Written by Karen Ostrowski, Director, Health Policy and Regulatory Affairs (Consultant), Civitas
Overview of ACCESS
CMS’ ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) model is a 10-year national test designed to shift chronic condition management away from visit-based billing and toward new Outcome-Aligned Payments (OAPs). These are recurring, condition-focused payments that participants earn only when Medicare beneficiaries meet defined clinical outcome thresholds. It’s a meaningful change from traditional Medicare’s fee-for-service approach and signals CMS’ interest in technology-supported, longitudinal care that doesn’t rely on coding volume.
The model focuses on four clinical tracks — early CKM risk factors, diabetes/CKD/ASCVD, chronic MSK pain, and behavioral health conditions such as depression and anxiety. CMS emphasized technology as a core enabler but intentionally left the definition open. Tools could include remote monitoring, digital therapeutics, asynchronous care platforms, behavioral coaching tools, and potentially AI-supported workflows. They didn’t say as much out loud, but it was implied.
The first performance period starts July 1, 2026. Based on the listening session, not everything is finalized; some details (especially technical ones) are clearly still being developed.
Why This Matters for Civitas Members
With ACCESS, CMS is describing a care model that only works if timely, multi-source data is available. They never used the terms “HIE,” “HDU,” “APCD,” or “CIE,” but the underlying assumption was hard to miss. The workflows they described rely on:
- longitudinal clinical histories,
- device-generated signals,
- lab and imaging data flowing from multiple sources,
- medication information that’s up to date,
- PROMs collected consistently,
- and coordination across multiple care teams.
Most providers don’t have this infrastructure on their own, but it is the exact infrastructure Civitas members already operate. However, ACCESS presumes a level of interoperability that exists unevenly across the country. Where it does exist, it’s because of the work HIEs, HDUs, APCDs etc. have done. That makes members central to whether the model actually works in practice.
Implications for Civitas Members
The ACCESS model shifts the focus in chronic care from “activities performed” to “measurable improvement.” To meet outcome thresholds, participants will need reliable access to labs, imaging, medication data, device data, and PROMs. Many digital-first companies and specialty groups will struggle to meet those requirements without external support.
Civitas members can play a few important roles, and in some regions already do:
- acting as the aggregation point for multi-source clinical data;
- supporting attribution and identity matching across sites;
- enabling PROMs or device data integration where providers lack capacity;
- facilitating communication across fragmented care teams;
- and, for members with CIE functions, supporting navigation and social-care workflows.
During the listening session, CMS described care management workflows that strongly implied closed-loop referrals and broad navigation support even if those terms weren’t explicitly used. That’s another area where existing member infrastructure aligns with what ACCESS requires.
Opportunities for Civitas Members
This new model gives Civitas an opportunity to reinforce its role as a national convener on shared data infrastructure, particularly because CMS has not yet defined technical requirements for PROMs, device integration, or data validation. Those gaps could benefit from early guidance informed by member experience.
It also strengthens the ROI story for health data utilities. Revenue will depend on achieving outcomes, and outcomes depend on data quality and completeness. Many providers understand this conceptually, but ACCESS ties it to payment in a very direct way.
Another area to watch is payer alignment. The model is structured in a way that Medicaid agencies and commercial plans may try to mirror or adapt. Civitas has a unique vantage point to help shape alignment early rather than react to fragmentation later.
Lastly, ACCESS will draw in newer, digital-first companies entering the Medicare space. Many of them will need help with compliance, outcomes reporting, and integration into local data ecosystems. Members could fill that gap quickly.
Challenges and Risks with the CMS ACCESS Model
Some of the uncertainties may create implementation challenges. CMS hasn’t yet clarified which data sources will be accepted, and it wasn’t clear from the session how strict they plan to be. PROMs and device data were both mentioned, but the details felt pretty early-stage. AI also wasn’t addressed much, even though the model seems designed to make room for it.
Billing and coding details remain open. OAPs replace many FFS services, so CMS will need new indicators, documentation expectations, and co-management codes. Those may not all be finalized by July 2026, which could slow early adoption. Risk adjustment is also a real concern. If the methodology doesn’t fully capture patient complexity — particularly for rural, multi-chronic, or underserved populations — some organizations may be disadvantaged. APCD and HIE data may be helpful here, but only if CMS allows them to be incorporated.
There’s also the unevenness of existing data infrastructure. ACCESS will be much easier to implement in states with strong HIE/APCD/CIE ecosystems. In other places, providers may struggle to meet data requirements without additional support or investment.
What to Expect from Civitas
As CMS finalizes the details of ACCESS, Civitas will be taking several steps to support members and help coordinate shared priorities, including:
- helping members understand what infrastructure they already have that aligns with ACCESS;
- convening a small working group around PROMs, device data, and outcome reporting;
- engaging CMS early on data governance and risk adjustment;
- highlighting member examples where similar chronic care infrastructure already exists.
Closing Thoughts
The ACCESS model treats multi-source, real-time data as a baseline requirement rather than an aspirational feature. That shift alone moves Civitas members from the periphery of Medicare policy conversations to the center of how this model succeeds. If CMS wants outcomes to improve, they need the infrastructure Civitas members have already built – something worth keeping in mind as the policy details continue to develop.