Outcome-Aligned Payments
The ACCESS Model introduces Outcome-Aligned Payments (OAPs) — a fundamentally different approach to Medicare reimbursement that rewards measurable health outcomes rather than the volume of services delivered.
Key Principle
OAPs are recurring payments for managing a patient's qualifying condition, with full payment tied to achieving measurable health outcomes. This rewards results, not activities.
How OAPs Differ from Fee-for-Service
Traditional Medicare fee-for-service payments are tied to specific activities or devices. This creates several limitations for technology-supported care:
| Aspect | Fee-for-Service | Outcome-Aligned Payments |
|---|---|---|
| Payment Basis | Specific activities performed | Health outcomes achieved |
| Flexibility | Limited to defined services | Flexible care delivery methods |
| Focus | Volume of services | Value and results |
| Innovation | Constrained by billing codes | Encourages novel approaches |
| Technology | Limited payment pathways | Supports technology-enabled care |
Payment Structure
Recurring Monthly Payments
ACCESS care organizations receive recurring payments for managing each enrolled patient's qualifying conditions. These payments are structured to support sustained engagement and ongoing care management.
Initial vs. Continuation Periods
Most clinical tracks include two phases:
Initial Care Period (Year 1)
Higher payment rate during the first 12 months when intensive intervention and behavior change typically occurs. This period focuses on achieving initial outcome targets.
Continuation Period (Subsequent Years)
Reduced payment rate for ongoing maintenance and support. Patients who have achieved their initial targets can continue receiving care to maintain their improvements.
Performance Measurement
How Outcomes Are Measured
Each clinical track has specific, guideline-informed outcome measures and targets. CMS determines payment based on the overall share of patients who meet their defined outcomes.
Organization-Level Assessment
Payment is based on overall performance across your patient population, not individual patient outcomes. This allows organizations to earn full payment through strong overall performance even if some individual patients don't meet their target.
Track-Specific Measures
| Track | Example Outcome Measures |
|---|---|
| eCKM | Blood pressure reduction, weight loss percentage, HbA1c for prediabetes |
| CKM | HbA1c control, eGFR stabilization, blood pressure at target |
| MSK | Pain scale improvement, functional status scores |
| BH | PHQ-9 reduction, GAD-7 improvement, functional improvement |
Minimum Performance Thresholds
Organizations must meet a minimum threshold of patients achieving their outcome targets to receive full payment. This threshold increases with each participation year, encouraging continuous improvement.
- Year 1: Baseline threshold (accessible entry point)
- Year 2+: Progressively higher thresholds
Performance Accountability
Organizations that consistently fail to meet quality, safety, or outcome standards may be terminated from the model. CMS monitors performance throughout the model period.
Risk Adjustment
Why Risk Adjustment Matters
Patient populations vary in complexity and baseline health status. Risk adjustment ensures that organizations serving higher-acuity patients are not penalized for taking on more challenging cases.
ACCESS applies risk adjustment to:
- Outcome targets — Adjusted based on patient starting point and complexity
- Performance comparisons — Fair comparison across organizations
- Published results — Risk-adjusted outcomes in the public directory
Starting Point Matters
Outcome targets focus on clinical improvement or control based on each person's starting point. For example:
A patient with a starting blood pressure of 160/100 mmHg who achieves 150/90 mmHg demonstrates meaningful improvement, even if not yet at the ideal target of less than 130/80 mmHg.
Payment for Care Coordination
PCP Co-Management Payments
ACCESS is designed to complement traditional care, not replace it. Primary care providers and referring clinicians can receive co-management payments for:
- Documented review of patient progress updates from ACCESS organizations
- Coordination activities such as medication adjustments
- Problem list updates and care plan modifications
- Communication with ACCESS care teams
Co-Management Payment Details
| Component | Amount | Notes |
|---|---|---|
| Base Payment | ~$30 per service | Subject to geographic adjustment and standard Medicare payment adjustments |
| Onboarding Bonus | ~$10 additional | One-time payment for assisting with beneficiary onboarding and initial setup (requires CMS-specified modifier) |
| Frequency Limit | Once per 4 months | Per beneficiary, per track |
| Annual Maximum | ~$100 per year | Per beneficiary, per track |
Billing Requirements
To bill the Co-Management code, the clinician must review the ACCESS Care Update and place a brief written note in the EHR documenting the assessment and any care-coordination action (such as a medication change, updated problem list, monitoring instruction, or referral). There is no Part B beneficiary cost-sharing for this service, and advance consent from beneficiaries is not required.
Strengthening Collaboration
Co-management payments strengthen collaboration between ACCESS organizations and traditional providers, ensuring patients receive coordinated, comprehensive care. The ACCESS Co-Management Payment G-code, modifier, and additional billing guidance will be shared by CMS in 2026.
Information Sharing
ACCESS organizations must provide regular electronic updates to PCPs and referring clinicians on their patients' progress, enabling informed coordination of care.
Transparency and Public Reporting
Public Outcomes Directory
CMS will publish a public directory of all ACCESS participants including:
- Conditions they treat (clinical tracks)
- Risk-adjusted health outcomes
- Performance ratings
This transparency helps patients and referring clinicians make informed choices about ACCESS care organizations.
Rewarding Excellence
Public reporting of risk-adjusted outcomes recognizes and rewards excellent clinical performance, creating market incentives for quality improvement.
Payment Example
Here's a simplified example of how OAPs work in practice:
Patient Enrollment
A patient with hypertension (blood pressure 155/95 mmHg) enrolls with an ACCESS organization in the eCKM track.
Care Delivery
The organization provides technology-supported care: remote blood pressure monitoring, lifestyle coaching via app, medication management, and virtual check-ins.
Monthly Payments
The organization receives monthly OAPs for managing this patient's hypertension.
Outcome Assessment
At measurement points, CMS assesses whether the patient has achieved their outcome target (e.g., blood pressure reduced to under 140/90 mmHg or improvement of ≥10 mmHg).
Performance-Based Payment
If the organization's overall patient population meets the minimum threshold of patients achieving targets, they receive full payment. Strong performers earn full payments; underperformers may receive reduced payments.
Frequently Asked Questions
What happens if a patient doesn't achieve their outcome target?▼
Payment is based on overall organizational performance, not individual patient outcomes. If your overall patient population meets the minimum threshold, you can still earn full payment even if some individual patients don't reach their targets. This approach balances accountability with the reality that not every patient will achieve optimal outcomes despite best efforts.
How are outcome targets set?▼
Outcome targets are informed by clinical guidelines and established evidence. Targets focus on clinically meaningful improvement or control, taking into account patients' starting points. CMS publishes specific measures and targets for each clinical track in the Request for Applications.
Can cost-sharing be waived for patients?▼
Some ACCESS organizations may waive standard Medicare cost-sharing for patients to reduce barriers to care. However, participation is always voluntary for patients, and they retain all standard Medicare benefits and protections.
How does this differ from other value-based payment models?▼
Unlike many value-based models that focus on total cost of care or utilization reduction, ACCESS OAPs are directly tied to clinical outcomes — measurable improvements in health status. This creates clearer alignment between payment and patient benefit.
Next Steps
View Key Dates and Timeline
Important deadlines and milestones for the ACCESS Model
Start Your Application
Learn about the application process and requirements
Download the Request for Applications
Official CMS document with complete payment methodology details