CMS ACCESS Model Explained (And How Amigo Helps You Qualify)

CMS just unveiled the new digital-first ACCESS model (Advancing Chronic Care with Effective, Scalable Solutions), a 10-year voluntary program launching July 5, 2026 that shifts Medicare from fee-for-service to outcome-based reimbursement.

Put simply, ACCESS will pay providers when patients get healthier, not when visits or services are billed. In doing so, CMS is giving organizations the flexibility to adopt technology and tools that meaningfully improve patient outcomes. By encouraging technology-supported care, CMS aims to strengthen support for chronic conditions while rewarding clinicians and organizations that deliver real improvements.

What is the ACCESS model and why did CMS create it?#

90% of the $4.9 trillion spent annually on US healthcare is for people with chronic and mental health conditions like hypertension, diabetes, kidney disease, depression, and anxiety. These conditions require continuous management, which is fundamentally incompatible with the current visit-based, fee-for-service payment model.

CMS created ACCESS to address this problem. Traditional Medicare offers limited reimbursement for the continuous, tech-supported services that help chronically ill patients between appointments. As a result, many patients (especially in rural or underserved areas) lack access to modern tools that could meaningfully improve their health.

This new model changes the incentives by tying payments to outcomes rather than activities. Did blood pressure improve? Did pain or mood scores get better? Providers will be encouraged to use innovative digital tools and care models to improve patient health, with the ultimate goal of improving outcomes at scale and reducing long-term costs by keeping people healthier.

Who is ACCESS for?#

ACCESS is open to any organization capable of delivering integrated, tech-enabled chronic care. This can include but is not limited to:

• Primary care practices
• Multispecialty groups and health systems
• Orthopedic and musculoskeletal clinics
• Women’s health practices
• Behavioral health groups
• Weight loss clinics
• Virtual chronic care companies

CMS is explicitly encouraging partnerships between provider groups and tech companies to deliver the full spectrum of care.

How the ACCESS payment model works#

At the heart of ACCESS is a new payment model that replaces visit-based billing with recurring payments that reward results. The model includes two components, with Outcome-Aligned Payments for ACCESS participants and an additional Co-Management Payment for non-ACCESS clinicians.

1. Outcome-Aligned Payments (OAPs)#

ACCESS participants receive predictable, recurring payments for managing patients’ chronic conditions. Full payment depends on achieving measurable health improvements across your patient population, such as reducing blood pressure, improving depression scores (PHQ-9), or decreasing pain levels. Organizations earn higher payments when a greater share of patients meet clinical improvement targets for their track, and thresholds rise gradually each year, rewarding sustained success.

Payment rates by track

CMS has published the annual OAP allowed amounts per patient for each clinical track. These amounts include both the Medicare program payment (80%) and beneficiary coinsurance (20%), which providers can choose to waive uniformly.

The Initial Period rate applies when the provider is treating the patient in the clinical track for the first time within the past two years and at least one OAP Measure is not at target. The Follow-On Period rate applies for patients who have already been treated in the track or whose health measures are already on target.

Providers managing rural eCKM and CKM patients in the Initial Period receive an additional $15 fixed payment to offset connected device distribution costs.

When a patient is enrolled in multiple tracks with the same provider, CMS applies a 5% discount to the lowest-cost track(s) during overlapping months.

Payment frequency

CMS issues monthly payments equal to one-twelfth of the Medicare portion of the annual OAP for valid monthly claims. The sum of monthly payments may not exceed 50% of the Medicare portion of the annual OAP. The remaining 50% is withheld and reconciled after the 12-month care period based on outcome performance.

2. Co-Management Payments#

To support further collaboration, an ACCESS patient’s primary care physician or referring clinician can also bill Medicare for reviewing ACCESS updates and coordinating care. They can receive approximately $30 per review (up to $100/year per patient). These payments have no patient cost-sharing and help ensure PCPs stay actively involved in their patients' chronic care management.

The four clinical tracks#

ACCESS is organized into four clinical tracks that group chronic conditions requiring similar longitudinal, tech-enabled management. Organizations may participate in one or multiple tracks.

Each track has defined outcome measures that determine whether participants earn Outcome-Aligned Payments. For each measure, a patient meets the target by either reaching an absolute clinical threshold (e.g., systolic BP < 130 mmHg) or demonstrating a minimum improvement from their baseline (e.g., 15 mmHg reduction) - whichever comes first.

Early Cardio-Kidney-Metabolic (eCKM)#

Conditions covered: Hypertension or any two of the following: dyslipidemia, obesity/overweight with central adiposity, or prediabetes. This track focuses on preventing progression into more serious chronic disease.

Outcome targets:

• Blood pressure: systolic BP < 130 mmHg, or 15 mmHg reduction
• Weight: BMI < 30 kg/m² with no more than 5% weight gain, or 5% weight reduction
• HbA1c (prediabetes only): final HbA1c < 6.5%
• LDL-C (dyslipidemia only): final LDL-C < 100 mg/dL, or 30 mg/dL reduction

Cardio-Kidney-Metabolic (CKM)#

Conditions covered: Type 2 diabetes, chronic kidney disease (stages 3a/3b), and atherosclerotic cardiovascular disease.

Outcome targets:

• Blood pressure: systolic BP < 130 mmHg, or 15 mmHg reduction
• Weight: BMI < 30 kg/m² with no more than 5% weight gain, or 5% weight reduction
• HbA1c (diabetes only): final HbA1c < 7.5%, or 1 percentage point reduction
• LDL-C (dyslipidemia/ASCVD): final LDL-C < 100 mg/dL (or < 70 mg/dL for ASCVD), or 30 mg/dL reduction
• eGFR and uACR (diabetes/CKD only): baseline submission required

Musculoskeletal (MSK)#

Conditions covered: Chronic pain lasting more than three months, including back pain, osteoarthritis, neuropathic pain, and other conditions that impair physical function and quality of life.

Outcome targets: Participants select a PROM based on the patient's anatomical site of pain (e.g., PROMIS PF/PI for general pain, ODI for lower back, NDI for neck, QuickDASH for upper limb, KOOS JR for knee, HOOS JR for hip).

Additionally:

• Pain intensity (NRS): no more than 2-point increase from baseline
• PGIC: end-of-period submission required

Behavioral Health (BH)#

Conditions covered: Depression and anxiety disorders.

Outcome targets:

• PHQ-9 (depression): if baseline ≥ 10, a 5-point reduction; if baseline < 10, maintain below 10
• GAD-7 (anxiety): if baseline ≥ 10, a 4-point reduction; if baseline < 10, maintain below 10
• PGIC: end-of-period submission required
• WHODAS 2.0 (optional): baseline and end-of-period submission

How providers are evaluated#

Two adjustments determine whether participants receive their full withheld payment:

1. Clinical Outcome Adjustment: The Outcome Attainment Threshold (OAT) is set at 50% for the first effective period (July 5, 2026 - December 31, 2027). Participants earn full payment if at least half of their eligible patients meet all required OAP Measure targets.
2. Substitute Spend Adjustment: The Substitute Spend Threshold (SST) is set at 90%. At least 90% of eligible patients must not have received defined substitute services from other Medicare providers for the same condition during their care period.

Overview of ACCESS requirements#

At a high level, ACCESS participants must have (or build) the following capabilities:

• Medicare enrollment & clinical oversight: You must be enrolled in Medicare Part B and designate a physician Clinical Director (MD/DO) responsible for quality and patient safety.
• Data & measurement capabilities: You need reliable ways to collect patient data, pull in readings from wearables and medical devices, and submit clean digital documentation to CMS.
• Continuous patient support: ACCESS expects you to check in with patients between visits to collect PROs, monitor progress, answer questions, and keep them engaged over time.
• Outcome tracking & reporting: You must capture baseline measures, track follow-up results on schedule, and share accurate and complete data with PCPs and other clinicians.

How Amigo supports ACCESS participation#

Transitioning to an outcome-based model like ACCESS can reveal gaps in an organization’s capabilities. To participate successfully, organizations will need to collect PROs at scale, track outcomes consistently, engage patients between visits, integrate device data, and report structured metrics back to CMS.

Amigo fills these gaps by functioning as the ACCESS operating layer, helping organizations build the capabilities needed to meet program requirements.

1. Continuous outcomes tracking
   ACCESS pays for outcomes, which requires tracking and improving clinical outcomes like BP, A1c, weight, and PHQ-9/GAD-7 scores. Amigo can handle this entire lifecycle, including automated outreach to collect measurements, structured PRO delivery and scoring, real-time trend detection and escalation when metrics decline, and CMS-ready documentation that flows seamlessly into your EHR.
2. Automated PRO collection and scoring
   Many organizations struggle to regularly reach out to patients or to administer surveys like PHQ-9 or pain scales systematically. Amigo makes this process effortless by automatically sending, scoring, filing, and summarizing PROs between visits to ensure consistent data without adding burden on human staff.
3. Continuous chronic care support
   Most chronic care complications happen in the time between visits, which is why ACCESS requires protocols for ongoing care. With Amigo, your practice can deliver continuous care through a clinical expert AI agent that can engage patients 24/7 to send reminders, collect daily vitals, answer common questions, and nudge them toward healthier behaviors.
4. Multi-condition management
   Because each ACCESS track spans multiple chronic conditions, organizations will need unified workflows that provide a full picture of each patient. A single Amigo agent can manage multiple conditions for the same patient, with full context and tailored follow-up.
5. Automated documentation & reporting
   ACCESS requires rigorous data tracking that Amigo can automate end-to-end, including vitals, labs, PROs, and wearable/device data such as glucose readings or step counts. All data is captured and logged automatically, then assembled into structured documentation that aligns with CMS reporting requirements.

Get ready for ACCESS with Amigo#

ACCESS is a decade-long opportunity to redesign chronic care around outcomes. For organizations willing to embrace technology, it offers a new way to get rewarded for improving patient lives.

Application deadline: April 1, 2026

Program launch: July 5, 2026

Program runs until: June 30, 2036

CMS plans to open future cohorts, but early participants will benefit from earlier reimbursement and a longer runway to improve outcomes over the full 10-year period.

We’re here to help. Book a demo with our team to walk through your current gaps and learn how Amigo can help you meet ACCESS requirements with confidence.

For the full CMS payment and performance targets document, see: ACCESS Model Payment Amounts and Performance Targets (PDF)

For the latest updates, visit the official CMS ACCESS page.