Most of Medicare still pays for activity: a visit, a call, twenty minutes of care management in a month. The ACCESS model pays for something else. It pays an organization to manage a patient's chronic condition for a year, and it holds back a large share of the money until it can see whether that patient actually got better.
More than 160 organizations are already in, according to CMS's ACCESS page. If your coaching or care team works inside one of them, or wants to, the rules shape your team's year more than the payment amounts do. Here's how they work, read from CMS's own payment and targets document.
What the ACCESS model pays per patient
An organization joins one or more clinical tracks. For each patient it enrolls in a track, it gets a flat annual amount, paid monthly, and it's responsible for every qualifying condition in that track.
Those are allowed amounts, so they include the patient's 20% coinsurance, which organizations can choose to waive. After the first year, three of the tracks drop to a follow-on rate at half the initial amount: $210, $180 and $90. Rural patients on the two cardio-kidney-metabolic tracks add $15 in the first year. Musculoskeletal has no follow-on year until April 1, 2027, when CMS adds one alongside four new tracks for heart failure, COPD, substance use disorder and tobacco cessation.
If your team bills chronic care management today, one rule matters more than the rates. While a patient is in an active ACCESS care period, the participating organization can't bill other Medicare fee-for-service claims for that patient. Only the ACCESS codes. So for that patient, ACCESS replaces your chronic care management billing. It doesn't sit on top of it.
Half the money waits until the year is over
CMS pays monthly, but the monthly payments can't add up to more than half of Medicare's share of the annual amount. The other half is held back and settled after the patient's 12-month care period ends. A second adjustment can also cut it if the same patients get substitute services from other Medicare providers above a set level.
What mostly decides that settlement is the organization's outcome attainment rate: the share of its patients who finish the care period and hit every required target. For now the bar is 50%. That's a different 50% from the withheld half, and it's the one your team controls. Clear it and the organization can earn full payment even when some individual patients don't make it. CMS says the bar rises with each participation year.
Partial target attainment does not constitute success.
CMS, ACCESS Model Payment Amounts and Performance Targets
Why a patient who drifts away counts against you
This is the part a coaching team should read twice. A patient only counts as a success if every required measure is reported on time and every target is met. Hitting the blood pressure target and missing the final weigh-in counts as a miss.
And the patients you lose don't drop out of the math. CMS removes people who move out of your service area or stop being eligible. People who stop responding, or choose to leave, stay in the denominator.
The reporting clock is tight as well:
- Baseline measures within 60 days of enrollment, or the patient is dropped from the model.
- A new set of measures every 70 to 110 days.
- Final measures no later than day 425.
- Blood pressure, weight and questionnaire scores sent to CMS within 15 days of being taken.
Blood pressure and lab values can't be self-reported. Weight and the questionnaires can.
The targets a patient has to hit
Each measure passes one of two ways: the patient reaches a control level, or improves by a set minimum from their own baseline. CMS built it that way on purpose, so organizations don't avoid patients who start far from target. Its own example: a patient who starts at a systolic reading of 160 needs to reach 145 by the end of the year, even though the clinical goal is still under 130.
| Measure | Passes if |
|---|---|
| Systolic blood pressure | Under 130 mm Hg, or down 15 mm Hg from baseline |
| Weight | BMI under 30 with no more than 5% gain, or a 5% weight loss |
| HbA1c, diabetes | Under 7.5%, or down 1 point |
| Depression, PHQ-9 | Starting at 10 or higher, down 5 points |
| Anxiety, GAD-7 | Starting at 10 or higher, down 4 points |
Targets for the Effective Period, July 5, 2026 to December 31, 2027. Patients with prediabetes on the early cardio-kidney-metabolic track need an HbA1c under 6.5%.
Most of these are behavior targets with a lab value attached. Five percent of body weight, fifteen points of blood pressure and five points on a depression scale all move when a patient changes what they eat, how they move and whether they keep going.
What a CMS ACCESS model program needs from its coaching team
Read the rules from the coach's side and three jobs fall out. None of them is new. ACCESS just ties the money to them.
We've measured what contact between sessions does. In a 300-participant controlled study, program completion ran 17% with no coaching, 28% with coaching alone, and 36% with coaching plus technology, a 112% improvement over no coaching. The gap opened late: two people in the coaching-only group reached a third session, against seventeen once technology was added. That study measured program completion, not ACCESS targets, and the two are different measures. But it's the problem ACCESS is paying to solve. People who stop showing up don't get better on the record.
ACCESS won't stay a Medicare-only question, either. CMS has made its track billing codes usable by any payer, and it says major health plans have pledged to offer an ACCESS-aligned payment option. For a chronic care team, the patients who stay and the results you can show are starting to be what the money follows.
