ACCESS for Primary Care Providers and Referring Clinicians
New Ways to Support Your Patients with Chronic Conditions
Help your patients manage conditions like diabetes, pain, and depression with Medicare-enrolled health care providers in ACCESS that complement your care.
What is the ACCESS Model?
A new kind of chronic care support ACCESS is a 10-year CMS Innovation Center model (pilot) that offers ongoing, technology-supported chronic care — such as lifestyle support, remote monitoring, wearables, coaching, and medication management—from Medicare-enrolled health care providers at low or no cost to patients. These organizations are primarily paid based on whether patients' health actually improves. The voluntary model focuses on conditions affecting more than two-thirds of people with Medicare, including high blood pressure, diabetes, chronic musculoskeletal pain, and depression.
Built around your practice ACCESS is built to complement your care. You can refer patients to participating organizations, receive structured clinical updates at key moments, and bill a new Co-Management Payment for your coordination — all through your existing workflows.
Beneficiary Eligibility
ACCESS health care providers manage all qualifying conditions within a track. Patients may enroll in more than one track in which they have a qualifying condition. Enrollment doesn't change their other coverage.
| Track | Qualifying Conditions | Outcome Measures | Patient Cost* |
|---|---|---|---|
| eCKM** Early Cardio-Kidney-Metabolic | Hypertension, or two or more of: dyslipidemia, obesity/overweight with central obesity, prediabetes | BP, LDL-C, HbA1c, weight | Free or $6/month |
| CKM** Cardio-Kidney-Metabolic | Diabetes mellitus, chronic kidney disease (Stage 3a/3b), atherosclerotic cardiovascular disease (ASCVD) | BP, LDL-C, HbA1c, weight, uACR, eGFR | Free or $7/month |
| BH Behavioral Health | Depression, anxiety | PHQ-9, GAD-7, PGIC | Free or $3/month |
| MSK Musculoskeletal | Chronic musculoskeletal pain | PROMIS PF, PROMIS PI, PGIC | Free or $3/month |
*ACCESS organizations may uniformly waive patient cost-sharing
**Patients enroll in either eCKM or CKM (not both). CKM includes eCKM qualifying conditions, as clinically relevant.
How It Works
Connect Your Patient with an ACCESS Health Care Provider
Patients sign up directly with a participating health care provider. You can use the ACCESS Directory (launching July 2026) to find the right fit by condition and location and optionally support your patient through enrollment. ACCESS is currently available only for people with Original Medicare.
Beginning Winter 2028, CMS will publish risk-adjusted outcomes for each organization in the CMS ACCESS Directory and Data.CMS.gov so you can make informed referral choices.
Receive Care Updates
ACCESS health care providers are required to proactively share care updates with you at key points, via Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant secure electronic methods such as Direct Secure Messaging, network-supported push mechanism, or HIPAA-compliant eFax:
- Care initiation: Care plan and baseline measures
- Care escalation: Notification if clinical needs change or care is transitioned
- Care completion: Summary at the end of the care period
Clinical data will also be accessible in your EHR workflow, consistent with applicable federal privacy and security requirements. By July 2027, all ACCESS health care providers must connect to a CMS Aligned Network or Health Information Exchange, making structured patient data — including biomarkers (e.g., BP, HbA1c, LDL-C, weight), patient-reported outcome measures (e.g., PHQ-9), and medications where applicable — queryable through your existing systems.
Bill Co-Management
For care updates you review and act on, you may bill a limited number of times a year a Co-Management Payment (CMP), a Medicare payment with no beneficiary cost-sharing. Model participation is not required to bill the Co-Management Payment.
Sample Care Updates
The following samples illustrate Care Updates from an ACCESS health care provider to a PCP and referring clinician, consistent with the required template, for a patient in the Early Cardio-Kidney-Metabolic (eCKM) track and a patient enrolled in both the Behavioral Health (BH) and Musculoskeletal (MSK) tracks. All information is fictional and for illustrative purposes only.
About ACCESS Health Care Providers
Every participating ACCESS health care provider must:
- Be enrolled in Medicare as a provider or supplier;
- Designate a physician Medical Director;
- Comply with HIPAA and FDA requirements, licensure, and applicable federal and state licensure and other requirements; and
- Submit to ongoing CMS monitoring for quality, safety, or outcome standards.
Model Evaluation and Control Group
Because ACCESS’ new payment approach is being tested, a small share of people will be randomly assigned to a control group and will not be eligible to participate in the model for the 12 months. This process helps CMS evaluate the model’s impact, consistent with the Innovation Center’s authority. Individuals in a control group continue to have full access to all regular Medicare services and can work with their usual health care providers. The ACCESS health care provider will confirm the patient’s eligibility at enrollment.
If Your Patient Has Other Coverage
ACCESS is currently available only for people with Original Medicare. Some Medicare Advantage, Medicaid, and commercial plans offer programs aligned with ACCESS. If your patient is not in Original Medicare, check their plan for available options.
Fraud Awareness
Before referring patients to an organization, verify the organization’s participation in the ACCESS model by confirming their listing in the official CMS ACCESS Directory (launching July 2027). You may also see a "Find us on Medicare.gov" button on their website or materials. Clicking it should take you directly to their listing on Medicare's website.
ACCESS stands for Advancing Chronic Care with Effective, Scalable Solutions. CMS does not endorse any individual organization listed in the directory.
Page Last Modified:
06/05/2026 12:21 PM