How to collaborate with ACCESS organizations to support your patients' chronic care management.
ACCESS is designed to complement traditional care, not replace it. As a primary care provider or referring clinician, you play a crucial role in care coordination—and can earn additional revenue for your coordination activities.
Key Benefits: Extended care team support, better patient outcomes between visits, additional co-management revenue, reduced chronic care management burden, and transparency into ACCESS organization performance.
Patients with Original Medicare who have qualifying conditions: hypertension, diabetes, CKD, heart disease, chronic pain, depression, or anxiety
CMS will maintain a public directory of ACCESS participants including conditions treated and risk-adjusted clinical outcomes to help patients make informed choices
Refer patient to appropriate ACCESS organization, or inform patients they can self-enroll directly with a participating organization
ACCESS organizations must electronically share care plans, progress updates at clinical milestones, and completion notifications
Review patient updates, document coordination actions, and bill the co-management payment (no patient cost-sharing)
| Track | Qualifying Conditions |
|---|---|
| eCKM | Hypertension, or 2+ of: dyslipidemia, obesity, prediabetes |
| CKM | Diabetes, CKD (Stage 3a/3b), or cardiovascular disease |
| MSK | Chronic musculoskeletal pain (lasting 3+ months) |
| BH | Depression or anxiety |
A separate payment you can bill for coordinating care with ACCESS organizations. This is in addition to any other services you provide and has no beneficiary cost-sharing.
| Timing | Communication You'll Receive |
|---|---|
| Treatment Initiation | Care plan, baseline measurements, treatment goals |
| Clinical Milestones | Progress updates, outcome measurements, any concerns |
| Treatment Completion | Final outcomes, recommendations, transition plan |
Integration Methods: ACCESS organizations must integrate with a Health Information Exchange (HIE) or similar trusted network to allow you to securely access patient updates using standard data formats.
ACCESS organizations help co-manage your patients' chronic conditions
Technology-supported care between visits improves patient health
Co-management payment for coordination activities
ACCESS handles intensive condition management
Risk-adjusted outcomes help you choose quality partners
Patients retain all Medicare rights and can see any provider