What primary care physicians need to know about Medicare’s new ACCESS payment model

Medicare’s new ACCESS payment model, which will combine primary care and specialty care with technology to manage patient chronic conditions, is a month out from its official start on July 5.

ACCESS is short for Advancing Chronic Care with Effective, Scalable Solutions. It is a 10-year voluntary model to help patients manage high blood pressure, diabetes, chronic musculoskeletal pain, and depression. Those conditions affect more than two-thirds of Medicare beneficiaries.

What’s more, patients using original Medicare have limited access to technology-supported care for those chronic conditions due to Medicare payment barriers to services delivered continuously, remotely and often outside a traditional office visit. On June 4, the Centers for Medicare & Medicaid Services’ Innovation Center hosted an online webinar with three of the program planners describing how potential solutions could work.

Goals, tracks and connections

“CMS is testing a new outcome-aligned payment, or OAP, option that prioritizes results over activity volume,” said Puja Nair, ACCESS Model co-lead. “ACCESS strives to give technology-enabled care providers and organizations more flexibility to use innovative technology-supported delivery models that improve patient health and complement traditional care processes.”

CMS has built the model around four goals, she said.

• Expand patient access to technology-supported care options that original Medicare's fee-for-service structure has historically not covered.
• Promote coordinated, clinician-guided care by creating viable reimbursement for organizations that currently have no clear payment path under original Medicare, rewarding outcomes rather than the volume of services rendered.
• Drive competition by requiring CMS to maintain a publicly available directory on medicare.gov listing all participating organizations, the tracks they operate in, the conditions they treat and, once available, their risk-adjusted outcomes. This allows patients and referring physicians to make informed choices.
• Protect federal taxpayers by tying full payment to measurable clinical results, such as lowering blood pressure, reducing hemoglobin A_1c or achieving meaningful improvement in chronic pain or depression symptoms.

The model is organized into four clinical tracks:

• Early cardio-kidney-metabolic (eCKM) track focuses on prevention, targeting patients with hypertension or two or more early-stage risk factors including dyslipidemia, obesity or overweight with central obesity, and pre-diabetes.
• Cardio-kidney-metabolic (CKM) track addresses more advanced cases involving diabetes, chronic kidney disease and cardiovascular disease.
• The musculoskeletal (MSK) track covers chronic musculoskeletal pain.
• The behavioral health track addresses depression and anxiety.

Participating organizations are responsible for managing all qualifying conditions a patient has within a given track.

Primary care physicians and referring clinicians play a central but voluntary role. They do not need to apply or enroll in ACCESS to participate; rather, their role exists within their normal clinical workflow. They can refer patients to ACCESS participants, incorporate ACCESS-supported services into a patient's broader care plan, and receive structured updates at three key points: the start of care, the occurrence of a clinical escalation (meaning a patient is being transitioned out of the model), and care completion. These updates are transmitted through Health Insurance Portability and Accountability Act (HIPAA)-compliant methods including direct secure messaging and electronic fax.

ACCESS participants are also required to connect to a health information exchange (HIE) or a CMS-aligned equivalent network no later than July 2027, enabling primary care physicians to query patient data including biomarkers, patient-reported outcome measures and medication information directly within their existing workflows.

Primary care physicians and referring clinicians who review care updates and document accordingly can bill what the model calls a co-management payment (CMP), specifically for care coordination activities.

A hypothetical patient scenario offered during the webinar illustrated the model in practice: a Medicare beneficiary with low back pain and moderate depression works with a primary care physician uses the ACCESS participant directory to identify an organization providing services across both the MSK and behavioral health tracks. The PCP coordinates enrollment, receives a care plan and patient data through the HIE, and then bills the co-management payment.

Beneficiaries may enroll at any point during the model's duration.

Keeping primary care physicians in the loop of patient care

One of the central premises of the ACCESS model is that primary care physicians will not be cut out of their patients' care when those patients enroll with an ACCESS participant, said Anna Rabil, ACCESS Model Quality Lead for the CMS Innovation Center.

The model is designed to keep the primary care physician, or PCP, as the central coordinator while ACCESS participants take on day-to-day management of qualifying chronic conditions. The model establishes specific rules governing how and when clinical information must flow back to the PCP.

ACCESS participants are required to establish connectivity to a health information exchange, or HIE, a CMS-aligned network or an equivalent trusted network. This infrastructure enables transparent, ongoing sharing of clinical data with PCPs and referring clinicians, reducing the fragmentation that has long plagued chronic disease management across multiple providers.

Before any information is shared, however, ACCESS participants must first obtain the patient's consent to proactively send care updates to their identified PCP and referring clinicians. Clinicians may also establish additional data-sharing arrangements with ACCESS participants to support more robust coordination, provided those arrangements comply with applicable federal law, including the Anti-Kickback Statute, which prohibits financial arrangements that could improperly influence medical referrals.

At minimum, ACCESS participants are required to share care updates with PCPs and referring clinicians at three defined points in the care timeline:

• The first update must be sent within 10 days of submitting all baseline OAP measures, which are the initial clinical data points used to track a patient's progress. This update includes the care plan, baseline measures, the contact responsible for the patient's care and the initial treatment goals.
• The second update must be delivered within 30 days after the end of the 12-month care period, or sooner if the patient is no longer aligned with the ACCESS participant. This summary covers outcomes achieved, current medications and any follow-up recommendations.
• The third required update must be shared within 10 days of any transition of the patient to another practitioner or care setting because clinical needs have exceeded what the ACCESS model is designed to provide.

CMS emphasized that these represent the floor, not the ceiling, of communication. PCPs and referring clinicians are encouraged to negotiate more frequent updates with ACCESS participants, and participants are expected to go beyond the minimum where clinically appropriate. Importantly, PCPs can bill a specific ACCESS billing code for reviewing these required care updates, in addition to other reimbursable care coordination activities discussed elsewhere in the model.

The care plan itself must follow a standardized template. Required elements include patient identifying information such as name and date of birth, the ACCESS participant's contact details, the name of the medical director overseeing the patient's care, the clinical track or tracks the patient is enrolled in, qualifying conditions, care start date and applicable OAP measure values. The template also requires documentation of the patient's current medications and symptoms, the participant's treatment plan, including any lifestyle interventions or symptom management strategies along with a timeline for collecting the next round of clinical data. The template additionally includes guidance for PCPs on billing the co-management payment, or CMP, and general information about the model.

All care updates must be transmitted through HIPAA-compliant secure electronic method, such as direct secure messaging or electronic fax.

The new $30 CMP for coordinating physicians

Primary care physicians and other eligible clinicians who actively coordinate care with ACCESS participants on behalf of enrolled patients will be able to bill a new reimbursement code specifically created for the model, beginning with the model launch on July 5, said Colman Adams, ACCESS Model payment lead in the CMS Innovation Center.

To bill the CMP, an eligible clinician must review a care update electronically shared by an ACCESS participant and complete at least one related care coordination activity. That activity can include adjusting or reconciling a patient's medications, updating the problem list, modifying follow-up instructions, coordinating care among other involved clinicians, communicating with the ACCESS provider, documenting clinical agreement or disagreement with ACCESS recommendations, or making a referral. The minimum time threshold is five minutes of clinician time spent on the review and associated activity.

Eligible Medicare Part B clinicians include physicians and physician assistants, among other provider types. Beginning in October 2026, federally qualified health centers (FQHCs) and rural health clinics (RHCs) will also be eligible to bill through Medicare Part A, while pharmacies and medical supply companies with pharmacists on staff will be eligible to bill through Medicare Part B.

The CMP pays $30 per service, subject to geographic adjustments based on the Medicare physician fee schedule geographic adjustment factor, meaning actual payments will vary by location. The payment is available up to three times per 12-month care period per beneficiary per ACCESS clinical track. If a patient is enrolled in more than one track, clinicians may bill CMPs for each track, provided that distinct review and care coordination activities were performed for each. Critically, beneficiary cost sharing does not apply to the CMP; CMS will pay 100% of the Medicare allowed amount.

Clinicians who assist a patient with onboarding and initial setup may also bill an additional $10 payment the first time they submit a CMP claim for that beneficiary, using a CMS-specified modifier. Qualifying onboarding activities include helping the patient identify an appropriate ACCESS participant, supporting enrollment, educating the patient about the ACCESS provider's role, assisting with device or application setup and confirming that data transmission has been successfully initiated. The onboarding payment may be billed for each beneficiary-and-track combination, provided that actual onboarding support was rendered.

Accurate documentation is essential. Each CMP claim must be supported by records showing the clinician reviewed the care update electronically shared by the ACCESS participant. The date of service on the claim must match the date of the documented review and care coordination activity. The place of service code must reflect the reviewing clinician's practice setting, including telehealth settings where applicable. The diagnosis code must correspond to a qualifying condition within the beneficiary's specific ACCESS track. Claims submitted with an incorrect track diagnosis code will be denied. CMS directs clinicians to Section 3.0.2.4 of the ACCESS implementation guide for a list of track-specific diagnosis codes.

The rendering clinician listed on the claim must be the Medicare-enrolled professional who performed the documented review, identified by their national provider identifier. The billing provider field must report both the practice's tax identification number and the clinician's NPI. The referring provider field is optional on CMP claims.

Eligible clinicians may continue billing all standard, non-ACCESS services as they normally would — participation in the co-management payment does not restrict other billing activity.