CMS ACCESS Model: Payments Announced Ahead Of April 1 Application Deadline

Key Takeaways:

• CMS has announced ACCESS Model payment rates, which range from $90 to $420 per beneficiary per year (i.e., $7.50 to $35 per month), depending on model track.
• The ACCESS Model creates a new payment pathway enabling technology-enabled care organizations to serve Traditional Medicare beneficiaries through fixed, outcome-based payments.
• The model will allow for reimbursement of digital health technologies that are available to commercially insured patients but that have been difficult for Medicare beneficiaries to access due to reimbursement challenge.
• Applications for the first cohort are due April 1, 2026.

For digital health companies that have struggled to access Medicare reimbursement under existing payment structures, this model is worth a close look. This 10-year model from the CMS Innovation Center creates a dedicated payment pathway enabling technology-enabled care to serve Traditional Medicare beneficiaries, with payments tied to clinical outcomes rather than service volume. The model launches July 1, 2026.

Why CMS Is Pursuing This Model

Technology-enabled care organizations have grown rapidly in recent years, with over $10 billion invested in the sector in 2024 alone. These organizations offer care models ranging from AI-guided therapy and wearable monitoring to app-based coaching and remote medication management.

Despite this growth, most technology-enabled care organizations currently serve commercially insured populations and have been largely unable to reach Medicare beneficiaries. Medicare fee-for-service has been poorly suited to technology-enabled care, which is often continuous and remote, because the reimbursement rules generally only pay providers per billable service or encounter (e.g., office visits, tests, procedures) delivered at identifiable points in time. Technology-enabled care, by contrast, aims to prevent unnecessary office visits and hospitalizations by replacing in-person services with remote management and intervening early through remote monitoring and data analytics.

The ACCESS Model attempts to correct this misalignment through Outcome-Aligned Payments (OAPs)—fixed per-patient payments for managing chronic conditions, with full payment contingent on clinical outcomes.

Key Elements of the Application

Applicants must be Medicare Part B-enrolled organizational entities identified by a single Taxpayer Identification Number and eligible to bill under the Medicare Physician Fee Schedule. Applicants must also have a medical director, be licensed under state law and meet other requirements. Organizations not currently enrolled in Medicare Part B may need to enroll to participate. Digital health companies that are not yet enrolled in Medicare Part B must either become a Medicare Part B provider or supplier or partner with a Part B provider or supplier (other than a DMEPOS supplier) that will become the ACCESS participant and the digital health company would then deliver its services through an arrangement with that organization.

Each applicant must select one or more of four initial clinical tracks:

• Early Cardio-kidney-metabolic (eCKM), covering conditions such as hypertension and prediabetes;
• Cardio-kidney-metabolic (CKM), covering diabetes and chronic kidney disease;
• Musculoskeletal (MSK), covering chronic pain; and
• Behavioral Health (BH), covering depression and anxiety. Payment for each track is tied to specific clinical outcome measures, such as improvements in blood pressure, weight, pain scores, or mental health symptom assessments.

The model uses a randomized evaluation design, meaning participants must inform prospective beneficiaries that they may be randomly assigned to a control group and ineligible to receive services under the model.

Two other features are worth highlighting. Participants can waive beneficiary cost-sharing entirely under the patient incentive safe harbor, thereby removing what is often a barrier to patient enrollment. And CMS will pay primary care physicians and referring clinicians approximately $30 to review care updates from ACCESS Participants, with no cost-sharing required from beneficiaries. The intent is to build referral relationships and support coordinated care.

Key Considerations and Tradeoffs

The ACCESS Model presents a meaningful opportunity, but organizations considering participation should carefully evaluate several issues before applying.

• Payment Economics. The announced payment rates—ranging from approximately $7.50 to $35 per beneficiary per month depending on the clinical track—are modest. Organizations accustomed to higher reimbursement from commercial payers will need to assess whether Medicare volume and patient retention rates can make the economics viable at these levels. That said, the model's fixed payment structure offers predictability, and the ability to waive beneficiary cost-sharing could support higher enrollment and engagement rates than a traditional fee-for-service arrangement. Organizations should model their unit economics carefully, accounting for the costs of clinical delivery, technology infrastructure, and the administrative overhead associated with Medicare participation.
• Medicare Enrollment and Compliance Infrastructure. For digital health companies not currently enrolled in Medicare Part B, participation will require either direct enrollment or a formal partnership with an enrolled Part B provider or supplier. Either pathway carries significant regulatory implications. For example, Medicare enrollment subjects an organization to the False Claims Act, which imposes treble damages and per-claim penalties for the submission of false or fraudulent claims, which presents materially different risks than most commercial arrangements. Participants will also need to establish compliance programs adequate to meet Medicare's billing, documentation, and reporting requirements, which may require meaningful investment in compliance personnel and systems.
• Fraud and Abuse Considerations. The model's structure, which involves referral relationships between ACCESS Participants and primary care physicians, raises questions under the federal Anti-Kickback Statute and the physician self-referral law (the Stark Law). Although CMS has indicated that the $30 care coordination payments to referring clinicians are a feature of the model, participating organizations will need to ensure that any additional arrangements with referring providers are structured to comply with applicable fraud and abuse laws or fall within available safe harbors or exceptions. Organizations that partner with Part B providers to serve as the ACCESS Participant will similarly need to ensure that their contractual arrangements do not create impermissible financial relationships.
• Strategic Value Beyond Direct Revenue. Despite these challenges, early participation may offer strategic benefits that extend beyond the model's direct payments. Participation provides a structured entry point into Medicare—a market that will only grow as the population ages—and generates real-world outcomes data in a Medicare population that could be valuable for future payer negotiations, regulatory engagement, and product development. Organizations that demonstrate strong clinical outcomes under the model may also be well-positioned if CMS expands the model or develops successor programs.

Looking Ahead

The model's first application deadline of April 1, 2026 is quickly approaching. Applications received after April 1, 2026 but before October 1, 2026 will be considered for participation beginning on January 1, 2027, with subsequent applications considered for later cohorts.

Organizations interested in the early cohorts should be taking concrete steps now. As an initial matter, organizations should evaluate which clinical track or tracks align with their existing capabilities and patient populations, and whether their outcomes data is sufficiently robust to meet the model's performance targets. Organizations not currently enrolled in Medicare Part B should begin the enrollment process or identify potential Part B partners promptly, as Medicare enrollment can involve meaningful lead times. Organizations should also assess whether their technology platforms and data systems can support the model's reporting and evaluation requirements.

More broadly, the ACCESS Model may signal a directional shift in how CMS approaches reimbursement for technology-enabled care. If the model demonstrates that fixed, outcome-based payments can improve care for Medicare beneficiaries while reducing overall costs, it could influence future CMS rulemaking and create additional pathways for digital health participation in Medicare. Organizations that establish a track record under this model may be well-positioned to benefit from that evolution.

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