CMS ACO models have shown potential to enhance aspects of care and reduce costs. ACO Models have resulted in lower hospitalizations and reduced emergency department visits and reduced other avoidable high-cost care for their patients. However, earlier models were not constructed for smaller, more rural, and independent practices or those that serve high-needs patients.
LEAD is designed to be more inclusive of these types of provider practices, with improved benchmarks, prospective payments, and other innovative policies that even the playing field and by extension allow for more people, including those with complex health needs, to benefit from better coordinated, accountable care. LEAD also includes design features that put more focus on preventive care to support healthier aging and gives health care providers expanded flexibility to check in with patients regularly, reach out before problems escalate, and coordinate care that happens between visits — not just during them.
LEAD incorporates key features aligned with the Innovation Center strategy to promote evidence-based prevention, support patient empowerment, and drive choice and competition.
Aims
LEAD aims to:
- Increase the scope of ACOs — to include more small, more rural, and more independent health care providers and Community Health Centers.
- Enhance evidence-based prevention and care coordination for more patients, including those with high-needs.
- Empower patients to be more actively involved in their care.
Innovation
LEAD will better support health care providers and expand participation in ACOs through:
- A 10-year pathway toward sustainable benchmarks.
- Flexible, capitated population-based payments to support team-based care and downstream value-based care arrangements.
- Integration of care for special populations, including patients with complex needs and dually eligible beneficiaries.
Additional innovations include new Benefit Enhancements and Beneficiary Engagement Incentives that create incentives for beneficiaries to seek care from providers in ACOs, including Part B cost sharing support and by 2029, a Part D premium buy down.
Design
LEAD includes key design features:
Integration of high-needs patients: Support for high-needs patients, including more accurate risk adjustment and benchmarking, will be integrated across all ACOs, creating an incentive for more providers to develop the capabilities to care for patients with complex needs. At the same time, organizations that specialize in care for complex, chronic populations will be able to care for more of their patient population under an accountable care framework.
Two voluntary risk-sharing options:
- Global Risk: Eligible to receive up to 100% of their savings and liable for up to 100% of total losses relative to their established performance benchmark.
- Professional Risk: Eligible to receive up to 50% of total savings and liable for up to 50% of total losses relative to their established performance year benchmark.
Healthy living flexibilities: Will offer participants the option of Benefit Enhancements and Beneficiary Engagement Incentives that support the delivery of coordinated, proactive, and preventive care. This includes tools for ACOs to encourage beneficiaries to seek care from high-value providers, including Part B cost sharing support and, by 2029, a Part D premium buy down.
Medicaid integration: LEAD aims to support the integration of Medicare and Medicaid services for patients receiving Medicare benefits through Original Medicare. The goal is to create incentives (where none currently exist) for Medicare and Medicaid health care providers to coordinate care and improve outcomes for dually eligible beneficiaries in Original Medicare. During an initial planning phase from March 2026 through December 2027, CMS will identify two states that are interested in partnering to develop a framework for ACO-Medicaid partnership arrangements. This framework will help define how ACOs and Medicaid organizations can work together to share data and coordinate care to improve outcomes, including preventing avoidable hospitalizations and help patients remain engaged in their communities. Pending successful completion of the planning period, ACOs in the selected states would have the opportunity to enter partnership arrangements with Medicaid organizations.
CMS Administered Risk Arrangements (CARA): The CARA initiative will provide robust CMS support to ACOs to enable episode-based risk arrangements between ACOs and their specialists and provider organizations to facilitate greater and stronger Preferred Provider relationships with these downstream health care providers. In addition, CARA will feature an episode-based falls prevention program.
Overview Materials
