The Center for Medicare and Medicaid Innovation (CMMI), created by the Affordable Care Act in 2010 (Section 1115A), designs, tests, and scales payment and service-delivery models that improve quality while lowering cost across Medicare, Medicaid, and CHIP. It has launched 50+ experimental payment models, from ACOs to bundled payments. A new wave of models for those enrolled in original Medicare directly reshapes how revenue is earned, how patient complexity is recognized, and how performance is measured.
This article summarizes these new models and their potential impacts, as well as next steps for stakeholders.
MAHA ELEVATE: Lifestyle and functional medicine interventions
What it is: MAHA ELEVATE (Make America Healthy Again: Enhancing Lifestyle and Evaluating Value-based Approaches Through Evidence) funds up to $100 million in 30 three-year cooperative agreements to test evidence-based, whole-person interventions in nutrition, physical activity, sleep, and stress, which are not currently covered by original Medicare. The model is voluntary (Notice of Funding Opportunity early 2026; first cohort launches Sept 1, 2026; second cohort in 2027). Proposals must include nutrition or physical activity and may come from community-based organizations, health systems, Federally Qualified Health Centers, rural clinics, and academic sites.
Impact: Though grant-funded (not claims-paid), ELEVATE builds the evidence base on cost and quality for prevention. If scaled, those findings can influence coding expectations, prevention-focused quality benchmarks, and care-management playbooks.
ACCESS: Outcome-aligned payments for tech-enabled chronic care
What it is: ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) is a 10-year voluntary model starting July 2026. It tests outcome-aligned payments (OAPs), which are recurring payments tied to patients meeting condition-specific targets rather than to delivered activities, across four tracks: early cardio-kidney-metabolic (CKM), such as diabetes, chronic kidney disease, atherosclerotic cardiovascular disease; musculoskeletal pain; and behavioral health (depression/anxiety). The initial application deadline is April 1, 2026, for the start of July; a later cohort may begin January 1, 2027. Referring clinicians who co-manage patients may earn ~ $100/beneficiary/year. Risk-adjusted outcomes will be publicly reported. ACCESS expects interoperable data sharing (HIE connectivity, electronic care-plan exchange) and reconciles payment against risk-adjusted outcomes.
FDA linkage (TEMPO): The Food and Drug Administration’s Technology-Enabled Meaningful Patient Outcomes (TEMPO pilot lets selected digital-health manufacturers request enforcement discretion (e.g., premarket review) while collecting real-world data aligned to ACCESS, creating a coordinated path from evidence to reimbursement (statements of interest opened January 2, 2026).
Impact: ACCESS is explicitly outcomes-based and risk-adjusted, demanding accurate baseline assessment, longitudinal data capture, and stratified reporting. Successful programs align HCC capture (to reflect true complexity) with track-specific targets (e.g., A1c, BP, PHQ-9) and stand-up interoperable data flows that keep numerators/denominators audit-ready.
LEAD: The successor to ACO REACH— Longer honrizon, broader reach
What it is: LEAD (Long-term Enhanced ACO Design) replaces ACO REACH after 2026, running January 1, 2027–December 31, 2036, the longest Centers for Medicare & Medicaid Services (CMS) test to date. It lowers barriers to ACO participation for small/rural practices and specialized/high-needs providers through improved benchmarking, flexible cash flow, and patient-centric tools (request for applications in March 2026). The information on this model to date indicates global (100/100) and professional (50/50) risk options, plus a planning phase to pilot Medicaid integration in two states. LEAD also emphasizes coordinated care for high-needs patients, including the dually eligible and homebound.
Impact: Expect updated risk adjustment and benchmarking to better reflect complexity and reduce adverse selection. Sustained performance will hinge on accurate diagnosis capture, prevention-focused measures, and closing gaps that drive avoidable utilization. LEAD’s design alters attribution, networks, and outreach for organizations serving complex populations.
WISeR: Targeted prior authorization to reduce low-value care
What it is: The WISeR (Wasteful and Inappropriate Service Reduction) model pilots technology-enhanced prior authorization or pre-payment review for a defined list of low-value or fraud, waste, and abuse-prone services in six states from January 1, 2026–December 31, 2031. CMS combines AI/ML with clinical review through participating tech companies; providers can submit prior authorization or accept pre-payment review. Early documentation lists ~17 service categories (e.g., epidural steroid injections, specific stimulators, skin/tissue substitutes). The goal: reduce inappropriate utilization, lower spending, expedite determinations, and ease administrative burden.
Impact: WISeR is not risk-bearing, but it will shift utilization patterns, especially in orthopedics, pain, sleep, and wound care, affecting benchmarking inputs (procedure rates, complications, avoidable care). Organizations should tighten coverage-criteria documentation and proactively route patients to clinically appropriate alternatives to protect quality and patient experience.
What leaders should do now
· Map measures to money: For each model, identify the measures that drive payment and where risk adjustment applies; align documentation and measure logic accordingly (e.g., ACCESS track endpoints).
· Tighten diagnosis capture: Focus on CKM, musculoskeletal pain, and behavioral health; prioritize specificity, persistence, and clinical corroboration to match outcome targets.
· Stand up outcomes dashboards: Build track-level views (baseline → target → current), stratified by risk and social determinants of health (SDoH), and validate against model definitions.
· Close the loop on referrals: Monitor referral patterns, completion, and outcomes, including referrals addressing SDoH, to ensure accountability across partners.
· Harden interoperability: Confirm HIE connections, FHIR-based exchange, and device/RPM feeds to support ACCESS reconciliation and any required public reporting.
Conclusion
More than ever before, these models push the market to “prove what improved.” With these models, CMMI moves to tie payment to measurable outcomes, strengthening risk adjustment and benchmarking for complex populations, and spotlighting prevention while curbing low-value care. Organizations that proactively move now by tightening documentation, operationalizing interoperable data flows, and engaging patients to hit condition-specific targets, will be best positioned as these models mature.
Reach out to the experts at Centauri for a deeper understanding of these models, their impacts, and how Centauri can support your end-to-end strategy with a sharp focus on risk adjustment integrity and true interoperability.
About the author
Dawn Carter, BSBA, MHA, CPC, CRC, CPMA, CDEO, CPCO, AAPC Fellow, senior director, health policy and regulatory affairs at Centauri Health Solutions. Her career in health care spans 30 years, which most recently includes extensive experience in developing revenue integrity software solutions focusing on encounter management, risk adjustment, and social determinants of health for the Medicare Advantage, Medicaid, and Commercial health plan markets. She also provides revenue cycle and risk adjustment strategic advisory services for these markets. Prior to that, her experience spans all domains of health care including health plan claims/EDI, enrollment and provider systems administration, finance, compliance, and health care applications development. Her experience also includes multiple teaching engagements in medical administration, billing, and coding. She is a passionate and prolific industry speaker, author, blogger and subject matter expert in claims, EDI management, risk adjustment, and social determinants of health.
Carter holds the following certifications, in addition to a Bachelor of Science degree in Business Administration, a Master of Science in Healthcare Administration, and is a Doctoral Candidate in Business Administration, Healthcare Management: Certified Professional Coder (CPC); Certified Risk Adjustment Coder (CRC); Certified Professional Medical Auditor (CPMA); Certified Documentation Improvement Expert – Outpatient (CDEO); Certified Compliance Professional Compliance Officer (CPCO); and Certified Scrum Master and Scrum Product Owner (CSM/CSPO).