Advancing All-Payer Health Equity Approaches and Development (AHEAD)
Model Summary
1. Executive Summary and Strategic Context
The AHEAD Model is CMS's most ambitious state-based total cost of care (TCOC) initiative, testing whether hospital global budgets combined with primary care investments can improve population health, reduce disparities, and curb healthcare cost growth. Operating for 11 years (2024-2035), AHEAD selects up to eight states to implement multi-payer hospital global budgets covering Medicare fee-for-service, Medicaid, and at least one commercial payer.
Six states have been selected across multiple cohorts: Maryland (Cohort 1, performance year starting January 2026), and Connecticut, Hawaii, Vermont, Rhode Island, and select New York counties (Bronx, Kings, Queens, Richmond, Westchester) as later cohorts with performance years beginning January 2027. Each participating state receives up to $12 million in cooperative agreement funding over six years.
AHEAD builds on CMS's previous state-based models: Maryland's All-Payer Model (2014-2018) and Total Cost of Care Model (2019-2025), Vermont's All-Payer ACO Model, and Pennsylvania's Rural Health Model. Maryland's transition from TCOC to AHEAD is particularly significant, as the state must implement the new model framework by January 2026 to maintain its longstanding global budget arrangements.
1.1 Strategic Significance
AHEAD represents a fundamentally different approach than episode-based or ACO models: rather than restructuring individual payment transactions, it replaces fee-for-service volume incentives with fixed prospective budgets for entire hospitals. This is the closest CMS has come to single-payer-style budget constraints within the U.S. multi-payer system. If successful, AHEAD could become the template for mandatory state-level global budget models in the 2030s.
2. Model Architecture and Regulatory Framework
2.1 Legal Authority
AHEAD operates under Section 1115A of the Social Security Act (CMS Innovation Center authority). The model was announced September 2023, with a Notice of Funding Opportunity (NOFO) published for state applications. CMS updated model specifications in September 2025, extending the end date to December 2035 and aligning cohort timelines.
2.2 Cohort Structure and Timeline
| Cohort | States | Pre-Implementation | Performance Year 1 | Model End |
|---|---|---|---|---|
| Cohort 1 | Maryland | 2024-2025 | January 2026 | December 2035 |
| Cohort 2 | Connecticut, Hawaii, Vermont | 2025-2026 | January 2027 | December 2035 |
| Cohort 3 | Rhode Island, New York (select counties) | 2025-2026 | January 2027 | December 2035 |
2.3 Model Components
Hospital Global Budgets (HGB): Fixed annual prospective payments to participating hospitals based on historical net patient revenue (NPR) baseline, trended forward with adjustments for case mix, market shifts, outliers, quality performance, and health equity. Covers both inpatient and outpatient services. Medicare FFS HGB methodology set by CMS; Medicaid HGB methodology set by state Medicaid agency subject to CMS approval.
Primary Care AHEAD: Voluntary primary care component enabling participating practices to receive enhanced Medicare payments including fixed per-beneficiary payments, incentive payments, and continued fee-for-service payments. FQHCs, Rural Health Clinics, and other primary care practices in participating states/regions may participate.
Total Cost of Care Accountability: Participating states are accountable for limiting total healthcare spending growth statewide. CMS targets approximately 6-7% of Medicare FFS revenue tied to HGB by model end, with 30% threshold required by Performance Year 4.
Multi-Payer Requirement: States must recruit at least one commercial payer to participate in hospital global budgets by Performance Year 2. This can include private insurance plans, state employee health plans, or Medicare Advantage plans.