Advancing Chronic Care with Effective, Scalable Solutions (ACCESS)

Analysis updated November 9, 2026

Strategic questions for your team

Can our organization sustain cash flow under the ACCESS payment waterfall — where 100% of the annual OAP is paid in monthly installments during months 1–6 but the remaining 50% is withheld until post-period reconciliation — given that our withheld balance could face up to a 50% Clinical Outcome Adjustment reduction if our Outcome Attainment Rate falls below the 50% OAT threshold during the first 18 months?
Do we have the clinical infrastructure and data pipeline to submit FHIR-based OAP Measure data — including baseline values within a defined window of alignment, quarterly interim submissions, and end-of-period results — via CMS's Data Reporting API for every aligned beneficiary across our chosen track(s), recognizing that failure to submit on time disqualifies those episodes from the OAR numerator and jeopardizes the full withheld payment?
Which clinical track(s) — eCKM ($360/$180 initial/follow-on), CKM ($420/$210), MSK ($180/no follow-on), or BH ($180/$90) — offer the best ratio of payment rate to our existing patient population density, clinical competency, and technology stack, and can our patient panel realistically achieve the track-specific outcome thresholds (e.g., 15 mmHg systolic BP reduction or <130 mmHg control for eCKM/CKM, 5-point PHQ-9 reduction for BH, 2-point PROMIS PI reduction plus 2-point PROMIS PF increase for MSK) at a rate at or above the 50% OAT?
How will we manage the Substitute Spend Adjustment risk — where our OAP is proportionally reduced if more than 10% of aligned beneficiaries receive listed substitute services from other Medicare providers (e.g., PT evaluations 97161-97163 for MSK, G0108 DSMT for eCKM/CKM, 90791/90792 psychiatric diagnostic evaluations for BH) — and do we have care coordination protocols robust enough to keep our Substitute Spend Rate at or above the 90% SST?
Are we prepared to comply with the FFS Exclusion requirement — which prohibits us and our affiliated entities (defined as 5%+ ownership interest, operational control, or any reassignment relationship under 42 CFR §424.80) from submitting any Medicare FFS claims for ACCESS-aligned beneficiaries during active care periods — and have we mapped all affiliated entities and existing FFS billing relationships that would be suppressed by CMS claims processing controls upon model entry?
Do we have a credentialed, Medicare-enrolled physician available and willing to serve as Medical Director with documented accountability for clinical policies, OAP Measure data validation, patient safety protocols, care escalation pathways, and ongoing HIPAA/FDA/licensure compliance — and is that physician's time commitment and liability exposure acceptable under our governance structure?
Can we meet the July 6, 2027 deadline to establish connectivity to a Health Information Exchange, CMS Aligned Network, or TEFCA-designated QHIN for bidirectional clinical data exchange, AND separately make available a (g)(10)-compliant FHIR API supporting the most recent USCDI version — and what is our current gap assessment and capital requirement to achieve both?
How does our ACO or risk-bearing arrangement interact with ACCESS OAPs beginning in 2028, when ACCESS expenditures will be incorporated into MSSP and ACO REACH benchmark and performance year calculations, and should we participate as an ACCESS Participant billing G-codes for non-ACO-aligned beneficiaries, or primarily in the referring/co-management role billing G0676-G0678 at $30 per service (up to 3x per 12-month period per track) to capture the $90–$100 annual co-management revenue stream while keeping ACO benchmark calculations clean?
What is our patient acquisition and consent workflow for the 90-day lock-in period — during which beneficiaries cannot switch participants — and how will we handle the white-coat hypertension disenrollment scenario in eCKM (where we retain payment for up to 2 months if we submit non-qualifying ambulatory BP readings, but face full recoupment if we do not), particularly given that a high rate of such non-qualifying alignments triggers CMS audit and corrective action?
Given that new tracks for heart failure, COPD, substance use disorder, and tobacco cessation launch April 1, 2027 without requiring reapplication from current participants, and that the model runs through June 30, 2036 with rolling cohort start dates available quarterly through July 1, 2033, what is our optimal entry cohort and track expansion roadmap to maximize revenue per aligned beneficiary while maintaining the clinical outcome performance needed to avoid termination under the Participation Agreement?
Given that NAACOS/Innovaccer survey data shows health care leaders are actively planning around ACCESS but broadly doubt it will generate positive financial returns, what is our realistic break-even analysis across each track — accounting for the technology investment required to meet FHIR/data reporting requirements, care coordination staffing, and the probability distribution of Clinical Outcome Adjustment reductions — and at what minimum panel size and outcome attainment rate does ACCESS participation become net-positive relative to remaining in traditional FFS or MSSP?
As digital health vendors and well-capitalized entrants (e.g., companies raising $40M+ Series A rounds specifically targeting Medicare care coordination platforms) begin competing for ACCESS alignment, what is our strategy to retain patient relationships and prevent aligned beneficiaries from being re-aligned to competitor participants during the periods outside the 90-day lock-in window, and do we have the technology stack to compete with purpose-built ACCESS-optimized platforms?
Given that health care leaders report shifting their broader technology strategy in response to ACCESS — prioritizing interoperability, remote monitoring, and outcomes analytics infrastructure — have we assessed whether our current EHR and population health platforms require replacement or significant augmentation, and what is the total cost of ownership and implementation timeline for ACCESS-ready technology relative to our expected OAP revenue across the model period?

Traps and concerns

50% Withhold Reconciliation Liquidity Trap
The ACCESS payment structure withholds 50% of the total annual OAP amount for months 7-12 of each care period, releasing those funds only after semi-annual reconciliation contingent on Clinical Outcome and Substitute Spend Adjustments. For a participant managing a mid-sized panel, this creates a structural cash flow gap: an organization earning $420/year per CKM patient across 500 beneficiaries would have $105,000 in withheld payments at any given reconciliation cycle, with no guarantee of full release. Organizations that fail to meet the 50% Outcome Attainment Threshold (OAT) face a Clinical Outcome Adjustment capped at 50% of the gross OAP — meaning a worst-case scenario yields only half of contracted revenue. Startups and early-stage digital health companies with thin operating capital are particularly vulnerable to insolvency if their first cohort underperforms. CMS can also offset future monthly payments or initiate formal overpayment recovery if withheld amounts are insufficient to cover adjustments, compounding cash pressure beyond a single reconciliation window.
FFS Exclusion Affiliation Misclassification Risk
The FFS Exclusion prohibits ACCESS Participants and 'affiliated entities' from submitting any Medicare FFS claims for aligned beneficiaries during active care periods, with affiliation defined broadly to include any 5% or greater direct or indirect ownership interest, day-to-day operational control under any arrangement, or any reassignment relationship under 42 CFR § 424.80. Organizations embedded within larger health system structures — including physician groups that have reassigned billing rights to a hospital TIN or private equity portfolio companies with cross-entity ownership — may inadvertently trigger the exclusion for affiliated entities they did not intend to be bound. Claims processing systems will incorporate automatic suppression controls, meaning a billing error in this area results in denied claims rather than a manual correction opportunity. Organizations must conduct a full entity-mapping exercise before enrollment; failure to do so risks complete revenue loss from FFS services across affiliated entities serving ACCESS-aligned beneficiaries, with no transitional grace period specified in the RFA.
FHIR API Data Submission Compliance Deadline Cliff
ACCESS requires participants to submit all OAP Measure data — including baselines, quarterly updates, and end-of-period results — exclusively through a FHIR-based Data Reporting API, with no alternative submission methods offered by CMS. Baseline data must be submitted within a defined timeframe after alignment (exact window specified in the Participation Agreement), and failure to submit timely baselines eliminates billing eligibility for that beneficiary. Clinical validity windows are tight — 15 days for MSK and BH PROMs, 15 days for blood pressure and weight in eCKM/CKM — meaning a technical outage or data pipeline failure during the collection window permanently disqualifies a measure submission rather than allowing a cure period. Additionally, by July 6, 2027, all participants must establish connectivity to an HIE or CMS Aligned Network and make available a (g)(10)-compliant API. Organizations that have not built or contracted for FHIR infrastructure prior to launch face a hard cutoff: the model explicitly states CMS is not offering alternative reporting methods. Any participant without production-ready API clients across all four functions — Eligibility, Alignment, Unalignment, and Data Reporting — cannot operationally bill for any enrolled beneficiary.
Substitute Spend Adjustment Attribution Blind Spot
The Substitute Spend Adjustment reduces OAP payments when more than 10% of an ACCESS Participant's aligned beneficiaries receive listed substitute services from other Medicare providers during their care period — services the participant cannot directly control. The initial Substitute Spend Threshold (SST) is 90%, and every percentage point below that threshold reduces payment proportionally up to a 25% maximum reduction. For the MSK track, substitute services include physical therapy evaluations (97161-97163) and RTM device setup (98975); for eCKM/CKM, they include ambulatory blood pressure monitoring, DSMT, and the Medicare Diabetes Prevention Program (G9880-G9887). A PCP who independently orders physical therapy for a beneficiary already enrolled in an ACCESS MSK program — with no notice to the ACCESS Participant — directly degrades the participant's SSR and triggers a payment penalty. While the BCDA API provides access to claims data to monitor substitute spend, claims lag in the system means participants may not detect substitution events until after the semi-annual reconciliation window has closed, leaving no opportunity for corrective intervention. Organizations serving high-comorbidity panels with engaged PCPs face systematic SSR pressure that is structurally difficult to manage below the 90% threshold.
Control Group Randomization Destroys Enrollment Projections
CMS has embedded a randomized controlled evaluation into ACCESS under which some otherwise-eligible beneficiaries are assigned to a control group and blocked from enrollment for 12 months upon eligibility check via the Eligibility API. The result code 'not-eligible-control-group' is returned at the point of pre-enrollment screening, meaning participants discover control group assignment only after investing in patient outreach, clinical validation, and onboarding workflows. Participants cannot predict or pre-screen for control group assignment, making it impossible to underwrite enrollment volume projections with precision. For organizations building financial models on a targeted panel size — essential for meeting the 50% OAT across a statistically meaningful denominator — control group attrition of even 10-15% of attempted enrollments could push a borderline participant below the minimum threshold required for full payment release. The Beneficiary Notices Reference document confirms participants must display CMS-mandated, unmodifiable language to control group patients and may not modify it, eliminating any ability to re-route these patients through alternative engagement strategies.
White-Coat Hypertension Recoupment Exposure
The RFA establishes a specific recoupment risk for eCKM participants who align beneficiaries solely on the basis of a patient-attested hypertension diagnosis. If follow-up ambulatory or home blood pressure readings confirm the beneficiary does not have hypertension, is not on antihypertensive medication, and does not otherwise meet eCKM qualifying conditions, the beneficiary must be disenrolled. Participants that proactively submit the non-qualifying readings to CMS may retain up to two months of payments; participants that fail to submit those readings face full recoupment of all payments for that beneficiary. For a high-volume digital health company with broad top-of-funnel enrollment across direct-to-consumer channels — where self-reported hypertension is common — the operational burden of systematically capturing and submitting follow-up home BP readings within the clinical validity window (15 days) is significant. A pattern of high non-qualifying alignment rates triggers CMS audit and corrective action exposure that could escalate to participation termination, meaning the financial risk extends beyond individual recoupments to potential loss of the entire model revenue stream.
ACO Benchmark Inclusion Creates Dual-Accountability Conflict
For 2026 and 2027, CMS will exclude ACCESS OAPs from ACO benchmark and performance year calculations for MSSP and ACO REACH. Beginning in 2028, however, ACCESS OAP expenditures will be included in ACO benchmark and performance year calculations. This creates a delayed but significant financial conflict for primary care organizations participating in both an ACO and ACCESS: their ACO benchmark will be reset to include ACCESS expenditures, potentially reducing shared savings by attributing previously untracked chronic care spending to the performance year. ACO participants who also serve as ACCESS Participants — or who refer aligned beneficiaries to ACCESS organizations — will need to model the 2028 benchmark recalibration impact before the transition occurs. The RFA's guidance that ACOs 'should consider applicable legal requirements including compliance with the Anti-Kickback Statute and Physician Self-Referral Law' when referring beneficiaries to ACCESS Participants adds a compliance layer that most ACO legal teams have not yet addressed, introducing contracting and referral arrangement risk that could constrain the very care coordination the model is designed to incentivize.