Payer Resources
While the ACCESS Model is being tested in Original Medicare, the outcome-aligned payment approach can be adopted by other payers. This page provides guidance for Medicare Advantage plans, Medicaid programs, and commercial payers interested in similar models.
Cross-Payer Alignment
CMS is committed to promoting consistent, outcome-based payment structures across payers. Implementation resources including reference provider agreements, source code, and technical documentation will be made available to help payers optionally align their contracting and performance models with ACCESS.
Medicare Advantage Plans
Can MA Plans Participate in ACCESS?
ACCESS is being tested in Original Medicare. However, Medicare Advantage organizations may independently adopt similar outcome-aligned payment arrangements with their contracted providers without participating in the ACCESS Model directly.
No Waiver Required
MA plans do not need a waiver to implement ACCESS-like arrangements. Plans have flexibility to structure payments under existing program requirements.
Key Considerations for MA Plans
What flexibility do MA plans have?▼
Medicare Advantage plans have significant flexibility to:
- Design outcome-aligned payment arrangements with network providers
- Structure payments that reward health outcomes rather than volume
- Implement technology-supported care programs for chronic condition management
- Create value-based contracts without CMS approval for the payment methodology
This flexibility exists under current MA program rules and does not require participation in the ACCESS Model.
How can MA plans structure similar arrangements?▼
MA plans interested in ACCESS-like models should consider:
- Payment Design — Structure recurring payments tied to measurable health outcomes
- Clinical Tracks — Focus on similar chronic conditions (hypertension, diabetes, MSK pain, behavioral health)
- Technology Requirements — Require participating providers to use technology-supported care approaches
- Quality Measures — Adopt guideline-informed outcome measures aligned with ACCESS specifications
- Provider Selection — Contract with organizations capable of delivering integrated, technology-enabled care
Medical Loss Ratio (MLR) Considerations
Do ACCESS-Like Payments Count Toward MLR?
MLR Treatment
Outcome-based payments for patient care would generally be considered medical expenses in the MLR numerator when the benefits and payment arrangements satisfy applicable requirements.
Regulatory Framework
Payments qualify as incurred claims or quality improvement activities when they satisfy the requirements under:
- 42 CFR § 422.2420(b)(2) — Definition of incurred claims
- 42 CFR § 422.2430(a) — Activities that improve health care quality
Payments must not be claims or activities otherwise excluded under regulations.
What types of payments qualify?▼
The following types of outcome-aligned payments would generally count as medical expenses:
- Outcome-Aligned Payments (OAPs) — Recurring payments for managing chronic conditions tied to health outcomes
- Performance Bonuses — Additional payments for achieving quality targets
- Care Coordination Payments — Payments for integrated care management activities
- Technology-Supported Care — Payments for remote monitoring and digital health services
Plans should document that payments are for direct patient care activities and meet MLR regulatory requirements.
Are policy changes needed?▼
No MLR policy changes are needed to support outcome-aligned payment arrangements. The current regulatory framework accommodates these payment structures when properly documented and implemented in compliance with existing requirements.
Medicaid Implementation
Can Medicaid Plans Implement ACCESS-Like Models?
Yes. States may allow Medicaid managed care plans to voluntarily implement ACCESS-like approaches through existing regulatory authority.
In Lieu of Services and Settings (ILOS) Authority
ILOS Framework
The In Lieu of Services and Settings (ILOS) authority under 42 CFR § 438.3(e)(2) and 438.16 provides a pathway for Medicaid managed care plans to offer ACCESS-like services.
Under ILOS authority, plans can provide services or settings that are:
- Medically appropriate — Clinically suitable for the beneficiary's condition
- Cost-effective substitutes — Economically efficient alternatives to state plan services
- Voluntary for beneficiaries — Offered to willing participants only
- State-authorized — Approved by the state Medicaid agency
Implementation Pathway
State Authorization
The state Medicaid agency must authorize the ILOS arrangement. States have flexibility to determine whether and how an ACCESS-like model qualifies as an ILOS.
Managed Care Contract Updates
Reflect the ACCESS-like model in managed care contracts, ensuring compliance with all requirements in 42 CFR part 438.
Documentation Requirements
Meet all applicable documentation, monitoring, and reporting requirements outlined in CMS's managed care regulations and related guidance.
Plan Implementation
Managed care plans implement the outcome-aligned payment arrangements with qualified providers.
Is a CMS waiver required?▼
Generally, no separate CMS waiver is needed to implement ACCESS-like models under ILOS authority. The ILOS authority is part of existing managed care regulations.
However, states must:
- Comply with all requirements in 42 CFR part 438
- Meet documentation, monitoring, and reporting requirements
- Ensure proper authorization and contract documentation
Can plans offer additional services?▼
Yes. Plans retain the ability to cover services that are in addition to those covered under the Medicaid state plan in accordance with 42 CFR § 438.3(e)(1).
Important: The cost of such additional services cannot be included when determining the payment rates under 42 CFR § 438.3(c).
Cross-Payer Alignment Resources
CMS Support for Payer Alignment
CMS is developing resources to help payers implement consistent outcome-aligned payment approaches:
| Resource | Description | Availability |
|---|---|---|
| Reference Provider Agreements | Template contracts for outcome-aligned arrangements | Coming 2026 |
| Technical Documentation | API specifications and data exchange standards | Coming 2026 |
| Source Code | Open-source tools for payment calculations | Coming 2026 |
| Implementation Guide | Step-by-step guidance for payer adoption | Coming 2026 |
Benefits of Cross-Payer Alignment
When multiple payers adopt similar outcome-aligned approaches:
- Providers can invest in infrastructure knowing it works across payers
- Patients receive consistent care regardless of coverage
- Technology vendors can build solutions that scale across markets
- Quality measurement becomes more standardized and comparable
Commercial Payer Considerations
Adapting ACCESS for Commercial Plans
Commercial health plans and self-insured employers can also implement ACCESS-like models. Key considerations include:
What regulatory requirements apply?▼
Commercial plans are subject to different regulatory frameworks than Medicare or Medicaid. Consider:
- State insurance regulations — Vary by state and product type
- ERISA requirements — For self-insured employer plans
- ACA requirements — Essential health benefits and network adequacy
- Accreditation standards — NCQA, URAC, or other accrediting bodies
Consult with legal and compliance experts to ensure arrangements meet all applicable requirements.
How should outcomes be defined?▼
While commercial populations may differ from Medicare, similar outcome measures can apply:
- Clinical measures — Blood pressure, HbA1c, lipids, weight
- Patient-reported outcomes — Pain scales, PHQ-9, GAD-7
- Functional measures — Work productivity, activity levels
- Utilization measures — ER visits, hospitalizations, readmissions
Consider population health characteristics when setting targets and risk-adjusting results.
What technology infrastructure is needed?▼
Commercial payers implementing ACCESS-like models need:
- Data exchange capabilities — APIs for eligibility, enrollment, and outcomes reporting
- Provider credentialing — Verification of clinical capabilities and technology infrastructure
- Quality measurement — Systems to track and validate outcome measures
- Payment processing — Ability to process outcome-aligned payments
- Reporting dashboards — Transparency tools for providers and members
Frequently Asked Questions
Can a payer participate in ACCESS while also running their own program?▼
For MA plans: The ACCESS Model is for Original Medicare only, so MA plans cannot directly participate. However, they can run parallel programs with similar designs for their MA members.
For Medicaid: State Medicaid programs can implement ACCESS-like models independently through ILOS authority while CMS tests the ACCESS Model in Medicare.
Will CMS share ACCESS performance data with other payers?▼
CMS will publish aggregated, risk-adjusted outcomes for ACCESS participants in a public directory. This data can inform other payers about provider performance, though detailed claims data will not be shared.
How can payers get updates on ACCESS implementation resources?▼
Payers interested in alignment resources should:
- Monitor the CMS Innovation Center website for announcements
- Contact ACCESSModelTeam@cms.hhs.gov with specific questions
- Review the ACCESS Request for Applications for model design details
Are there opportunities for formal CMS collaboration?▼
CMS is interested in cross-payer alignment to maximize the impact of outcome-aligned payment approaches. Payers with specific proposals or questions about collaboration should contact the ACCESS Model team.
Relevant Regulations
Medicare Advantage
- 42 CFR § 422.2420(b)(2) — Incurred claims definition
- 42 CFR § 422.2430(a) — Quality improvement activities
Medicaid Managed Care
- 42 CFR § 438.3(c) — Payment rates
- 42 CFR § 438.3(e)(1) — Additional services
- 42 CFR § 438.3(e)(2) — In lieu of services and settings
- 42 CFR § 438.16 — ILOS requirements
- 42 CFR part 438 — Managed care requirements
Contact Information
For ACCESS Model Questions:
- Email: ACCESSModelTeam@cms.hhs.gov
For Medicare Advantage Questions:
- Contact your CMS Regional Office or the MA program
For Medicaid Questions:
- Contact your State Medicaid Agency or CMS State Operations
Next Steps
Official Documents
Download the ACCESS RFA for detailed model specifications
Technical Requirements
Review technology infrastructure and API specifications
Outcome-Aligned Payments
Understand how OAPs work in the ACCESS Model