OROutcome RailACCESS Model ROI calculator

How much ACCESS Model revenue are you leaving on the table?

Medicare's ACCESS Model (live since July 5, 2026) pays a fixed annual allowed amount per aligned beneficiary across four clinical tracks — up to $420 per patient, per year — and withholds half of the Medicare portion until outcomes are reconciled. Use CMS-published rates and your own panel to size the opportunity.

Your patient panel Defaults are illustrative

Enter eligible Medicare patients per clinical track, and how many are enrolled today. The pre-filled counts are placeholders, not benchmarks — estimates are fine.

Track	Eligible	Enrolled today

Assumptions Yours to set

Defaults are illustrative starting points, not benchmarks or predictions. Adjust every value to match your own population and performance data.

Achievable enrollment of eligible patients 70%

Your estimate of the share of eligible patients you could realistically align to the model.

Current outcome attainment rate (OAR) 35%

Share of enrolled patients meeting all outcome targets today. Below CMS's 50% Outcome Attainment Threshold, part of the withheld payment is at risk.

Projected OAR — your scenario 60%

A scenario you choose to model, not a prediction. At or above 50%, CMS pays 100% of the withheld amount. This tool makes no claim about how any product affects attainment.

Rural beneficiaries (eCKM/CKM) 10%

Rural eCKM/CKM patients add $15 in the Initial Period (CMS device-distribution add-on).

We waive the 20% beneficiary coinsurance

$0 projected per patient, per year

That's $0/year in projected ACCESS revenue not being captured under these inputs.

Talk to us about reconciliation-ready reporting →

Based on CMS-published ACCESS Model payment amounts (Effective Period Jul 2026–Dec 2027). Actual payments depend on enrollment, outcome attainment, and CMS payment adjustments. Not a guarantee of revenue.

Opportunity 1 · Unenrolled patients

Projected revenue from patients you could enroll but haven't.

Opportunity 2 · Performance upside

Withheld payment recovered in your scenario.

At risk today

Withheld payment your enrolled panel would forfeit at current attainment, under this tool's payout assumption.

Modeling assumption CMS has published that ≥50% attainment earns 100% of the withheld payment, but has not yet published the exact below-threshold reconciliation formula (its payment adjustment code reference is expected later in 2026). This tool assumes the withhold is earned proportionally (OAR ÷ 50%) below the threshold. That is an illustrative assumption, not CMS policy — figures involving sub-50% attainment will change when CMS publishes the formula. Do not use for contractual or financial planning.

Methodology & sources

Payment rates are CMS-published annual allowed amounts per beneficiary (Initial Period, Effective Period Jul 5, 2026 – Dec 31, 2027): eCKM $360, CKM $420, MSK $180, BH $180. Allowed amounts include the 80% Medicare payment and 20% beneficiary coinsurance (which participants may waive under a uniform policy). Rural eCKM/CKM beneficiaries add $15.
MAC corroboration (added 2026-07-11): the first MAC-published operational fee schedule (First Coast Service Options, dated 06/30/2026) lists the OAP billing codes at per-month allowed amounts that annualize to these rates exactly — eCKM initial $30.00/mo (=$360/yr), CKM $35.00 (=$420), MSK $15.00 (=$180), BH $15.00 (=$180); follow-on $15.00/$17.50/$7.50 (=$180/$210/$90), no MSK follow-on code. OAP amounts appear flat national (no locality pricing) on that schedule. It is a fee schedule only — it does not publish the below-threshold reconciliation formula, so the modeling assumption above stands.
Payment mechanics: CMS pays monthly; the sum of monthly payments may not exceed 50% of the Medicare portion. The remaining 50% is withheld and reconciled after the 12-month care period. If ≥50% of your aligned beneficiaries meet all outcome targets (the Outcome Attainment Threshold), you earn 100% of payment. Below that, see the modeling-assumption note above — CMS's exact formula is not yet published.
Opportunity 1 (unenrolled) = (achievable enrollments − current enrollments) × projected per-patient revenue at your scenario OAR. Includes coinsurance (unless waived), which is beneficiary-paid and not outcome-contingent.
Opportunity 2 (performance) = currently enrolled patients × (withhold earned at scenario OAR − withhold earned at current OAR). Medicare-portion dollars only.
Headline per-patient figure = (Opportunity 1 + Opportunity 2) ÷ (newly enrolled + currently enrolled patients) — a blended projection across both gaps, single Initial-Period care year.
Not modeled: Follow-On Period rates (eCKM $180 / CKM $210 / BH $90; MSK has none — roughly half the Initial rates), the Substitute Spend Adjustment (payment reductions above a 90% substitute-spend threshold), the multi-track 5% discount, beneficiary attrition/unalignment, and clinician-side Standard Co-Management payments (billed per review by co-managing clinicians — separate codes with locality-adjusted pricing and a first-month onboarding modifier; not ACCESS-participant OAP revenue).
Sources: CMS, ACCESS Model Payment Amounts and Performance Targets, Effective Period Jul 5, 2026 – Dec 31, 2027 (cms.gov/priorities/innovation/files/access-payments-amts-perf-targets.pdf); First Coast Service Options, ACCESS model HCPCS G-code allowed amounts, 06/30/2026 (medicare.fcso.com/fees/access-model-hcpcs-g-code-allowed-amounts).

Disclaimer: This calculator provides illustrative projections based on published CMS payment amounts for the ACCESS Model Effective Period (July 5, 2026 – December 31, 2027). Actual payments depend on beneficiary eligibility and alignment, outcome attainment, the Clinical Outcome Adjustment, the Substitute Spend Adjustment, data reporting compliance, geographic adjustments, and other model requirements. Enrollment and attainment defaults are illustrative placeholders, not benchmarks, forecasts, or representations about any product's effect on outcomes. This is not a guarantee of revenue, reimbursement advice, or legal advice. CMS may update rates and rules.