This month sees the start of a new Centers for Medicare & Medicaid Services (CMS) care model that will test expanded provision of digital health tools to help manage prevalent chronic conditions for patients with traditional Medicare coverage.
Nearly <a href="https://www.cms.gov/priorities/innovation/access-model-accepted-applicants” rel=”nofollow noopener” target=”_blank”>200 organizations are participating in the CMS Innovation Center’s Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model. They will provide technology-based services to Medicare patients with hypertension, prediabetes, chronic kidney disease, musculoskeletal pain, depression or other chronic conditions. Some of the names involved include Alyka Health, Headspace, Liza Health, Noom, Weight Watchers and Withings.
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“ACCESS is an important step toward bringing new, effective digital health tools into everyday care for Medicare patients. We applaud CMS and, in particular, Director Abe Sutton’s team at the Center for Medicare and Medicaid Innovation, for this new approach,” AMA CEO John Whyte, MD, MPH, said in a statement when the model was introduced last year
In an interview with Dr. Whyte for an episode of the “AMA Moving Medicine” video podcast posted in December, Sutton said that “ACCESS is all about advancing chronic care with effective, scalable solutions.”
ACCESS organizations will get modest monthly payments linked to improvements in specific patient health outcomes for these chronic conditions. Although each organization must have a physician clinical director, the only Medicare payments they can submit claims for are the ACCESS-specific monthly payments. They cannot submit claims for any individual services like visits, tests, or procedures to Medicare, as these will still be provided by patients’ regular physicians
Participating organizations also must comply with HIPAA and Food and Drug Administration requirements, as well as applicable federal and state licensure and other requirements. They also will submit to ongoing CMS monitoring for quality, safety and outcome standards. Risk-adjusted outcomes for each organization will be published starting in the winter of 2028
In response to physician questions submitted by the AMA and others, CMS has developed a dedicated webpage specifically for doctors who have questions about ACCESS and whose patients may enroll with an ACCESS participating organization.
Here are CMS’ answers to some key questions relevant to referring and primary care physicians
Do I need to apply or enroll in the model to refer patients?
No. If you are an eligible Medicare Part B-enrolled physician, you can refer patients and bill co-management payments
What is the co-management payment?
The co-management payment is a Medicare payment for eligible physicians who review a documented ACCESS care update and perform at least one related care-coordination activity such as a medication adjustment, problem-list update or referral. There is no beneficiary cost-sharing
How much is the co-management payment?
The standard co-management payment is $30 per service, subject to geographic adjustment. If you help a patient with onboarding and initial setup, you can also bill a one-time $10 add-on modifier the first time you bill for that patient and track
How often can I bill the co-management payment?
You can bill up to three times per 12-month care period, per patient, per ACCESS track. If a patient is enrolled in multiple tracks and you perform distinct coordination activities for each, you may bill separately for each
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Do I need to bill differently from my usual Medicare claims?
The co-management payment uses new HCPCS G-codes that align with the different tracks within ACCESS: G0676 for hypertension, type 2 diabetes, chronic kidney disease and more; G0677 for chronic musculoskeletal pain; G0678 for behavioral health. Otherwise, standard Medicare billing rules apply. Your existing Medicare billing for other services is unaffected
How will I coordinate care with ACCESS health care providers?
Participating ACCESS organizations are required to send you structured care updates at key points:
- At care initiation, including care plan and baseline measures.
- If there is a clinical escalation.
- At the end of each care period.
These care updates are delivered via HIPAA-compliant electronic methods, such as Direct Secure Messaging, network-supported push mechanisms or HIPAA-compliant electronic fax. By July 2027, all participating ACCESS organizations will be required to connect to a CMS Aligned Network, Health Information Exchange, or similar trusted network. This means clinical and medication data—including blood pressure, HbA1c, LDL-C, weight, patient-reported outcome measures, and medications, where applicable—should be queryable through your existing EHR workflows.
Does referring a patient to ACCESS change my relationship with them?
No. Your patient can continue to see you and any other physician or health professional who accepts Medicare. Participating ACCESS organizations provide supplemental chronic care support. They do not replace your role as the patient’s primary physician
Which of my patients are eligible for ACCESS?
Patients with original Medicare who have one or more qualifying conditions may be eligible. Eligibility is confirmed by the ACCESS participant at enrollment. CMS says that about seven in 10 Medicare beneficiaries qualify for at least one track
The CMS webpage includes further details on billing, outcome measures and targets, qualifying ICD-10 diagnoses and more
Visit AMA Advocacy in Action to find out what’s at stake in reforming Medicare payment and other advocacy priorities the AMA is actively working on
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