Last evening, CMS released payment rates and associated clinical outcome requirements for the CMMI ACCESS Model. ACCESS Model Payment Amounts and Performance Targets v10
The model provides Outcome-Aligned Payments (OAPs) for managing beneficiaries' qualifying conditions over a 12-month Care Period, with full annual payment explicitly tied to achieving specified clinical and patient-reported outcomes.
Payments are structured in two tiers:
- A higher-paying Initial Period to support onboarding and early clinical improvement
- A lower-paying Follow-On Period for ongoing management
Annual allowed amounts range from $180 to $420, depending on the clinical track (eCKM, CKM, MSK, BH), with limited rural add-ons in certain tracks.
CMS will:
- Pay monthly installments equal to one-twelfth of the Medicare portion
- Withhold 50% of total payment pending year-end reconciliation based on performance
Payments may be reduced through:
- Clinical Outcome Adjustment – Requires at least 50% of aligned beneficiaries to meet all required measure targets to earn full payment
- Substitute Spend Adjustment – Triggered if overlapping services exceed a 90% threshold
- Multi-track discounts for beneficiaries aligned to multiple tracks with the same participant
The model embeds defined clinical and patient-reported outcomes directly into payment determinations across all tracks-cardiometabolic (eCKM/CKM), Behavioral Health (BH), and Musculoskeletal (MSK). Measures include objective clinical metrics (e.g., blood pressure, HbA1c, LDL, kidney function) as well as validated PROs such as PHQ-9, GAD-7, PROMIS Physical Function and Pain Interference, ODI, NDI, QuickDASH, KOOS JR, HOOS JR, and pain intensity scales.
Participants must submit baseline and periodic data (often quarterly and at year-end), meeting either defined control thresholds or minimum clinically meaningful improvement targets.
Collectively, the model ties reimbursement to documented clinical and functional improvement, reinforcing accountability for measurable outcomes rather than service volume.
ATA Action is conducting a comprehensive review of the payment rates and clinical framework and will share additional analysis in the coming days. We encourage members to review the materials and share feedback with the ATA and ATA Action policy team to inform next steps.
Thank you.
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Lani Reilly
VP Industry Engagement
American Telemedicine Association
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