ACCESS, or Advancing Chronic Care with Effective, Scalable Solutions, Model

What It Is: The Centers for Medicare & Medicaid Services ACCESS Model is a voluntary, technology-enabled chronic care management model of the Center for Medicare and Medicaid Innovation that begins in July 2026 and will accept rolling applications through April 2033. The model is designed to support patients with multiple chronic conditions through condition-specific care tracks and emphasizes remote, digital, and hybrid care delivery approaches. Unlike traditional fee-for-service payment models that reward visit volume, ACCESS participants are paid based on patient outcomes, creating incentives to improve quality of care and health outcomes. ACCESS provides payment for services not traditionally paid for by Medicare.

Eligible Entities:

ACCESS Participants

• Medicare Part B-enrolled providers and suppliers who provide the digital health tool and technology-supported care
• Organizations must have a physician medical director.

Referring Providers and Co-Managers

• Physicians, physical therapists in private practice, and other Medicare Part B providers
• Responsible for reviewing ACCESS care updates and performing related care coordination activities for patients enrolled in an ACCESS track

Population Focus:

Four condition-specific tracks:

• Cardio-kidney-metabolic
• Early cardio-kidney-metabolic
• MSK: chronic musculoskeletal pain
• Behavioral health

Care Delivery:

• Beneficiaries are assigned a single track or multiple tracks based on the four tracks above.
• Care may include digital programs and monitoring, remote check-ins, and care coordination.

Payment Structure:

• Outcome-Aligned Payments:
  • Fixed annual payments that go to ACCESS participants (PTs are not eligible for payment) and are tied to improving patient outcomes
• Co-Management Payments:
  • Based on reviewing patient data, providing care updates, and adding documentation to the electronic health record (PTs are eligible for payment)
  • ~$30 per service (every 4 months) plus ~$10 additional for onboarding support = up to ~$100 per beneficiary per year.

Strategic Physical Therapist Opportunity:

• Identify appropriate patients and refer to an ACCESS participant organization for technology-supported care management.
• PTs can act as key members of the interdisciplinary care team, receiving updates on patient progress and incorporating those insights into rehabilitation plans.
• MSK triage and care management: Help determine who is appropriate for ACCESS versus who requires skilled physical therapy.
• Billing opportunity: Provide co-management services and receive co-management payments when partnering with ACCESS participants.
• ACCESS can be used as a maintenance or transitional program postdischarge from skilled physical therapy treatment.
• No active physical therapy plan of care required.

AHEAD, or Achieving Healthcare Efficiency through Accountable Design, Model

What It Is:  The AHEAD Model is a voluntary, state-based total cost of care initiative from the Center for Medicare and Medicaid Innovation that is designed to drive healthcare transformation at the state and regional levels through multipayer alignment. The model aims to improve population health outcomes while slowing healthcare cost growth by encouraging coordinated, accountable care across participating states. It began in January 2026 and will run through December 2035 and is being implemented in phases. Maryland launched as the first cohort in January 2026. Connecticut, Hawaii, and Vermont are scheduled to join in January 2028 as Cohort 2, while Rhode Island and New York will participate as Cohort 3, also beginning in January 2028. The Centers for Medicare & Medicaid Services has also indicated that an additional one to two states may be selected to join the model, with performance periods beginning in 2028 and/or 2029.

Eligible Entities:

• States
• Primary care practices
• Hospitals
• Geo entities

Population Focus:

• All residents in the participating states; specifically targeting underserved communities and those with complex chronic conditions

Payment Structure:

• Hospital Global Budgets:
• Predictable revenue, global budget savings opportunity, rewards population health management, and requires Medicaid alignment
• Enhanced Primary Care Payments:
• Enhanced and advanced payment pathways; invests in upstream prevention, specialty care, and behavioral health integration; and requires Medicaid alignment
• GEO AHEAD:
• Geographic Accountable Care Organization; shared savings opportunity; enhances care management and care coordination; and optional Medicaid alignment

Strategic Physical Therapist Opportunity:

• Statewide falls and frailty prevention — PTs can be a valuable partner and improve safety for the frail population and in turn help states reduce their total cost of care. There are opportunities to advocate for PT-led falls prevention and community mobility programs to be included in states' Population Health Accountability Plans.
• Support for value-based primary care and population health — Since AHEAD stresses prevention, care coordination, and chronic condition management, PT's are well-positioned to provide interventions that can improve outcomes and reduce costly healthcare utilization.

ASM, or Ambulatory Specialty Model

What It is: The mandatory Ambulatory Specialty Model, first introduced under the 2026 Proposed Physician Fee Schedule and revised in the 2027 PFS, focuses on specialists who frequently treat Original Medicare beneficiaries with low back pain or heart failure. Under the model, selected providers will be assessed on performance measures across quality, cost, improvement activities, and promoting interoperability, using an approach similar to the Merit-based Incentive Payment System Value Pathways framework, or MIPS MVP. In addition to these performance measures, participants will be accountable for financial outcomes through a risk-based payment arrangement, with opportunities for shared savings as well as the risk of potential financial losses based on their performance relative to peers. The model is scheduled to begin on Jan. 1, 2027, and will operate for five performance years through Dec. 31, 2031.

Eligible Entities:

• Initially, participation will be limited to specialists practicing in approximately one-quarter of core-based statistical areas and metropolitan divisions who treat either heart failure or low back pain.
• Eligible providers must have historically treated at least 20 heart failure or low back episodes annually, as identified by the episode-based cost measure methodology.
• Specialists included:
  • Heart failure cohort
    • Cardiology physicians
  • Low back pain cohort
    • Anesthesiology, pain management, interventional pain management, neurosurgery, orthopedic surgery, or physical medicine and rehabilitation

Population Focus:

• Original Medicare beneficiaries with heart failure or low back pain.

Payment Structure:

• The model incorporates elements of the MIPS MVP framework along with a two-sided financial risk arrangement.
• Based on performance relative to peers, participant providers may receive positive or negative payment adjustments to future Medicare Part B claims for covered services.

Strategic Physical Therapist Opportunity:

• Physical therapists are well positioned to support the goals of ASM by delivering high-value, evidence-based care that can improve functional outcomes, reduce avoidable hospitalizations, and potentially decrease the need for more costly interventions, including surgery.
• Demonstrating the value of physical therapy in managing low back pain and supporting individuals with heart failure may create opportunities for stronger care integration and collaboration with participating specialists.

CJR-X, or Comprehensive Care for Joint Replacement Expanded, Model

What It Is: CJR-X is an expansion of the Comprehensive Care for Joint Replacement, or CJR, model finalized in the 2027 Hospital Inpatient Prospective Payment Systems Rule that aims to improve care for Original Medicare patients undergoing hip, knee, and ankle replacements performed in both inpatient and outpatient settings. Participating hospitals will be responsible for ensuring patients receive high-quality, coordinated, affordable care from the time of their procedure through the first 90 days of recovery. If adopted, it will be mandatory nationwide and begin on Jan. 1, 2028.

Eligible Entities:

• Most hospitals paid under the Inpatient Prospective Payment System would be required to participate in CJR-X.

Population Focus:

• Original Medicare patients undergoing lower extremity joint replacement procedures (hip, knee, and ankle replacements)

Payment Structure:

• CJR-X uses an episode-based payment model in which acute care hospitals participating in the model are assessed against a target price that assumes all costs associated with the LEJR episode of care, beginning with the procedure and ending 90 days following discharge from the procedure.
• It includes all related items and services paid under Medicare Part A and Part B for eligible CJR-X patients, with few exceptions.
• This model incentivizes hospitals to avoid expensive and harmful events that increase episode spending and reduce the opportunity for reconciliation payments.

Strategic Physical Therapist Opportunity:

• PTs will play a vital role in helping hospitals achieve quality and cost goals by improving patient function, promoting safety, and preventing postsurgical complications through evidence-based physical therapist interventions.
• Effective physical therapy management can contribute to better patient outcomes to help hospitals succeed under the CJR-X model.
• Hospital-based physical therapists will play an important role in early mobility and discharge planning.
• Community-based physical therapists will play an important role in promoting safe, independent mobility, risk management, pain management, and restoration of normal movement patterns.

GUIDE, or Guiding an Improved Dementia Experience, Model

What It Is: GUIDE is a voluntary, nationwide Center for Medicare and Medicaid Innovation model testing the impact of comprehensive services and supports for people with dementia and their caregivers. The evidence-based services being tested include: care navigation, 24/7 access to a support line, caregiver training and education, respite services, and connections to community resources. The model began on July 1, 2024, and will run for eight years.

Eligible Entities:

• Medicare Part B-enrolled providers and suppliers who establish programs to provide ongoing longitudinal care and support to people with dementia through interdisciplinary teams
  • Two tracks:
    • Established program track – Prior experience serving individuals with dementia and implementing most GUIDE care delivery requirements. Began delivering GUIDE services on July 1, 2024.
    • New program track – Completed a pre-implementation year to establish programs. Began delivering GUIDE services on July 1, 2025.

Population Focus:

• Community-dwelling Original Medicare beneficiaries living with dementia

Payment Structure:

• Monthly Dementia Care Management Payments:
  • Monthly tiered per-patient payments to support a collaborative care approach based on patient complexity and caregiver burden
  • Payments adjusted as a result of participant performance across quality measures
• Respite Services Payments:
  • Up to $2,500 annually per eligible patient for services that temporarily relieve qualifying caregivers of their caregiving responsibilities

Strategic Physical Therapist Opportunity:

• Physical therapists can support GUIDE participants by supporting beneficiaries in maintaining mobility, function, balance, and independence for as long as possible.
• Physical therapists can serve as interdisciplinary care team members by identifying changes in functional status, supporting caregiver education, and coordinating with other clinicians to optimize patient outcomes.
• Evidence-based physical therapist services may reduce falls risk, prevent functional decline, and help patients remain safely in their homes and communities, which aligns closely with GUIDE's goals.

LEAD, or Long-Term Enhanced ACO Design, Model

What It Is: Following the conclusion of the ACO Reach Model, LEAD is a voluntary Center for Medicare and Medicaid Innovation accountable care organization model that will run from Jan. 1, 2027, through Dec. 31, 2036. LEAD uses improved benchmarking to appeal to a broader mix of healthcare providers, including smaller, independent, or rural-based practices with a focus on preventive care.

Eligible Entities:

• Current ACO participants, as well as those organizations new to ACOs

Population Focus:

• Traditional Medicare beneficiaries, particularly high-needs populations and those with complex chronic conditions

Payment Structure:

• LEAD will provide ACOs with monthly prospective payments to support enhanced care investments and greater flexibility to deliver patient-centered care.
• There is also an opportunity for increased payments based on risk-sharing options:
  • Global risk: Eligible entities will receive up to 100% of their savings and will be 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 will be liable for up to 50% of total losses relative to their established performance year benchmark

Strategic Physical Therapist Opportunity:

• CMS-Administered Risk Arrangements, aka CARA, a component of the LEAD Model, will feature an episode-based falls prevention program and support episode-based risk arrangements between ACOs and specialists.
  • Physical therapists' expertise in falls prevention creates opportunities to participate in these arrangements and demonstrate PTs' value in improving outcomes and reducing avoidable utilization.
• More broadly, physical therapists can support LEAD's goals through chronic condition management, care coordination, and partnerships with participating ACOs.
• Physical therapists should engage with ACOs in their respective geography to pursue partnership or collaborative opportunities.

MAHA ELEVATE, or Make America Healthy Again: Enhancing Lifestyle and Evaluating Value-based Approaches through Evidence, Model

What It Is: The Center for Medicare and Medicaid Innovation MAHA ELEVATE is a voluntary model that will evaluate up to 30 evidence-based proposals with proven success to determine which may best support conventional care and suit the health promotion and disease prevention needs of people with Original Medicare. Interventions tested in MAHA ELEVATE will inform future Original Medicare coverage determinations or potential future Centers for Medicare & Medicaid Services Innovation Center models designed to improve the health of beneficiaries and cut healthcare costs.

Eligible Entities:

• To be selected, applicants must demonstrate that they — or their partners — are experienced in delivering these interventions and that the interventions are safe and effective for the target population and supported by peer-reviewed literature. Additionally, they must demonstrate experience with data collection or the ability to accurately collect and report data in a timely manner, with appropriate beneficiary safeguards. Eligible applicants include the following:
  • Private medical practices
  • Health systems and accountable care organizations
  • Academic organizations
  • Functional, lifestyle, preventive, and integrative medicine centers
  • Federally Qualified Health Centers and Rural Health Clinics
  • Community-based organizations
  • State or local governments
  • Indian Health Service/Tribal Services/Urban Indian Programs
  • Senior living communities

Population Focus:

• Original Medicare beneficiaries, particularly older adults at risk for chronic disease

Payment Structure:

• The model will provide approximately $100 million to fund three-year cooperative agreements for up to 30 proposals that promote health and prevention for Original Medicare beneficiaries.

Strategic Physical Therapist Opportunity:

• Highlighting the role of physical therapy in MAHA ELEVATE participating organizations in chronic disease management.

TEAM, or Transforming Episode Accountability, Model

What It Is: This mandatory Center for Medicare and Medicaid Innovation episode-based payment model requires selected acute care hospitals to coordinate and manage care for Original Medicare beneficiaries undergoing one of five surgical procedures: lower extremity joint replacement, surgical treatment of hip and femur fractures, spinal fusion, coronary artery bypass graft, and major bowel procedures. Participating hospitals are held accountable for the quality and cost of care delivered throughout the surgical episode, beginning with the hospitalization and extending through 30 days after discharge. The model is intended to encourage care coordination, improve patient outcomes, and reduce unnecessary spending across the episode of care. The program began on Jan. 1, 2026, and will run through Dec. 31, 2030.

Eligible Entities:

• Hospitals paid under the Inpatient Prospective Payment System and located in selected Core-Based Statistical Areas are required to participate in TEAM.

Population Focus:

• Original Medicare beneficiaries undergoing one of five surgical procedures listed above

Payment Structure:

• TEAM uses an episode-based payment approach in which participating acute care hospitals are held accountable for all costs associated with an episode of care, beginning with the inpatient stay or outpatient procedure and extending through 30 days following hospital discharge.
• TEAM participants receive target prices for included episodes each year based on all Medicare Parts A & B items and services in each episode.
• Performance is evaluated by comparing actual Medicare fee-for-service spending during an episode to the target price, as well as assessing performance on established quality measures.
• When total Medicare spending for an episode is below the target price, TEAM participants may earn reconciliation payments from the Centers for Medicare & Medicaid Services, adjusted based on quality performance.

Strategic Physical Therapist Opportunity:

• Evidence-based physical therapy services can reduce the risk of complications, emergency department visits, hospital readmissions, and potentially avoidable procedures, helping to lower overall episode spending.
• Improved patient outcomes and reduced episode costs may enhance hospital performance under TEAM and increase opportunities for favorable reconciliation payments from CMS.
• Community-based physical therapy providers should be aware of the TEAM participants in their area and seek opportunities for partnership and collaboration by demonstrating potential for improved outcomes across the episode.