A follow-up to “The CMS ACCESS Model Is an Operations Contract. Here's the Math.” Written for clinical operations leaders and chief operating officers at participating organizations. Data as of Q2 2026.
When we published the first piece, the payment amounts were still guesswork. They are not anymore. CMS has released the full payment schedule and performance targets for the July 2026 launch, so we can now see the whole board: what each track pays, what unlocks the money, and exactly what a patient has to achieve for any of it to count.
First, the optimistic read, because it is warranted. It is a good thing that CMS is running a ten-year, outcomes-based experiment in chronic care. Virtual care has spent years being paid for grudgingly, through fee-for-service codes that fight the model. ACCESS is the first time the federal government has said, in writing, manage the condition, prove the outcome, and we will pay you on a recurring basis for a decade. That is a real pathway. The fact that fourteen commercial payers have already committed to building their own versions for 2028 tells you the private market sees the same opening. The opportunity is large, and it favors whoever moves first and runs clean.
Now the numbers.
Payment by track
The allowed amount blends Medicare's 80 percent with the patient's 20 percent coinsurance. Most participants plan to waive the coinsurance, so the realistic figure to build your model around is the Medicare portion. Half of that is paid monthly across the year; the other half is withheld and reconciled at the end of the twelve-month care period. Here is each track, richest to leanest:
- CKM (advanced cardio-kidney-metabolic): $420 allowed. Medicare portion with coinsurance waived is $336, paid as about $14 a month ($168 across the year) with $168 withheld. Follow-on year: $210 allowed. Rural add-on: +$15.
- eCKM (early cardio-kidney-metabolic): $360 allowed. Medicare portion $288, paid as about $12 a month ($144 across the year) with $144 withheld. Follow-on year: $180 allowed. Rural add-on: +$15.
- MSK (musculoskeletal): $180 allowed. Medicare portion $144, paid as about $6 a month ($72 across the year) with $72 withheld. No follow-on period, no rural add-on.
- BH (behavioral health): $180 allowed. Medicare portion $144, paid as about $6 a month ($72 across the year) with $72 withheld. Follow-on year: $90 allowed. No rural add-on.
CKM is the richest line at $420, reflecting the heavier resource load of advanced cardio-kidney-metabolic care. BH and MSK sit at the floor at $180. One more wrinkle: when a single patient is in multiple tracks with you, CMS applies a 5 percent discount to the lower-cost track.
The two gates that unlock the withheld half
The withheld 50 percent is not a formality. It is released only if you clear two thresholds, and both are measured at the organization level, not patient by patient:
- Clinical Outcome Adjustment. The metric is your Outcome Attainment Rate (OAR): the share of aligned beneficiaries who complete the 12-month period and meet every required measure target. The threshold is at least 50 percent (the OAT). Below it, payment is prorated as OAR divided by 50 percent, capped at a 50 percent cut.
- Substitute Spend Adjustment. The metric is your Substitute Spend Rate (SSR): the share of beneficiaries who did not receive a defined substitute service from another Medicare provider for the same condition. The threshold is at least 90 percent (the SST). Miss it and you lose up to 25 percent.
There is a trap inside the first gate worth stating plainly: partial attainment is zero. A beneficiary counts toward your Outcome Attainment Rate only if every required measure for the track is reported on time and met. A patient who improves on three of four measures, or hits all four but misses a reporting window, contributes nothing. The math rewards completeness, not effort.
What “met” means, by track
Each measure is satisfied if the patient hits either the control target or the minimum-improvement target.
eCKM track
- Blood pressure: control is final systolic below 130; minimum improvement is a 15 mmHg systolic reduction.
- Weight and BMI: control is BMI below 30 with no more than 5 percent gain; minimum improvement is a 5 percent weight reduction.
- HbA1c: for prediabetes, final below 6.5 percent; all others simply report a baseline.
- LDL-C: for dyslipidemia, final below 100 or a 30 mg/dL reduction; all others report a baseline.
CKM track
- Blood pressure: control is final systolic below 130; minimum improvement is a 15 mmHg systolic reduction.
- Weight and BMI: control is BMI below 30 with no more than 5 percent gain; minimum improvement is a 5 percent weight reduction.
- HbA1c: for diabetes, final below 7.5 percent or a 1 percentage-point reduction; all others report a baseline.
- LDL-C: for dyslipidemia or ASCVD, final below 100 (below 70 with ASCVD) or a 30 mg/dL reduction; all others report a baseline.
- Kidney health (eGFR, uACR): for diabetes or CKD, report a baseline; no target.
BH track
- Depression (PHQ-9): if baseline is under 10, final under 10; if baseline is 10 or higher, a 5-point reduction.
- Anxiety (GAD-7): if baseline is under 10, final under 10; if baseline is 10 or higher, a 4-point reduction.
- PGIC: submit at end of period.
MSK track
- Function and pain PROM by site (no control target, improvement only): PROMIS PF +2 and PI −2; or ODI −8 for low back; NDI −8 for neck; QuickDASH −10 for arm, shoulder, or hand; KOOS JR +10 for knee; HOOS JR +10 for hip.
- Pain intensity (NRS): no more than a 2-point increase.
- PGIC: submit at end of period.
The non-clinical activities that also gate payment
This is the part that is pure operations, the requirements that decide payment regardless of how healthy the patient becomes:
- Baseline measures, submitted via the FHIR API within 60 days of alignment. Miss it and the beneficiary is unaligned and you cannot bill.
- Quarterly measure submission, 70 to 110 days after the prior submission. Miss it and you break continued-billing eligibility.
- End-of-period measures, no later than 425 days from alignment. Miss it and that patient is a non-attainer.
- Measurement recency windows: blood pressure, weight, and PROMs must be within 15 days; labs within 1 to 2 years. Outside the window, the submission is invalid and counts as non-attainment.
- Data source rules: blood pressure and labs cannot be self-reported; weight and PROMs can. A self-reported value where it is not allowed is invalid.
This is the list that belongs on the wall of every ACCESS operations team. A patient can be improving and still pay you nothing because a blood pressure reading landed outside its fifteen-day window or a quarterly submission slipped past day 110. Under ACCESS, an on-time measurement is worth as much as the outcome it records.
Our perspective
We will give you ours and let you reach your own. Look at the rates again. At roughly six to fourteen dollars per patient per month, there is no version of this program that supports a traditional, human-heavy operating model. You cannot staff a coordinator to chase every reading, a scheduler to rebook every missed visit, and a biller to reconcile every submission, and still clear margin at those rates. The numbers do not allow it.
We do not think that is an accident. We believe the rates were set deliberately low to force the manual labor out of the loop and reward organizations that deliver care through technology instead of headcount. Read that as cynical if you like. We read it as aligned, because the same design that makes the rates feel brutal is the design that expands access. A model that only pays out when it runs lean is a model that pushes the entire field toward serving more patients per clinician. Those are the facts as the numbers present them. Make your own judgment.
What we are sure of is who wins. CMS will publish every participant's risk-adjusted outcomes. When the commercial payers choose partners for their 2028 programs, they will choose from that public leaderboard. The organizations that run the cleanest operation in 2026 and 2027, the ones whose patients complete the cadence and hit the targets, are the ones who rise to the top and earn the higher-paying multi-payer contracts that follow. The cream rises, and for once it rises in public.
If you are building your ACCESS operating model
We run scheduling, capacity, and back-office operations for telehealth networks and hospitals. We have cut clinics' scheduler workload by about 90 percent and back-office operations by roughly 74 percent on the platform. If you are standing up your operating model for July, we would like to compare notes on how you are approaching it. Book some time with our team.
Rooting for the participants
To the teams already on the list, we are rooting for you:
Headspace · Mederva Health · Headway · SonderMind · Concert Health · TailorCare · Bold · PocketRN · Wysa · Limbic · Innerwell · Override · Holon Health · Plethy · JOGO Health
And a warm welcome to the names added this quarter, including Sailor Health, Heyday Health, Perry Health, Fabric, and Mindspan. The full, continuously updated participant list lives on CMS's site.
The information in this post was accurate as of Q2 2026.
