SMARTMETER Cms Access Model User Guide

SMARTMETER Cms Access Model

Overview

The ACCESS Model is a CMS payment model that replaces traditional fee-for-service with Outcome-Aligned Payments (OAPs) by paying for measurable clinical results rather than visit volume or service codes. It is technology-enabled for scalable chronic care delivery.

Model Specifications

Model start date	July 5, 2026
Model duration	10 years
Application deadline	April 1, 2026
Scope	Nationwide
Geography	All 50 states + territories (voluntary)
OAP structure (high level)	Fixed recurring monthly payments tied to measurable clinical outcomes (not visit volume/service codes)
Clinical tracks (4)	Early Cardio-Kidney-Metabolic (eCKM), CKM, Musculoskeletal (MSK), Behavioral Health (BH)
Technology-first delivery (as stated)	Virtual care, remote monitoring, AI-assisted delivery, and FDA-cleared software devices explicitly permitted
Rolling applications	Through April 1, 2033
Cohort information (as stated)	Cohort 1 begins July 2026 (end date shown as June 30, 2036)
eCKM qualifying conditions	Hypertension OR 2+ of: dyslipidemia, obesity/overweight (central), prediabetes
eCKM OAP measures	BP, LDL-C, Weight/BMI, HbA1c
eCKM enrollment constraint	Stage 0 CKM (prevention focus); cannot enroll with CKM simultaneously
CKM qualifying conditions	1+ of: Diabetes mellitus, CKD Stage 3a/3b, ASCVD
CKM OAP measures	BP, LDL-C, Weight/BMI, HbA1c + eGFR & uACR (if diabetes/CKD)
MSK qualifying condition	Chronic musculoskeletal pain (3+ months)
MSK OAP measures	NRS pain, PROMIS PF+PI, site-specific PROMs (QuickDASH, KOOS, HOOS, ODI, NDI), PGIC
BH qualifying condition	1+ of: Depression (min. PHQ-9 10 for Initial Period), Anxiety (min. GAD-7 10 for Initial Period)
BH OAP measures	PHQ-9, GAD-7, PGIC. Optional: WHODAS 2.0 12-item
BH period constraint (as stated)	Single 12-month period only—no Follow-On
BH note (as stated)	No rural add-on

WHAT IS THE ACCESS MODEL

A new CMS payment model replacing fee-for-service with Outcome-Aligned Payments (OAPs) —paying for RESULTS, not visits. Explicitly designed for technology-enabled, digital health chronic care delivery

10,000+ digital health companies · $10B+ invested in 2024 · Most currently serve commercial only —ACCESS opens Medicare forthe first time

CLINICAL TRACKS & BENEFICIARY ELIGIBILITY

Beneficiary Requirements: Original Medicare Parts A & B (primary payer) · No Medicare Advantage/PACE/Hospice · Not in control group · Not already aligned for same track within 3 months

REIMBURSEMENT STRUCTURE —HOW PARTICIPANTS GET PAID

• 80/20 Split: Shown amounts are TOTAL allowed (Medicare 80% + beneficiary coinsurance 20%). Participants may waive beneficiary cost-sharing as a uniform policy
• Multi-Track Discount: 5% discount on the lower-cost track(s) when beneficiary enrolls in multiple tracks with the same Participant.
• Payment Schedule: Monthly installments = 1/12 of Medicare portion. MONTHS 1–6: 100% of monthly installments paid. MONTHS 7–12: Withheld; reconciled after 12-month care period based on outcome performance.

MAXIMUM OAP —MULTI-TRACK BENEFICIARY ENROLLMENT

Key Rule: Beneficiaries may enroll in up to 3 tracks simultaneously —eCKM OR CKM (never both) + MSK + BH. Maximum value uses CKM (highest rate) + MSK + BH in the Initial Period

INITIAL vs. FOLLOW-ON PERIOD —PAYMENT TIERS

REQUIREMENTS FOR REIMBURSEMENT

PARTICIPANT ELIGIBILITY

• Medicare Part B–enrolled organization (single TIN), PFS-eligible
• Excludes DMEPOS suppliers and laboratory suppliers
• Designate a Medicare-enrolled physician as Medical Director
• All clinicians individually Medicare-enrolled; billing rights reassigned to TIN
• Active state licensure; scope-of-practice compliance in every operating state
• Pass CMS program integrity screening and enrollment review

BILLING & CLAIMS

• Monthly claims using track-specific ACCESS G-codes
• List ALL qualifying condition ICD-10 codes at highest specificity
• Submit within 90 days of date of service
• Claims ‘zero-paid’ by MACs; Innovation Payment Contractor (IPC) issues payment
• Each claim = attestation of active care delivery & compliance
• Cannot submit FFS claims for aligned beneficiaries during care periods

DATA & REPORTING

• Submit baseline OAP Measures via FHIR API within 60 days of alignment
• Quarterly OAP Measures every 70–110 days from prior submission
• End-of-period measures within 425 days of alignment (365 + 60 grace)
• Early reporting window: 90 days early (eCKM/CKM), 180 days (BH/MSK)
• HIE connectivity required within 12 months of model start
• FHIR-based standardized API (USCDI, §170.315(g)(10))

CARE COORDINATION

• Identify beneficiary’s PCP and referring clinician at enrollment
• Electronically share standardized care updates (Direct Secure Messaging or HIE)
• Required moments: Care Initiation (10 days), Completion (30 days), Escalation (10 days)
• Use CMS-provided standardized care plan template for all updates
• Make care updates accessible to beneficiaries directly
• Beneficiary consent required before sharing information with care team

PERFORMANCE-BASED PAYMENT ADJUSTMENTS

Only ONE downward adjustment applied per semi-annual reconciliation —the LARGER of the two. Adjustments are calculated against total annual OAP, applied to the withheld 50%.

OAP PAYMENT LAYERS —BENEFICIARY LEVEL vs. PATIENT PANEL LEVEL
The ACCESS payment system operates on two distinct layers —monthly payments are calculated at the individual beneficiary + track level; performance adjustments are calculated across the full participant panel, blending all tracks together

PAYMENT CALCULATION EXAMPLES

OAP MEASURE TARGETS —KEY CLINICAL THRESHOLDS

EXCEPTIONS, NUANCES & CRITICAL EDGE CASES

White-Coat Hypertension (eCKM Only)
May align based on patient-attested HTN diagnosis. If follow-up home/ambulatory readings confirm NO hypertension and no other qualifying conditions → beneficiary disenrolled. Retain up to 2 months payments IF non-qualifying readings submitted to CMS. OtherwiseALL payments recouped. Applies ONLY to eCKM/HTN —not other tracks or conditions

FFS Exclusion —No Dual Billing
ACCESS Participants AND affiliated entities (5%+ ownership, operational control, or reassignment relationships) CANNOT submit Medicare FFS claims for aligned beneficiaries during care periods. CMS systems auto-suppress FFS billing. Does NOT restrict beneficiary access —only affects payment routing.

eCKM CKM Cannot Overlap
Beneficiaries cannot be enrolled in BOTH eCKM and CKM simultaneously (CKM encompasses all eCKM measures and care). If already in eCKM and later qualifies for CKM, beneficiary may switch immediately —the normal 3-month lock-in does NOT apply to this specific track switch.

Randomized Evaluation / Control Group
Beneficiary-level randomization at 90:10 (intervention:control). Control group beneficiaries are ineligible for 12 months. Participants MUST inform beneficiaries about possible control assignment before querying the eligibility API. CMS provides exact standardizedlanguage —use it verbatim.

MSK —Single Period, No Follow-On
MSK is one 12-month period only —no Follow-On Period. No rural device add-on. No ‘control’ target —only minimum improvement is measured. After 90 days, beneficiaries may switch or disenroll freely. No additional periods offered by same Participant.

BH Baseline Scores & Period Eligibility
BH beneficiaries with PHQ-9 <10 AND GAD-7 <10 at baseline are NOT eligible for the Initial Period on that basis alone. They may enroll directly in Follow-On Period only with a provider referral AND documented diagnosis history within the past 18 months.

REQUIRED CLINICAL EXCLUSIONS —WHO CANNOT ENROLL

MANDATORY: These exclusions cannot be waived. Participants may propose additional exclusions for their service model but cannot exclude an entire condition from a track.

SUBSTITUTE SPEND LISTS —CODES THAT TRIGGER THE SSA

Only triggered if billed by ANOTHER Medicare provider during the beneficiary’s ACCESS care period AND the claim’s principal diagnosis matches the beneficiary’s ACCESS qualifying condition.

eCKM / CKM Track —Substitute Spend List

• Ambulatory Blood Pressure Monitoring (93784, 93786, 93788, 93790)
• Ambulatory Continuous Glucose Monitoring (95249–95251)
• RPM / SMBP Device Set-up (99453, 99473) ←
• Diabetes Self-Management Training —DSMT (G0108)
• Intensive Behavioral Therapy —Cardiovascular (G0446), Obesity (G0447)
• Medical Nutrition Therapy —Initial Visit (97802)
• RTM Patient Education / Device Set-up (98975)
• Medicare Diabetes Prevention Program —MDPP (G9880, G9881, G9886, G9887)

MSK Track

• PT Evaluation (97161–97163)
• OT Evaluation (97165–97167)
• RTM Patient Ed./Device Set-up (98975)

BH Track

• DHMT Digital Device + Treatment (G0552, G0553)
• Psychiatric Diagnostic Eval (90791, 90792)
• RTM Patient Ed./Device Set-up (98975)
• Initial Psych Collaborative Care Mgmt (99492)

RPM —SSA IMPACT & OPPORTUNITY
RPM device set-up codes (99453, 99473) are on the eCKM/CKM Substitute Spend List. This means if another provider bills RPM device set-up for the same condition during an ACCESS care period, it counts AGAINST the Participant’s SSR —potentially triggering a payment reduction.

CO-MANAGEMENT PAYMENT —PARTNERING WITH PCPs SMARTMETER | CMS ACCESS Model Training | Confidential

PCPs and referring clinicians earn a new Co-Management Payment for reviewing ACCESS clinical updates —billed separately from OAP by the clinician, not the ACCESS Participant.

BENEFITS —FOR ACCESS PARTICIPANTS (PROVIDERS) SMART METER

BENEFITS —FOR MEDICARE BENEFICIARIES

KEY DATES & SMART METER NEXT STEPS

URGENT: Cohort 1 application deadline is April 1, 2026. Target partner organizations should be applying NOW —or already in the process.

ACCESS MODEL —QUICK REFERENCE CHEAT SHEET

Source: CMS ACCESS Model RFA v1.1 (Feb 12, 2026) + Payment Amounts & Performance Targets (Effective July 5, 2026 –December 31, 2027) | Internal use only