Payment Model Details
CMS has published the specific payment rates and financial architecture for the ACCESS Model. Here's everything you need to know about how money flows from CMS to participants — and what it takes to keep it.
Source
Payment details are drawn from the CMS ACCESS Technical FAQs and the official Request for Applications. Rates shown are annual allowed amounts per aligned beneficiary.
Payment Rates by Track
Each clinical track has its own annual allowed amount, split between an Initial Period (first 12 months of active care) and a Follow-On Period (subsequent maintenance).
| Track | Initial Period | Follow-On Period |
|---|---|---|
| eCKM (Early Cardio-Kidney-Metabolic) | $360 / year | $180 / year |
| CKM (Cardio-Kidney-Metabolic) | $420 / year | $210 / year |
| MSK (Musculoskeletal) | $180 / year | N/A |
| BH (Behavioral Health) | $180 / year | $90 / year |
Rural Add-On
Beneficiaries in rural areas enrolled in eCKM or CKM tracks during the Initial Period receive an additional $15 to offset higher operational costs related to connected device distribution and support.
Why MSK Has No Follow-On Period
The MSK track focuses on functional restoration within a single 12-month care episode. Patients graduate once they meet their functional improvement targets (measured via PROMIS, Oswestry, QuickDASH, and similar patient-reported outcome instruments). There is no ongoing maintenance phase.
Financial Architecture: The 50/50 Withhold
CMS does not pay the full allowed amount upfront. Instead, payments are structured around a performance withhold:
Monthly Disbursement
CMS disburses 50% of the annual allowed amount in equal monthly installments throughout the care period. For example, an eCKM participant would receive roughly $15/month per beneficiary during the initial period ($360 × 50% ÷ 12).
Outcome Assessment
At the end of the care period, CMS evaluates whether the organization met its Outcome Attainment Threshold across all aligned beneficiaries.
Withhold Release
Organizations that meet or exceed the threshold receive the withheld 50%. Those below the threshold receive a proportionally reduced amount — but the reduction is capped at 50% of the withhold (meaning you keep at least 25% of total allowed payments in the worst case).
Outcome Attainment Threshold (OAT)
The OAT is the minimum share of aligned beneficiaries who must meet all required clinical targets for the organization to recover its full withhold.
| Period | OAT |
|---|---|
| Effective Period (July 2026 – Dec 2027) | 50% |
| Subsequent Periods | To be determined by CMS |
How the OAT Works
- If 50% or more of your aligned beneficiaries meet their clinical targets → you receive the full withheld amount
- If you fall below 50% → the withheld amount is reduced proportionally, but the reduction is capped so you never lose more than 50% of the withhold
- Clinical targets are track-specific and based on guideline-informed measures (blood pressure, HbA1c, PHQ-9, functional status scores, etc.)
Targets Are Per-Beneficiary, Payment Is Per-Organization
Each beneficiary must meet all of their required outcome measures to count toward the OAT. But the payment decision is made at the organization level — strong performers on some patients can offset weaker results on others.
Co-Management Payments
Primary care providers and referring clinicians are not left out. CMS created a separate payment for care coordination with ACCESS organizations.
| Component | Amount | Notes |
|---|---|---|
| Base Co-Management Payment | ~$30 per service | For documented review of ACCESS care updates and coordination actions |
| Onboarding Add-On | ~$10 additional | One-time, for assisting with initial beneficiary setup |
| Frequency Limit | Once per 4 months | Per beneficiary, per track |
| Annual Maximum | ~$100 per year | Per beneficiary, per track |
| Beneficiary Cost-Sharing | $0 | No Part B co-insurance for co-management services |
What Triggers a Co-Management Payment
The referring clinician must:
- Review the ACCESS Care Update sent by the participating organization
- Place a brief written note in the EHR documenting their assessment
- Document any care-coordination action taken (medication change, updated problem list, monitoring instruction, referral, etc.)
No advance beneficiary consent is required, and there is no patient cost-sharing for this service.
Substitute Spend Adjustments
The Substitute Spend Adjustment reduces OAPs when aligned beneficiaries receive defined substitute services from other Medicare providers above a defined Substitute Spend Threshold (SST). During Year 1 (the Effective Period), the SST is 90 percent for all ACCESS Participants.
Why This Exists
The adjustment incentivizes integrated care delivery and prevents CMS from paying twice for the same type of chronic disease management. ACCESS participants are expected to be the primary manager of the conditions covered by their enrolled tracks.
Multi-Track Discount
When a beneficiary is aligned to multiple tracks with the same ACCESS Participant, CMS applies a 5 percent discount to the monthly OAP of the lowest-cost track(s) to reflect administrative and operational efficiencies associated with delivering integrated care.
- If a beneficiary is in two tracks, the discount applies to the lower-cost track during overlapping months
- If a beneficiary is in three tracks, the discount applies to the two lowest-cost tracks
- The discount is not applied to the beneficiary's coinsurance responsibility
- If a beneficiary is aligned to different tracks with different ACCESS Participants, no discount applies — each participant receives the full Medicare portion
Example
A beneficiary is enrolled in MSK ($180/year) and, seven months later, enrolls in eCKM ($360/year) with the same participant. CMS applies a 5% discount to the MSK track for each month the two tracks overlap, because MSK has the lower allowed amount.
FFS Exclusion Rule
This is a critical operational constraint:
No Concurrent FFS Billing
ACCESS participants and their affiliated entities may not submit Medicare FFS claims for other services furnished to aligned beneficiaries during active care periods. Only ACCESS-specific G-codes are permitted for these patients.
This means your organization cannot bill traditional Medicare codes for the same beneficiaries you're managing under ACCESS. Plan your revenue model accordingly.
Beneficiary Cost-Sharing
CMS has created a safe harbor allowing participants to waive the standard 20% Medicare co-insurance on Outcome-Aligned Payments as a beneficiary engagement incentive.
- Waiver must be applied uniformly — you cannot selectively waive for some patients and not others
- The waiver is optional, not required
- No cost-sharing applies to co-management payments regardless
Reporting Requirements
ACCESS uses standardized G-codes and FHIR-based reporting APIs. Key deadlines within each care period:
| Milestone | Deadline |
|---|---|
| Baseline Measures | Within 60 days of alignment |
| Quarterly Reports | On 70–110 day cycles |
| End-of-Period Report | By day 425 |
Standardized Infrastructure
CMS has established standardized G-codes and FHIR-based reporting APIs for the model. This positions ACCESS payments to function less like fee-for-service billing codes and more like capitated outcome contracts — with the transparency infrastructure to match.
Interaction with Other Programs
ACOs
- 2026–2027: ACCESS expenditures have no impact on ACO benchmark calculations
- 2028 onward: ACCESS expenditures will be included in ACO benchmarks
Medicare Advantage
MA plans may independently adopt similar outcome-aligned payment arrangements without needing a CMS waiver. The ACCESS Payer Pledge encourages this alignment.
Medicaid
States may implement ACCESS-aligned payment structures through In Lieu of Services (ILOS) authority under Medicaid managed care.
Multi-Payer Adoption
The ACCESS Model explicitly invites multi-payer adoption. The standardized G-codes, FHIR APIs, and published outcome measures are designed to be portable across payers — making it easier for commercial insurers and Medicaid plans to align their payment models with ACCESS.
Frequently Asked Questions
What is the maximum annual revenue per beneficiary?▼
For the highest-paying track (CKM), the maximum is $420/year during the initial period and $210/year during follow-on. Rural beneficiaries add $15. Revenue scales with the number of aligned beneficiaries and the share meeting outcome targets.
What happens if I fall just below the 50% OAT?▼
Your withheld payment is reduced proportionally, but the reduction is capped at 50% of the withhold. So even in the worst case, you retain at least 75% of the total allowed amount (50% monthly disbursement + 25% partial withhold release).
Can I participate in multiple tracks simultaneously?▼
Yes. An organization can participate in multiple clinical tracks, and a single beneficiary can be aligned to more than one track if they have qualifying conditions in each. Payment rates apply per track, per beneficiary. When a beneficiary is in multiple tracks with the same participant, a 5% multi-track discount applies to the lowest-cost track(s) during overlapping months.
How does the rural add-on work?▼
The $15 rural add-on applies to eCKM and CKM tracks during the Initial Period only, based on the beneficiary's geographic designation. It offsets higher operational costs related to connected device distribution and support in areas where in-person device pickup may not be practical.
Next Steps
Understand Outcome-Aligned Payments
How OAPs work conceptually and what they mean for your practice
Explore Clinical Tracks
Detailed requirements and measures for each of the four tracks
CMS Technical FAQs
Official CMS frequently asked questions with full technical details