Medicare

Medicare

CMS ACCESS Model: A New On-Ramp to Outcomes-Based, Tech-Enabled Care in Traditional Medicare

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The Centers for Medicare & Medicaid Services (CMS) Innovation Center recently published applications for its new ACCESS Model (Advancing Chronic Care with Effective, Scalable Solutions), a 10-year voluntary initiative beginning July 2026. The model is designed to advance outcomes-based, technology-enabled care delivery in Original Medicare and aligns with the Innovation Center’s priorities of strengthening prevention, empowering beneficiaries, and promoting performance-based competition. ACCESS is particularly suited to organizations with mature clinical operations and data infrastructure, offering a new pathway for tech-supported services. 

This article summarizes the model’s design, highlights key considerations for prospective applicants, and addresses common questions our Medicare and technology experts fielded during a recent Health Management Associates (HMA)/Leavitt Partners webinar. 

What the ACCESS Model Is Testing 

ACCESS evaluates whether Outcome-Aligned Payments (OAPs)—recurring payments contingent on measurable clinical improvement—can reduce spending while maintaining or improving quality for beneficiaries with chronic conditions. The model tests whether incentivizing technology supported care can produce reliable clinical outcomes while complementing traditional care delivery. 

Who may participate? Organizations must be Medicare Part B–enrolled providers or suppliers (excluding DMEPOS [Durable Medical Equipment, Prosthetics, Orthotics, and Supplies] and labs). Participants may enroll beneficiaries directly, operate across multiple clinical tracks, and manage all qualifying conditions within each selected track. Beneficiary participation is voluntary, and individuals may switch ACCESS participants every 90 days. 

Clinical tracks. At launch, the four clinical tracks reflect high-prevalence chronic conditions with established care pathways and strong evidence for technology-supported interventions: 

  • Early Cardio-Kidney-Metabolic (eCKM) 
  • Cardio-Kidney-Metabolic (CKM) 
  • Musculoskeletal (MSK) 
  • Behavioral Health (BH) 

Payment. OAPs vary by track and performance period. CMS pays a portion prospectively each quarter and withholds 50 percent pending reconciliation based on: 

  • Clinical outcomes attainment: The percentage of aligned beneficiaries who complete the 12‑month performance period and achieve track‑specific clinical targets relative to their baseline. 
  • Substitute‑spend test: Ensures beneficiaries do not receive duplicative fee-for-service (FFS) services for conditions managed under ACCESS. 

Technology and data exchange. ACCESS takes a tech-forward approach. Key expectations include use of Fast Healthcare Interoperability Resources (FHIR®) based Application Programming Interfaces (APIs) for eligibility, consent, claims sharing, and care coordination—part of the broader federal push to modernize the health data ecosystem. CMS also plans to publish a public directory that lists participants, tracks, cost-sharing policies, and risk-adjusted outcomes to enable consumer and clinician choice. 

Regulatory coordination. To complement ACCESS and expand the pipeline of technology-supported interventions, the US Food and Drug Administration’s (FDA) TEMPO (Technology-Enabled Meaningful Patient Outcomes) pilot allows selected US-based digital health device manufacturers to participate while generating real-world evidence. Up to 40 device manufacturers may participate across clinical areas. 

This coordinated CMSFDA effort is intended to reduce barriers to innovation and accelerate access to safe, effective digital tools that can support chronic disease management. 

Key Considerations for Applicants 

Program integrity and fraud/abuse. CMS has emphasized program integrity across Medicare and Medicaid, and ACCESS reflects that emphasis. Applicants and their parent organizations should expect rigorous screening. Participants must also operationalize controls to pass the substitute spend test and maintain auditable evidence of outcomes and beneficiary consent. 

Overlap with Accountable Care Organizations (ACOs) and other models. Patients may participate in ACCESS and be aligned with an ACO simultaneously; however, “participant overlap” raises important operational and financial issues. ACCESS includes an FFS exclusion policy that prohibits participants or affiliated entities from billing Medicare FFS for any services delivered to the same beneficiaries for the duration of their ACCESS episode. As a result, traditional providers, ACO-aligned clinicians, and integrated delivery systems must assess whether they can segment patient populations or if partnering is more feasible. 

Eligibility and clinical scope. ACCESS is focused on relatively stable, chronically ill beneficiaries and excludes those with more acute/severe conditions. Participants must accept responsibility for all qualifying conditions a beneficiary has within a track. 

Outcomes performance. The ACCESS Model places substantial emphasis on clinical performance and care coordination. Participants are paid in full only if enough patients hit outcomes targets. Early cohorts will likely skew toward organizations with mature clinical protocols, robust engagement models, and demonstrated outcomes. Applicants should be financially prepared to tolerate withholds, beneficiary switching, and follow-on period payment reductions after year one. 

Digital infrastructure and interoperability. ACCESS presumes API-driven data exchange, including consent capture, eligibility checks, claims/clinical data integration, and bidirectional information sharing with the patient’s broader care team. Applicants should ensure they have a FHIR API server and meet the requirements described in the CMS Health Tech Ecosystem pledge.

Go-to-market and referral strategy. Beneficiary alignment is voluntary and will be facilitated by CMS’s planned public directory with risk-adjusted outcomes. Access participants will benefit from strong referral relationships—especially with ACOs and primary care providers—both to enroll eligible beneficiaries and to minimize substitute services. A field strategy grounded in evidence, patient engagement, and interoperability with local providers is critical to success. 

Connect with Us 

Applications for the first ACCESS Model performance period are due April 1, 2026, with model launch in July 2026; applications submitted later would start January 1, 2027. Because ACCESS is a rolling, decade-long model, some organizations may choose to stage entry. 

ACCESS is the most explicit Innovation Center opportunity to date on outcomes-based, tech-enabled chronic care in Traditional Medicare. It offers digital health and advanced care organizations a direct line to FFS beneficiaries with payment tied to results, not activities. Success will favor teams that combine clinical excellence, consumer-grade engagement, and API-level interoperability, as well as manage program integrity, ACO overlap, and beneficiary churn. 

For questions or support assessing readiness, developing an application, or operationalizing the model, contact Amy Bassano, Ryan Howells, or Kate de Lisle. 

CMS Releases 2027 Advance Notice with Medicare Advantage and Part D Rates

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The Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2027 Advance Notice and Payment Policies for the Medicare Advantage (Part C) Part D Prescription Drug Program on January 26, 2026. The Advance Notice begins CMS’s annual rate-setting cycle and describes proposed updates to Medicare Advantage (MA) growth rates, benchmark rebasing, risk adjustment, Star Ratings, and Part D payment parameters. CMS previously released a proposed rule in November 2025 that included policy changes to the Star Ratings system and enrollment policies for MA and Part D starting in contract year 2027. (Read the Health Management Associates (HMA) summary here.) 

Comments on the Advance Notice are due February 25, 2026, and CMS will publish the final CY 2027 rate announcement no later than April 6, 2026.  

This article provides an early look at the proposed methodological updates and draft capitation rates. Wakely, an HMA Company, will publish a detailed analysis of the Advance Notice in early February. 

Payment Impact on Medicare Advantage Organizations 

CMS estimates a national per capita MA growth rate of 5.10 percent from 2026 to 2027, with fee-for-service (FFS) non-end-stage renal disease (non-ESRD) growth of 5.10 percent and FFS dialysis end-stage renal disease (ESRD) growth of 6.17 percent. 

The 5.10 percent growth rate reflects projected increases in per capita FFS Medicare spending for beneficiaries who are aged/have disabilities and serves as the primary driver of 2027 benchmark updates, interacting with rebasing and risk adjustment changes to determine final capitation payments. The growth rate reflects updates to how CMS pays for skin substitutes in the 2026 Medicare Physician Fee Schedule. These updates resulted in significantly lower projected costs and materially reduced the growth rate. 

These preliminary estimates inform the development of MA benchmarks and may change in the final rate announcement. 

Table 1. Estimated Impact of Proposed Payment Changes on Medicare Advantage Plan Payments, CY 2027 

                                        Year-to-Year Percentage Change 
Impact  CY 2027 Advance Notice  
Effective Growth Rate4.97%
Rebasing/Re-pricingTBD
Change in Star Ratings-0.03%
MA Coding Pattern Adjustment0%
Risk Model Revision and Normalization-3.32%
Sources of Diagnoses-1.53%
Expected Average Change0.09%
Source: Centers for Medicare & Medicaid Services. 2027 Medicare Advantage and Part D Advance Notice. January 26, 2026. Available at: https://www.cms.gov/newsroom/fact-sheets/2027-medicare-advantage-part-d-advance-notice. 

Medicare Advantage Benchmarks, Rebasing, and Risk Adjustment 

The Advance Notice describes CMS’s approach and changes that will affect payment to plans, including: 

  • Excluding from the risk adjustment process diagnoses submitted from chart reviews with unlinked claim records. In the Fact Sheet, CMS estimates this change will reduce Part C payments by 1.53 percent. 
  • Rebasing county FFS rates for 2027 using 2020–2024 claims data, continuing CMS’s practice of updating benchmarks annually to reflect the most current FFS experience. The Advance Notice also reiterates the statutory framework for calculating benchmarks, including applicable and specified amounts, benchmark caps, and quality bonus payments. 
  • Updating the CMS Hierarchical Condition Category (CMS-HCC) and Prescription Drug Hierarchical Condition Category (RxHCC) risk adjustment models and associated normalization factors for CY 2027 and continuing to apply the statutory MA coding pattern difference adjustment to account for systematic differences in diagnosis coding between MA and FFS. 

Quality Bonus Payments, Star Ratings, and Part D Updates 

CMS states that contracts with 4 or more Stars receive a 5 percentage-point quality bonus, while new and low-enrollment contracts receive a 3.5percentage-point bonus. The Advance Notice also includes updates related to Part C and Part D Star Ratings measures and methodological refinements. 

For Part D, CMS outlines proposed updates to the defined standard benefit parameters for CY 2027, as well as changes to Part D risk adjustment, normalization, premium stabilization, reinsurance, and risk-sharing, with additional policy context provided in the Contract Year 2027 Medicare Advantage and Part D proposed rule. 

Connect with Us 

The CY 2027 Advance Notice provides early signals on benchmark growth, rebasing, and payment methodology changes that will shape MA and Part D payments in 2027. Stakeholders should begin evaluating the potential implications for bid development, benefit design, and financial performance as CMS moves toward finalizing rates in April. 

HMA supports Medicare Advantage and Part D stakeholders with payment impact modeling, scenario analysis, and strategic advisory services related to benchmark rebasing, risk adjustment, Star Ratings, and Part D payment policy to help organizations prepare for the CY 2027 rate announcement. 

For details about the finalized payment and policy rules, contact our featured experts,  Tim Courtney and Rachel Stewart. 

Preparing for Change: A Look at Proposed State Fiscal 2027 Budgets

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As of January 1, 2026, nine governors had released proposed budgets for state fiscal year (SFY) 2027. With the phase down of federal funding and substantial policy changes approved in the 2025 budget reconciliation act (P.L. 119-21, OBBBA), these proposals offer insights into how governors plan to manage mounting fiscal pressures, navigate new federal mandates, and position their programs for long-term sustainability. 

Today, Health Management Associates Information Services (HMAIS) published its first preliminary review of proposed SFY 2027 budget proposals. The initial installment includes budgets from Alaska, Colorado, Florida, Mississippi, New Mexico, South Dakota, Utah, Virginia, and Wyoming, with the latter two proposals covering the fiscal 2026–28 biennium. 

HMAIS will release periodic updates as additional governors publish their budget proposals—the same rolling approach we used in 2025 (here and here). Because 15 states enacted 2025–27 biennial budgets last year, HMAIS also might review substantial mid-biennium health-related adjustments or supplemental funding. 

The remainder of this article provides a snapshot of several notable themes and emerging trends detailed in the full report. 

Implementation of New Federal Requirements 

State leaders are preparing budgets for SFY 2027 at a time of heightened fiscal stress and structural uncertainty. Entering 2026, governors are facing reductions in federal funding, particularly in Medicaid and Supplemental Nutrition Assistance Program (SNAP) funding. In addition, they are preparing for new federal requirements that will begin to take effect later this year, including narrower flexibilities for financing and Medicaid community engagement policies and more frequent eligibility redeterminations. 

Against this backdrop, governors are using FY 2027 budget proposals to comply with OBBBA’s mandates and to stabilize their safety net programs and realign state operations around stricter fiscal realities. 

Medicaid Work Requirements. Virginia’s proposed budget includes funding to implement federal Medicaid community engagement requirements, including a recommendation to add nine new authorized positions in SFY 2027 and 12 more in fiscal year 2028 to meet workload demands. In addition, South Dakota’s governor proposed amending the state’s 2026 budget to secure funding to implement these requirements. 

Eligibility and Redetermination. Several governors are proposing investments to support heightened eligibility checks across Medicaid, SNAP, and Temporary Assistance for Needy Families (TANF). For example, Colorado Gov. Jared Polis’s budget proposes $19.1 million to improve the state’s eligibility system for programs such as Medicaid, SNAP, and TANF. Utah’s proposed budget includes a recommended allocation of nearly $16.5 million to the Department of Workforce Services for “H.R. 1 Medicaid Eligibility Administration,” and nearly $10 million for the “H.R. 1 SNAP Administrative Services.” 

SNAP Changes. States are backfilling lost federal funding and investing in error reduction and system modernization. New Mexico Gov. Michelle Lujan Grisham’s proposed budget, for example, includes $37 million to replace the decrease in federal funding for SNAP administration ($4 million of which will support 150 new full-time positions), as well as $8.9 million for systems improvements to reduce payment errors in SNAP. South Dakota Gov. Larry Rhoden’s proposed budget includes $5.5 million to offset a reduction in SNAP federal funding. 

Strategic Cost Containment 

Considering OBBBA implementation and the effects that it will have on their budgets, our first review of governors’ budget proposals signals that states are taking an aggressive posture toward limiting expenditure growth in 2026 and 2027. Initial proposals include targeted reductions, tighter utilization management, and restrictions on benefits. 

Since the 2025 legislative session, Colorado has taken multiple steps to prepare for declining federal revenue. For example, Governor Polis’s proposed budget accounts for multiple actions approved through an amended executive order that would reduce spending to brace for OBBBA’s impacts. Examples include: 

  • Reducing provider rates to 85 percent of the Medicare reimbursement rate 
  • Establishing limits on Community First Choice services 
  • Adjusting the home health nursing and therapy services payment methodology 
  • Introducing cost controls for Medicaid benefit categories that have shown disproportionate growth 
  • Implementing a $3,000 annual cap on adult Medicaid dental benefits and a $750 annual cap on dental benefits for individuals in the Cover All Coloradans program 
  • Changing the Cover All Coloradans behavioral health program from managed care to fee for service 
  • Reviewing provider fees in anticipation of possible State Directed Payment approval from the Centers for Medicare & Medicaid Services (CMS) 

Former Virginia Gov. Glenn Youngkin’s budget—now inherited by Abilgail Spanberger following her inauguration January 17, 2026—includes multiple cost-containment proposals, such as: 

  • Anticipated adjustments to capitation rates after a review of Medicaid managed care organizations 
  • A $2,000 annual limit on adult dental services Medicaid coverage 
  • Elimination of both automatic rate increases for psychiatric residential treatment facilities and qualifying addiction and recovery treatment services providers and automatic biennial inflation increases for medical assistance providers 
  • Restrictions on emergency maternity services to Medicaid enrollees who are ineligible for Medicaid because of their citizenship status 
  • Standardized hourly limits across home and community-based services waivers 
  • Actions related to “ensuring appropriate utilization” of services, such as applied behavioral analysis and crisis services 

States are expected to include additional cost-containment tools throughout 2026 and beyond as OBBBA’s fiscal effects become clearer over the coming months and years. 

What to Watch 

The budget proposals indicate the resources that executive agencies need and preview governors’ policy agendas for the year ahead. Stakeholders should track program reductions and rate changes, eligibility system investments, and shifts in care models. 

In addition, some of the announced budget proposals consider federal awards to states under the Rural Health Transformation Program (RHTP). For example, the Alaska Department of Health budget request addresses the state’s RHTP implementation plans, and Wyoming’s budget proposal outlines RHTP priorities. Many states are preparing RFP processes to operationalize their RHTP strategies and make progress on the goals of their initiatives. 

Connect with Us 

As federal funding uncertainties continue, states and other stakeholders will need to adapt their delivery systems, administrative structures, and financing models throughout OBBBA’s multiyear rollout. HMA offers expertise, analytics, and strategic advisory services needed to navigate this evolving landscape. For details contact Andrea Maresca and Kathleen Nolan. 

The full state of the states and governor budget report is available to HMAIS subscribers. In addition, HMAIS maintains a Rural Health Transformation Program (RHTP) Tracker that incorporates details of each initiative and the first year award.  

Outlook 2026: Rural Health Transformation Program

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As we kick off the new year, Health Management Associates (HMA) is launching a new series of brief, insightful interviews with our policy experts on issues that will define 2026—what’s changing, why it matters, and how federal, state, and industry decisions will shape what happens next. Building on our earlier analysis of the Rural Health Transformation Program ((RHTP), here and here), this week, we start with a pointed look at the Centers for Medicare & Medicaid Services’s (CMS) first year of RHTP awards. 

Rural Health, Ready or Not: CMS Wants Results in 2026

An interview with Kathleen Nolan, Senior Advisor, HMA, and Sara Singleton, Principal, Leavitt Partners, an HMA Company. 

Q: What do the new Rural Health Transformation Program awards tell us about US Department of Health and Human Services (HHS) and CMS priorities heading into 2026? 

Kathleen Nolan: One of the clearest signals is that CMS expects visible progress in 2026. This is not a program that gives states months of planning runway. The application made it clear that CMS wants states to start doing the activities they proposed right away—not just planning or propping up existing systems. CMS wants to see meaningful movement on implementation in 2026, especially in the areas of workforce, infrastructure, technology modernization, and care delivery redesign. 

Sara Singleton: Exactly, and CMS is using this investment to reinforce some of the administration’s broader policy goals. Many state proposals leaned heavily into chronic disease prevention, chronic care management, and expanding supports that promote healthier lifestyles. That alignment isn’t accidental. The Administration is looking for real traction on these priorities, and RHTP gives states both the resources and the accountability framework to make progress. So, the message from CMS is clear: Move quickly, implement strategically, and show early gains in the areas that matter for long-term population health. 

Q: Was anything in the awards themselves surprising? 

Singleton: There was a lot of speculation about how wide the spread in funding levels might be, particularly for states’ discretionary initiatives. But the distribution was relatively tight; 32 states fell in the “average” range of $190‒$230 million, with only four states above $230 million and 13 below $190 million. That suggests CMS isn’t signaling dramatic differences in expected performance or ambition. 

Nolan: It reinforces that CMS is looking for consistent, measurable progress from every state. States that struggle to implement their plans could see less funding in about years. 

Q: What should states keep top of mind heading into year one? 

Nolan: Accountability. CMS has made it clear they will adjust budgets in later years if states don’t meet expectations on reporting and evaluation. That also means states need to know where the dollars are going and what they are getting for the investment. Year one performance really matters. 

Singleton: And it’s not just CMS. Congress and the Office of Inspector General for HHS will also be watching how states use these funds. 

Q: What rural health policy developments are you watching in early 2026? 

Nolan: Decisions about the leadership for these initiatives and state legislatures. Federal investment can only go so far. States will need strong leaders and supportive policies to accelerate and sustain RHTP efforts in year one. What legislatures choose to prioritize will shape the impact of RHTP far beyond year one. 

Executive Branch Actions Target Drug Affordability in New Pricing Models

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The federal drug pricing landscape continues to undergo significant transformation as executive branch agencies advance an ambitious suite of regulatory and model testing initiatives intended to lower the costs associated with the Medicare and Medicaid programs. In response to ongoing concerns about rising out-of-pocket costs, increasing pressure to align US prices with those paid internationally, and the continued implementation of the Inflation Reduction Act (IRA), federal agencies are reshaping how prescription drugs are priced, reimbursed, and negotiated in federally financed programs. 

The current policy environment reflects a growing emphasis on benchmarking drug prices to those in peer nations, referred to as “most favored nation” (MFN) benchmarks, and accelerating actions that require or encourage manufacturers to offer lower net prices. Health Management Associates (HMA), is tracking these developments in the public payer space, replicating Centers for Medicare & Medicaid Services (CMS) payment methodologies, and modeling alternative policies to assist life science companies, payers, and other stakeholders. 

In this article, we review the administration’s recent efforts to reduce Medicare and Medicaid spending on drugs and biologics, including confidential manufacturer negotiations and three new models that together could reshape pricing dynamics across federal programs. 

Executive Branch Negotiations Seek to Drive Access to MFN Discounts 

In 2025, the administration issued an Executive Order directing federal agencies to pursue strategies to establish MFN pricing, linking US prices for certain drugs to the lowest (or second lowest) adjusted net prices among a targeted set of peer countries. Following the order, federal officials sent letters to 17 major pharmaceutical and biotechnology manufacturers, urging them to negotiate agreements that would voluntarily align prices with MFN-based benchmarks. 

To date, 14 manufacturers have signed agreements, though full details remain confidential. These agreements are understood to accomplish the following: 

  • Provide state Medicaid programs with access to MFNbased discounts 
  • Require that new drugs be launched in the United States at MFNaligned prices 
  • Offer certain drugs at discounted directtoconsumer prices through a forthcoming “TrumpRx” program, expected to launch later this year 

Reports suggest that manufacturers entering these MFN-related arrangements may receive exemptions from several federal actions, including the Center for Medicare and Medicaid Innovation (Innovation Center) demonstration models described below and certain tariff-related policies. 

MFNLinked Models Designed to Lower Drug Costs Across Medicare and Medicaid 

Along with the negotiation efforts, the CMS Innovation Center has proposed three models that would test MFNbased pricing through structured rebate mechanisms. Each model targets different segments of the market while testing how international benchmarks could be integrated into federal drug payment policy. 

New Models Test Alternatives to Inflation Rebates 

Announced in December 2025, the Global Benchmark for Efficient Drug Pricing (GLOBE) Model and the Guarding US Medicare Against Rising Drug Costs (GUARD) Model are designed to test alternative approaches to the Inflation Reduction Act’s (IRA) inflation penalty policies. CMS plans to test the models’ potential for market driven price reductions if manufacturers choose to lower list prices instead of paying MFN-based rebates. 

Key features of the GLOBE Model are as follows: 

  • Applies to 25 percent of Medicare fee-for-service (FFS) beneficiaries using certain Part B drugs 
  • Beginning in October 2026, becomes mandatory for select drugs and targets highspending, physicianadministered Part B categories, excluding products already subject to IRA negotiations, generics, biosimilars, and certain lowspend products 
  • No changes to physician and hospital reimbursement, although beneficiaries expected to see reduced cost sharing 

The GUARD Model will similarly test whether applying MFN-based rebates to Medicare Part D drugs will lower Medicare costs. Key aspects of this model include: 

  • Fiveyear model that would start January 1, 2027 
  • Target therapeutic categories with more than $69 million in annual Part D spending 
  • No impact on plan bids and beneficiary cost sharing 

These models rely on pricing data from 19 countries. Manufacturers that voluntarily submit net price information would trigger quarterly benchmark updates; otherwise, CMS will use a fixed list price based benchmark for the entire pilot period. 

CMS is seeking comments on whether additional categories, for example cell and gene therapies, should be excluded from GLOBE. GUARD is also open for comment through February 23, 2026. 

GENErating cost Reductions fOr US Medicaid (GENEROUS) Model 

The GENEROUS model, expected to begin in 2026, creates a voluntary pathway for state Medicaid programs and manufacturers to enter supplemental rebate agreements tied to MFNaligned prices. MFN pricing under this model is based on the second lowest net price in G7 countries plus Denmark and Switzerland. GENEROUS is also expected to align with pricing commitments negotiated through the administration’s manufacturer agreements. 

Key Considerations and Potential Impacts 

The combined effect of federal negotiations and Innovation Center models could be substantial, though outcomes will depend on manufacturer participation, benchmark stability, and operational feasibility. Key considerations include: 

  • State Medicaid savings, especially the extent to which MFN‑linked rebates exceed existing supplemental rebates 
  • Reduced Medicare beneficiary cost sharing for Part B included in GLOBE 
  • Shifts in manufacturer pricing strategies, including potential changes to US launch prices 
  • Interactions with the IRA, particularly Part D redesign and Part B inflation penalties 

Connect with Us 

HMA experts continue to track the federal drug pricing landscape closely as comments, operational details, and implementation timelines evolve across these initiatives. Our team replicates CMS payment methodologies and models alternative policies using the most current Medicare FFS and Medicare Advantage (100%) claims data. 

For more information and questions about the policies described in this article, please contact our experts below.

CMS Innovation Center’s ACCESS Model: What Medicare Organizations Need to Know

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On December 1, 2025, the Centers for Medicare & Medicaid Services (CMS) Innovation Center announced its latest model—ACCESS (Advancing Chronic Care with Effective, Scalable Solutions). A national, voluntary 10-year model designed to test outcomes-focused payment for technology-enabled care used in managing chronic conditions common among Original Medicare (fee-for-service) beneficiaries, ACCESS addresses the long-standing gap between Medicare’s payment system and technology’s capacity to improve healthcare delivery. 

The digital health technology and provider communities have expressed considerable interest in ACCESS. The US Department of Health and Human Services (HHS) and CMS highlighted the model at the December 4, 2025, Modernizing America’s Care for the Better event (recording here), noting over 250 organizations have already expressed interest in the model. Nonetheless, many details need clarification before the program launches.  

Health Management Associates (HMA) has reviewed the ACCESS model and is engaging with those agencies and organizations working on design and implementation. In this article, we share early insights and considerations for Medicare organizations and technology manufacturers interested in participating, as well as potential implications for the broader market. 

Model Overview 

ACCESS aligns with the administration’s strategic priorities for the Innovation Center, including: 

  • Incentivize greater use of technology in chronic disease prevention and management 
  • Increase access to tech-enabled care by overcoming payment barriers, while ensuring care is clinician-guided, coordinated, and accountable 
  • Expand clinicians’ ability to offer innovative care through a straightforward payment pathway 
  • Promote competition by publishing risk-adjusted performance results 
  • Reduce overall Medicare costs 

Core Requirements for ACCESS Participants 

Participants in the model (ACCESS care organizations) must be Medicare Part B participating providers or suppliers, exclusive of durable medical equipment, prosthetics, orthotics, and laboratory suppliers. Notably, these organizations must designate a Medicare-enrolled medical director to oversee care quality and compliance. These organizations will collaborate with primary care providers and other referring clinicians to offer tech-enabled services that complement traditional care, including: 

  • Telehealth software 
  • Wearable devices for continuous monitoring (e.g., sleep, heart rate, movement, glucose, etc.) 
  • Apps to track and coach lifestyle changes 

Care may be delivered in person, virtually, asynchronously, or through other clinically appropriate tech-enabled methods. 

While CMS has yet to release full details on covered digital health solutions, ACCESS care organizations are expected to offer integrated, technology-supported care, which may include: 

  • Clinician consultations 
  • Lifestyle and behavioral support (e.g., nutrition, exercise, smoking cessation) 
  • Therapy and counseling 
  • Patient education 
  • Care coordination 
  • Medication management 
  • Ordering and interpreting diagnostic tests and imaging 
  • Use or monitoring of Food and Drug Administration (FDA)-authorized devices 

ACCESS is intended to be a supplemental approach to traditional care. Primary care physicians and specialists will be able to refer patients to ACCESS organizations and will receive regular electronic updates on patient progress. 

New Options for Beneficiaries 

Unlike most other Innovation Center models, beneficiaries will be able to voluntarily sign up directly with an ACCESS organization or receive a referral from a physician. CMS will maintain a public directory of ACCESS participants, including the conditions they treat and their risk-adjusted outcomes, to help providers and beneficiaries make informed choices based on their needs. 

 Chronic Condition Focused Clinical Tracks 

ACCESS will launch with four clinical tracks, grouping related conditions with similar care approaches. Although CMS may add additional tracks and conditions in the future, the first four tracks address common chronic conditions among Medicare beneficiaries (affecting over two-thirds of Medicare beneficiaries). 

  1. Early Cardio-Kidney-Metabolic (eCKM): Hypertension, dyslipidemia, obesity, prediabetes
    Outcome measures: Control of or improvement in blood pressure (BP), lipids, weight, HbA1c 
  2. Cardio-Kidney-Metabolic (CKM): Diabetes, chronic kidney disease (CKD), atherosclerotic cardiovascular disease (ASCVD) 
  3. Outcome measures: Control or improvement in BP, lipids, weight, HbA1c; CKD/diabetes require eGFR (estimated glomerular filtration rate) and UACR (urine albumin-to-creatinine ratio) data submission 
  4. Musculoskeletal (MSK): Chronic pain
    Outcome measures: Improvement in pain intensity, interference, function (via validated patient-reported outcome measures [PROMs]) 
  5. Behavioral Health: Depression and/or anxiety
    Outcome measures: Improvement in symptoms (Patient Health Questionnaire-9 [PHQ-9], Generalized Anxiety Disorder-7 [GAD-7]); submission of World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) for overall function 

Participant organizations must manage all qualifying conditions within their chosen track. 

Payments 

CMS will release more details in the forthcoming request for applications (RFA). The model will use two payment approaches: 

  • Outcomes-Aligned Payments (OAPs): Paid to ACCESS organizations that achieve desired clinical outcomes, support technology-enabled interventions, and net savings for Medicare. OAPs are expected to be recurring (likely monthly) payments
  • Co-management Payments: Referring clinicians will receive approximately $30 per service, plus a one-time $10 bonus, for onboarding beneficiaries

To promote access in underserved areas, CMS will apply a fixed adjustment to OAPs for rural patients in qualifying tracks. 

FDA’s Complementary TEMPO Pilot 

The FDA’s Technology-Enabled Meaningful Patient Outcomes (TEMPO) pilot will work collaboratively with the ACCESS model. Manufacturers of digital health devices that have yet to receive FDA authorization can apply to TEMPO for enforcement discretion, allowing their devices to be used by ACCESS participants for covered care. The FDA is seeking statements of interest for participation in the TEMPO pilot beginning in January 2026. The agency plans to select up to 10 manufacturers in each of four specific clinical use areas to participate in the pilot. 

Next Steps 

Interested applicants should begin exploring participation as a Medicare Part B-enrolled provider if they have yet to enroll. Other key considerations for Medicare organizations include: 

  • Submit a nonbinding letter of interest to the Innovation Center 
  • Evaluate readiness to deliver technology-enabled, outcomes-focused care 
  • Assess capacity to manage qualifying conditions across clinical tracks 
  • Plan for data collection, reporting, and performance measurement 
  • Consider partnerships with technology vendors and referring clinicians 
  • Monitor regulatory developments and payment methodology updates 

How HMA Can Help 

HMA can help organizations navigate the application process, develop implementation strategies, and position your organization for success in the evolving Medicare landscape. If your organization is considering participation in ACCESS or wants to understand how this model could affect your market, contact our experts below.

CMS’s 2027 Medicare Advantage Proposed Rule Focuses on Outcomes and Competition

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On November 28, 2025, the Centers for Medicare & Medicaid Services (CMS) released the Contract Year 2027 Policy and Technical Changes to the Medicare Advantage Program and Medicare Prescription Drug Benefit Program. Each annual rulemaking cycle offers CMS an opportunity to recalibrate program priorities.  

This proposed rule offers a road map for CMS’s vision for Medicare Advantage (MA) and Part D. Signaling how CMS leadership intends to shape the MA and Part D programs beyond 2027—prioritizing outcomes, streamlining operations, and inviting dialogue on modernization—the proposed rule reflects a strategic imprint on the program’s trajectory. The deadline to submit comments is January 26, 2026. 

Given CMS’s goal of modernizing MA and Part D, plans, providers, and advocates should engage early to inform final policies. Health Management Associates (HMA) policy and actuarial experts, including Wakely and Leavitt Partners (both HMA companies), are analyzing and modeling the effect of the proposed changes. This article highlights some of the major policy updates that require near-term planning by states, Medicare Advantage plans, providers who serve MA beneficiaries, and their partners. 

Key Themes in the Proposed Rule 

Requests for Information 

CMS includes three significant requests for information (RFIs) and highlights additional opportunities to provide input on approaches to reduce administrative burden throughout the program. CMS’s modernization RFI focuses on financing and other strategies to support beneficiaries with plan selection. In addition, CMS seeks input on emerging trends in MA special needs plans (SNPs), citing concerns about rapid growth and potential program integrity issues. Consistent with the departmentwide priorities, the RFI also delves into potential strategies for plans to address nutrition and wellness benefits for MA enrollees. 

Figure 1. RFIs Signaling New Policy Directions 

Star Ratings Overhaul: Refocusing on Outcomes and Experience

CMS proposes significant changes to the Star Ratings system, which influences plan bonuses and consumer choice. The changes increase the focus on clinical care, outcomes, and patient experience of care measures where performance is not topped out and align with universal foundation of measures. 

  • Health Equity Index Rollback: Rather than implement the previously planned Excellent Health Outcomes for All reward (formerly Health Equity Index) for 2027, the agency will continue using the historical reward factor that incentivizes consistently high performance across all measures. 
  • Measure Streamlining: Twelve process-heavy or administrative measures will be removed. 
  • Behavioral Health: A new measure for depression screening and follow-up will be introduced for the 2027 measurement year, with integration into Star Ratings by 2029.  

Why It Matters: Removing these measures continues the shift away from administrative compliance, easing burden while strengthening quality incentives. 

Medicare and Medicaid Dual Eligible SNPs and Integration 

CMS is proposing several changes to improve how Medicare Advantage plans serve people who qualify for both Medicare and Medicaid (dual-eligible beneficiaries): 

  • Starting in calendar year (CY) 2027, CMS proposes to allow D-SNPs and I-SNPs two opportunities to change to their model of care (MOC)—the framework for how they coordinate care. These windows would be January 1 through March 31 and October 1 through December 31. 
  • When beneficiaries are automatically moved (i.e., passively enrolled) from one integrated D-SNP to another, CMS will no longer require the new plan’s provider network to closely match the old plan’s network. Instead, the new plan must ensure that all incoming members receive uninterrupted care for at least 120 days (up from 90 days), helping prevent gaps in treatment. 
  • In states where dually eligible individuals are explicitly carved out from or not required to enroll in Medicaid managed care, CMS proposes to let highly integrated dual eligible special needs plan (HIDE SNP) continue to enroll full-benefit, dual-eligible (FBDE) individuals in the same service area, even if those individuals are in Medicaid fee-for-service. This change is intended to maintain coverage and simplify enrollment for these beneficiaries. 

Why It Matters: While the proposed changes revise broader policies, the updates could have significant effects on D-SNP and MA integration. These changes also could shape states’ decisions regarding their integration policies. Plans should continue to monitor these developments. 

Other Notable Changes  

CMS proposes a new special enrollment period (SEP) for beneficiaries when their providers leave a plan’s network, eliminating the requirement that CMS deem the change “significant.” The intent of this change is to preserve continuity of care and ease the burden of beneficiaries switching plans. In addition, CMS plans to codify SEP policies for greater consistency. 

The proposed rule also calls for the following: 

  • Codifying multiyear changes stemming from the Inflation Reduction Act, including elimination of the coverage gap phase 
  • Lowering annual out-of-pocket thresholds and removal of cost sharing in catastrophic coverage 
  • Transitioning to the Manufacturer Discount Program and updating true out-of-pocket (TrOOP) calculations 
  • Clarifying specialty-tier drugs and subsidy structures 

As a result, plans will have updated financial responsibilities. 

Connect With Us 

As CMS sets a new course for Medicare Advantage and Part D, organizations face both opportunities and challenges in adapting to these changes. HMA brings deep expertise in Medicare policy, actuarial modeling, and operational strategy. Our team—including experts from Wakely and Leavitt Partners—can help plans, providers, and stakeholders interpret the proposed rule, assess its impact, and develop actionable strategies for compliance and competitive positioning. 

Whether you need data-driven analysis, scenario modeling, or hands-on support preparing for implementation, HMA is ready to partner with you to navigate the evolving Medicare landscape and achieve your goals. Contact our experts below to discuss your questions and how HMA can help.

Where Duals Integration Is Headed: State-by-State Intelligence

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Dually eligible individuals are those who qualify for both Medicare and Medicaid. This population accounts for a disproportionately small share of the total Medicaid or Medicare population, but they account for a disproportionately large share of spending across both programs.

Medicare Advantage Dual Eligible Special Needs Plans Play a Key Role

Over the last several decades, federal and state policymakers have developed and implemented a range of programs, demonstrations, and approaches to improve care for this population and strengthen alignment between Medicare and Medicaid, improve outcomes, and manage costs. Medicare Advantage (MA) Dual Eligible Special Needs Plans (D-SNPs) are a key vehicle to accomplish federal and state goals.

What to Expect in Medicare Advantage Contract Year 2026

In 2026 and beyond, we can expect significant state and local shifts in plan enrollment, due to new federal requirements and state demonstration program transitions. We will see states focused on advancing aligned plan enrollment and setting higher expectations for Medicare-Medicaid integrated programs.

A New Inventory to Stay on Top of State Markets

Health Management Associates (HMA) has published the Duals Integration Environmental Inventory, a state-by-state view of state Medicaid program structures and regulations shaping integration and D-SNP markets. This resource is designed to help state policymakers, insurers, and healthcare organizations track trends, identify opportunities, and inform strategic planning in an evolving policy landscape.

Looking Ahead at the Changes in 2026 and Beyond

Federal rules for the Medicare Advantage 2026 contract year—and state Medicaid contractual agreements with plans—strengthen D-SNP integration standards and coordination between states and plans. Examples include:

  • D-SNP Look-Alike Plans: In 2026, the threshold for identifying MA plans as D-SNP look-alikes will decrease from 70 percent to 60 percent. This 10-percentage point drop marks the second of two planned phasedowns in the threshold percentage. Look-alike plans are MA plans that are marketed to dually eligible individuals, but they are not required to comply with D-SNP integration requirements. Stronger federal standards will require MA look-alike plans with high dual enrollment to convert or exit the market, which is expected to lead to shifts in dually eligible enrollment into D-SNPs and other integrated products.
  • Financial Alignment Initiative Demonstration Transitions: The Centers for Medicare & Medicaid Services (CMS) has worked with several states operating capitated Financial Alignment Initiative (FAI) demonstrations to transition Medicare-Medicaid Plans (MMPs) to integrated D-SNPs by January 1, 2026. These states include Illinois, Massachusetts, Michigan, Ohio, Rhode Island, South Carolina, and Texas will end their FAI demonstrations on December 31, 2025.
  • 2027 D-SNP Rules: Beginning in 2027, D-SNPs affiliated with Medicaid managed care organizations (MCOs) must restrict enrollment to Medicaid MCO enrollees. In addition, federal rules will limit the number of D-SNP plan benefit packages, which will require additional coordination with Medicaid affiliates and planning in designing benefit packages and network.

State Medicaid Program Adjustments

States are working to align new federal D-SNP requirements with existing Medicaid managed care contracts, long-term services and supports carve-in strategies, and service-area mappings. Because State Medicaid Agency Contracts (SMACs) must be updated annually, all SMACs will need to incorporate the new D-SNP provisions as the new requirements take effect. This effort will require close coordination among state agencies, plans, and CMS to manage enrollee transitions, data-sharing, and communications.

Data-Informed Integration Insights

HMA’s Duals Integration Environmental Inventory is a single hub for insights into requirements, approaches to scope of integration programs, and enrollment data. The inventory will help plans and other types of organizations such as providers and community-based organizations to prepare for future contracting, compliance, and operational transitions.

This inventory is designed to answer the four major questions top of mind:

  • What is the state’s integration model and D-SNP type. The inventory identifies each state’s approach to integrating care for dually eligible populations, including states with Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs), Highly Integrated D-SNPs (HIDE-SNPs), coordination-only models, and Exclusively Aligned Enrollment (EAE) initiatives or comparable rules
  • Does the state’s program integrate LTSS and/or Behavioral Health? The inventory details whether long-term services and supports and behavioral health are carved into or out of managed care and how those benefits interact with Medicare coverage within D-SNP structures
  • What is the state’s enrollment policy? The inventory captures enrollment in HIDE/FIDE products, identifies Applicable Integrated Plan (AIP) states, and gauges overall alignment maturity
  • What is the state’s procurement and contract timeline? The inventory also tracks state procurement timelines, upcoming RFPs, and effective contract dates

Connect with Us

HMA experts are tracking state integration strategies, procurement timelines, and future state planning activities. Beyond the tracker, HMA colleagues provide tailored analysis and planning for state-specific initiatives. Our team can help health plans prepare for enrollment shifts, compliance requirements, and integration opportunities in 2026 and beyond. For information about subscription access to the HMA Information Services (HMAIS) inventory and to connect with HMA consultants who can address your integration questions, contact our experts below.

CY 2026 Physician Fee Schedule Tackles Site Neutrality, Cost-Drivers, and Alternative Payment Models

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On October 31, 2025, the Centers for Medicare & Medicaid Services (CMS) announced the final rule for the calendar year (CY) 2026 Medicare Physician Fee Schedule (PFS), which finalizes payment policies proposed earlier this year. The rule continues the administration’s focus on developing value-based payment strategies, enhancing care management, and developing innovative payment models. It emphasizes a shift from historical processes and methods of reimbursing clinician services, while also introducing payment policies that include a shift toward site neutrality and cost containment.

The final CY 2026 rule implements immediate policy changes and signals several areas on which CMS might focus its attention in future rulemaking. Through its responses to public comments and the rationale provided for finalized policies, CMS highlights potential shifts in priorities and emerging directions for Medicare payment policy, reflecting the views of the Trump Administration moving forward. Stakeholders should be attentive to these signals, as they provide valuable insights into where CMS could direct further reforms and adjustments in the coming years.

Health Management Associates (HMA) Medicare experts are reviewing the finalized policies and have identified the highlights outlined in this article. Stakeholders should consider the effect on payment in 2026 as well as the longer-term practice reforms, investments, and analysis that may be required to deliver high-quality services and remain sustainable.

Enhanced Care and Chronic Disease Management

CMS finalized new billing codes to support behavioral health integration and the Psychiatric Collaborative Care Model (CoCM) services delivered to patients who also receive Advanced Primary Care Management (APCM) benefits, along with an add-on code for in-home primary care to reflect added complexity. CMS also retains and repurposes the social determinants of health (SDOH) risk assessments billing code to align with the administration’s focus on addressing the root causes of chronic illness.

Takeaway: These changes are designed to support better care coordination, integration of physical and mental health services, and proactive management of patient risk factors. They indicate CMS’s intent to expand care management strategies beyond traditional settings and into future payment methodologies.

Establishing Specialty Care Models

The rule finalizes the mandatory Ambulatory Specialty Model (ASM) to test value-based payments for specialists who focus on heart failure and lower back pain. ASM adopts a framework similar to the Merit-based Incentive Payment System Value Pathways (MVP) and shares certain quality and cost measures with existing MVPs for heart disease and musculoskeletal care.

The model applies performance-based payment adjustments of up to 12 percent, covering 25 percent of Core-Based Statistical Areas (CBSAs) and metropolitan divisions, and is projected to save $177 million over its test period. ASM will run from 2027-2031, with payment adjustments applied during payment years from 2029-2033.

Takeaway: Stakeholders should plan for CMS’s continued interest in developing mandatory models and opportunities for specialists to participate in Innovation Center efforts.

Emphasis on Rebalancing the Payment System and Site Neutrality

Efficiency Adjustment

Citing the need to account for efficiencies gained in non-time-based services such as procedures, radiology services, and diagnostic tests, CMS finalized a 2.5 percent efficiency adjustment to work Relative Value Units (RVUs) for certain services and procedures, applied every three years. The agency notes it will monitor the three-year cadence and may refine the frequency in future rulemaking.

In response to public comments, CMS added several services to the exemption list in this final rule, including codes that introduced to the fee schedule in 2026, certain time-based services in physical medicine and rehabilitation, remote therapeutic monitoring (RTM), and drug administration, as well as time-based services on the CMS telehealth list.

Takeaway: The move signals a notable shift from the agency’s historical reliance on survey data provided by the American Medical Association (AMA)/Specialty Society Relative Value Scale (RVS) Update Committee (RUC) to establish practitioner time in PFS rate setting. Stakeholders should consider how CMS could build on this new approach in future rulemaking.

Site Neutrality

Site neutral policies will now use hospital outpatient data to set payment rates for certain services, including radiation oncology treatment delivery and some remote monitoring. In addition, the rule establishes the same payment rate in both physician office and hospital outpatient settings for certain supplies, including skin substitute products, and by implementing changes in the physician practice expense methodology.

By tackling practice expense reimbursement, CMS intends to recognize higher costs incurred by physicians who operate a freestanding office than by physicians who furnish care in the facility setting (i.e., indirect practice expenses). This methodology lowers practice expense payments to hospital-based physicians, resulting in double-digit cuts for many specialists in facility settings, while independent and group practice physicians generally will see increases.

Takeaway: The site neutrality changes underscore a broader long-term strategy advanced across multiple administrations to reduce payment disparities and discourage shifting care to higher-cost settings. While some providers will see payment increases and others will experience cuts, these adjustments are part of CMS’s effort to rebalance incentives and move toward value-based models. Stakeholders should recognize that this is not an isolated change, but a signal of continued policy evolution designed to align payment with efficiency and quality.

Strategies to Update PFS Practice Expense Payments

Although CMS implemented major methodology changes to allocate more indirect practice expense (PE) costs to services performed in physician offices and less to those in facility settings, the agency finalized a “status quo” approach. Specifically, the agency will continue using the existing practice expense per hour (PE/HR) values and cost share weights, despite being almost two decades out of date.

Takeaway: CMS indicates interest in revisiting practice expense data in future cycles, which may effect payment.

Positive PFS Conversion Factor Update

All providers and suppliers paid for services under the PFS will benefit from a positive update to the conversion factor, with Advanced Alternative Payment Model (APM) participants receiving a higher increase and one-time incentive payment. Specifically, under the final rule, two conversion factors will be available in CY 2026.

  • CMS will pay for services furnished by providers who participate in APMs using a conversion factor of $33.5675—a 3.77 percent increase (or $1.221) from the 2025 amount of $32.3465.
  • CMS will compensate providers who do not participate in a qualifying APM using conversion factor of $33.4009—a 3.26 percent ($1.0544) from CY 2025.

Both conversion factors reflect the 2.50 percent overall update required by statute, a 0.49 percent budget neutrality adjustment to account for RVU changes, and an updated factor of 0.75 percent for qualified APMs or 0.25 percent for non-qualifying APMs. CY 2026 is the final year in which eligible clinicians can receive an additional APM incentive. Qualifying clinicians will receive a one-time payment of 1.88 percent of their paid claims for covered professional services based on their performance two years earlier.

Takeaway: These updates provide short-term financial relief. The higher increase and bonus for APM participants signal CMS’s continued push toward alternative payment models, even as the incentive sunsets. Stakeholders should plan for a future in which APM participation remains a key strategy for maintaining revenue stability.

Telehealth-Related Flexibilities

CMS will implement several policy changes that will collectively extend the footprint of telehealth services in Medicare and expand access for Medicare beneficiaries. These changes directly impact Traditional Medicare beneficiaries, physicians’ offices, hospitals, and Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC).

  • All services on CMS’s Medicare telehealth coverage list are now permanently covered if they are separately payable and can be delivered via two-way audio-video.
  • CMS permanently removed frequency limitations on certain telehealth services, including follow-up inpatient and nursing facility services.
  • FQHCs and RHCs can serve as distant site telehealth providers for all services—not just mental health services—through December 31, 2026.
  • Virtual supervision is permanently allowed for nonsurgical services conducted in real time via two-way audio-video. This policy will apply across all settings, including FQHCs and RHCs requiring an on-site supervising physician.
  • Teaching physicians can be virtually present for resident services delivered in all training settings when care is provided via telehealth.
  • New services added to the Medicare telehealth coverage list, including certain psychological rehabilitation services, caregiver training services, and risk assessment services.

Takeaway: These changes solidify that telehealth has become an integral part of Medicare service delivery. By eliminating the distinction between temporary and permanent coverage, removing frequency limits, and allowing virtual supervision and teaching physician presence, CMS advances telehealth as a core component of its long-term strategy to improve access, care coordination, and efficiency. In addition, the change aligns with CMS’s commitment to modernizing payment policies to support virtual care models. Stakeholders should plan for continued growth and innovation in this space in future rulemaking cycles.

Other Final Policies

  • Addressing Rising Expenditures for Skin Substitutes: CMS addresses rising expenditures for skin substitute products, which are being adopted and used at a rapid rate. Specifically, the agency reclassifies most of these products as supplies billed incident-to physician services, paid at a uniform rate in both office and hospital outpatient settings rather than as Part B drugs. CMS projects that this change will save Medicare $19.6 billion in 2026 and standardize payment to providers who use these products. The policy takes effect on January 1, 2026. Accompanying these changes is the launch of a new model to test clinical review for certain services, including skin substitutes, in fee-for-service Medicare.
  • Medicare Shared Savings Program: CMS finalizes its proposal to limit the amount of time an accountable care organization (ACO) can participate in an upside-only risk track, provide more flexibility on the number of beneficiaries assigned to an ACO in its early year of operation, and refine quality measures and improve beneficiary attribution to better reflect care standards.
  • Drugs and Biological Products Incident-to Physician Services: The final rule addresses reimbursement for drugs paid incident-to a physician’s service, including policies related to the Inflation Reduction Act provisions, continued implementation of discarded units refund requirements, changes and clarifications to average sales price (ASP) reporting, and payment for procedures required to manufacture cell-based gene therapies.
  • Coding and Payment for Technology-Based Services: CMS pays for digital mental health treatment (DMHT) devices that have Food and Drug Administration (FDA) clearance or authorization and are furnished in conjunction with professional services, including initial education and onboarding. CMS expands these payment policies for DMHT used to treat of attention deficit hyperactivity disorder when providers adhere to established billing requirements. The agency recognizes that behavioral health conditions are common chronic diseases and that the field of digital therapeutics is evolving.

Contact an HMA Medicare Expert Today

HMA policy and rate setting experts are analyzing the details and impacts of the proposed rule and will provide additional updates on key Medicare policies as they become available. Our team can support stakeholder development of policy and data-oriented comments pertaining to this rule and on any other Medicare topic of interest. Contact our experts below to discuss your priorities and approach.

The Future of Integrated Care Programs for Dually Eligible Individuals in Massachusetts: Key Takeaways from the Fall 2025 MAHP/HMA Policy Forum

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Health Management Associates (HMA) recently co-hosted a policy forum with the Massachusetts Association of Health Plans (MAHP), entitled Advancing Better Outcomes: How the One Care and SCO Programs Improve Health for Older Adults and People with Disabilities on Medicare and Medicaid. More than 100 key decision makers from MassHealth (Medicaid), health plans, providers, community-based organizations, and advocacy organizations attended the conference, elevating the value of the MassHealth One Care and Senior Care Options (SCO) programs to dually eligible individuals. The policy forum also provided an important opportunity for state legislators and their staff to learn about these complex programs.

MassHealth One Care and SCO Programs

Massachusetts’ One Care and the SCO programs currently serve more than 125,000 individuals covered under MassHealth and Medicare, also known as dually eligible individuals. One Care is a population-specific program for dually eligible adults 21-64 years of age. SCO is a population-specific program for dually eligible older adults 65 and older, tailored to the needs of older adults. The One Care and SCO programs serve individuals with complex chronic conditions and disabilities, including mental health and substance use disorder needs, and high home-and-community-based service (HCBS) needs. The One Care and SCO programs advance independent living, recovery, and community living goals. Approximately 99 percent of One Care enrollees, and 95 percent of SCO enrollees, live in the community.

The One Care program is currently authorized as a Financial Alignment Initiative (FAI) demonstration program. The FAI demonstration ends December 31, 2025. MassHealth will continue the One Care program as a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) model. This transition from the FAI to a FIDE SNP model introduces changes to the program. A FIDE SNP model is a type of Medicare Advantage (MA) Dual Eligible Special Needs Plan (D-SNP).

HMA’s Role: Bringing National and State Expertise

In addition to creating the forum in partnership with MAHP, HMA shared its national and state policy expertise and local market insights with attendees during a series of presentations. HMA outlined ways in which the One Care and SCO programs offer more value to dually eligible individuals than the state’s fee-for-service (FFS) system.

The event focused on three key topics:

  • The national landscape for Medicare-Medicaid integrated care programs.
  • The value of the One Care and SCO programs and the role that health plans play in improving outcomes for adults who are eligible for both Medicare and Medicaid (“dually eligible”), and
  • The upcoming changes to the One Care and SCO programs, as reflected in the 2026 state Medicaid agency contracts (SMACs) with MassHealth.

Key Takeaways from the MAHP-HMA Conference

Key Takeaway #1. Nationwide trends suggest that Medicare-Medicaid integrated care programs will face competition and financial pressures.

Forum attendees were very interested in the national trends. At the national level, D-SNPs have bipartisan support. At the same time, D-SNPs should expect competition from Chronic Condition Special Needs Plans (C-SNPs) and innovation models developed by the Centers for Medicare and Medicaid Innovation (CMMI). CMMI models such as the Guiding an Improved Dementia Experience (GUIDE) Model and Accountable Care Organizations (ACO) Realizing Equity, Access, and Community Health (REACH) Model will compete with D-SNP models in some markets. Finally, presenters and panelists alike raised concerns about the financial risks that D-SNPs will face due to rising pharmacy costs and changes in Medicare payment methodologies.

Key Takeaway #2. The Massachusetts One Care and SCO programs provide significant value to dually eligible individuals in Massachusetts.

The One Care and SCO programs provide significant value to enrollees. As compared to FFS, Medicaid-Medicaid integrated care programs like One Care and SCO provide care coordination, a personal care plan, bundling prescriptions through a single provider, and other services.

Many forum attendees pointed out that the One Care program is one of the most advanced integrated care programs in the nation. One Care’s success is tied in part to the active and critical role that the One Care Implementation Council plays in shaping program policy. For more than a decade, the One Care Implementation Council and MassHealth have worked in partnership to improve the program. As shared by the Massachusetts Medicaid Policy Institute (MMPI): “The Commonwealth intends to preserve the Implementation Council’s role in the next phase of One Care, and to continue engaging the council as an essential partner in policy and program change, monitoring, and oversight.”

Key Takeaway #3. Over the last two decades, SCO and One Care plans have established many innovations.

The forum highlighted many innovations in these programs, from primary and urgent home care to place-based supports. It also provided an opportunity to talk about the important role and commitment that the plans have in emergency situations to ensure that members are safe in the face of a community crisis.

Panelists see many opportunities for plans to continue to evolve and improve outcomes and equity. For example, the One Care program has significant opportunities to address the behavioral health needs of dually eligible adults. Dually eligible adults with mental health and/or substance use disorder diagnoses are at higher risk of an emergency department visit and inpatient stay than other enrollees. Health plan per member per month (PMPM) spending on inpatient services for those with a behavioral health condition is much higher as a share of the total PMPM than other populations. The HMA data pointed to a need for further innovation in the mental health arena to advance better outcomes of quality of life and costs.

Key Takeaway #4. Conference attendees focused on the importance of addressing enrollees’ social determinants of health needs.

Throughout the day, the importance of community and addressing the social determinants of health (SDOH) was a common theme. Aging and disability leaders spoke about the importance of community organizations such as Aging Services Access Points (ASAPs), independent living centers (ILCs), recovery learning communities (RLCs) including peer support since most  One Care and SCO individuals live in the community.

Many One Care and SCO eligible individuals are often just one unmet health related social need away from the risk of hospitalization or institutionalization. Other attendees underscored the risk that enrollee living situations and recovery can become instantly unstable due to the death of an important family member. One aging leader described her role as “triaging risk.” Other leaders from the disability community urged plans to use z codes to improve plan and provider attention to identify and address the SDOH needs.

Looking Ahead

As Massachusetts prepares for the 2026 One Care and SCO contract year, the forum underscored the progress made over the past decade and the opportunities ahead to improve care coordination, collect z codes, and invest in outcomes-driven partnerships. Massachusetts is well-positioned to continue leading the nation in designing integrated care programs that improve health and support community living for older adults and people with disabilities.

HMA looks forward to supporting all organizations including state Medicaid programs and health plan and provider associations as they convene stakeholders to improve their integrated care programs. Our expertise includes program planning, strategy and implementation, technical support and evaluation, and state-specific knowledge to make projects successful. Please contact Ellen Breslin, Rob Buchanan, and Julie Faulhaber for more information on how HMA can help your organization.

Summary Facts About the One Care and SCO Programs
The One Care and SCO programs are population-specific programs, serving more than 125,000 individuals with MassHealth plus Medicare coverage.   MassHealth designed the One Care and SCO programs around the specific needs, preferences and goals of adults and older adults.The One Care program enrolls dually eligible adults with disabilities, ages 21-64 at the time of enrollment, covered under MassHealth Standard or CommonHealth and Medicare (Parts A and B, and eligible for Part D). Enrollees in One Care have multiple chronic conditions and disabilities including significant mental health and substance use disorder needs. The SCO program enrolls dually eligible adults ages 65 and older, covered under MassHealth Standard and Medicare (Parts A and B, and eligible for Part D). SCO enrollees have significant chronic conditions, many of which are associated with aging.
MassHealth launched the SCO program in 2004 and One Care in 2013.   The One Care program currently operates as a Financial Alignment Initiative (FAI) demonstration. The One Care and the SCO programs combine MassHealth & Medicare benefits into a single plan with one card and one care team. One Care covers medical, mental health, and prescription medications, plus support for daily tasks and independent living and recovery. Care coordinators help members stay healthy and get the services they need.
The One Care and SCO Programs Continue to Evolve. The FAI demonstration authority ends in 2025. Massachusetts will shift from the demonstration to a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) structure. The SCO program currently operates as a FIDE SNP model. The state reprocured the One Care and SCO plan network. The state selected five One Care plans and six SCO plans. New contracts for One Care and SCO plans start January 1, 2026.The new contracts create several changes including changes in eligibility for the program and enrollment processes, benefits, and financial payment provisions.
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