerotic cardiovascular disease (ASCVD)

Outcome Measures

  • •Control or minimum improvement in BP, lipids, weight, HbA1c
  • •Submission of eGFR and UACR data (for CKD and diabetes)

Key Definitions

  • Chronic kidney disease: Stage 3a and 3b only

Musculoskeletal (MSK)

Continuation: No

Qualifying Conditions

  • •Chronic musculoskeletal pain (pain lasting more than 3 months)
  • •Conditions affecting bones, joints, muscles, or connective tissues

Outcome Measures

  • •Minimum improvement in pain intensity
  • •Minimum improvement in pain interference
  • •Minimum improvement in overall function (via validated PROM)

Key Definitions

  • Focuses on resolving chronic pain during initial care period

Behavioral Health (BH)

Continuation: Yes

Qualifying Conditions

  • •Depression
  • •Anxiety
  • •Or both

Outcome Measures

  • •Minimum improvement in PHQ-9 (depression)
  • •Minimum improvement in GAD-7 (anxiety)
  • •Submission of WHODAS 2.0 12-item functional assessment

Track Comparison at a Glance

TrackPrimary FocusContinuation
eCKMBiomarkers (BP, lipids, weight, HbA1c)Yes
CKMBiomarkers + kidney function dataYes
MSKPatient-reported pain & functionNot yet (follow-on starts Apr 1, 2027)
BHPHQ-9, GAD-7, WHODAS 2.0Yes

Coming April 1, 2027

Announced by CMS on September 15, 2026. Current participants and applicants do not need to reapply. CMS has not yet published qualifying conditions, outcome measures, or payment amounts.

  • Heart Failure — monitoring focused on function, symptoms, and quality of life
  • COPD — maintain or improve lung function and ease symptoms
  • Substance Use Disorder — opioid, alcohol, and other substance use disorders, with support for co-occurring depression and anxiety
  • Tobacco Cessation — support for people who stop tobacco use
  • Chronic MSK Pain Follow-On — extended care after the initial 12-month MSK care period