CMS Payment Model Navigator
Click on the relevant stakeholder category or Centers for Medicare & Medicaid Services (CMS) payment model to access important information on each of these newly announced and launched programs. Please contact our team for additional insights, predictions and recommendations.
Announced Models Only
Implemented Models Only
Mandatory Models Only
Voluntary Models Only
Hospitals and Facilities
Health Technology
Physician Groups
Wellness
Pharmaceuticals
Guarding U.S. Medicare Against Rising Drug Costs
GUARD
Global Benchmark for Efficient Drug Pricing
GLOBE
Better Approaches to Lifestyle and Nutrition to Comprehensive Health
BALANCE
Long-Term Enhanced ACO Design
LEAD
MAHA: Enhancing Lifestyle and Evaluating Value-Based Approaches Through Evidence
MAHA Elevate
Wasteful and Innapropriate Service Reduction
WISeR
Advancing Chronic Care with Effective, Scalable Solutions
ACCESS
Transforming Episode Accountability
TEAM
Increasing Organ Transplant Access
IOTA
Ambulatory Specialty Model
ASM
GENErating cost Reductions fOr U.S. Medicaid
GENEROUS
Managed Care
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Sarah Starling Crossan
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Purpose: MAHA Elevate promotes the Trump Administration's priorities of prevention and lifestyle changes to improve health and manage chronic conditions. CMS will fund up to 30 cooperative agreements that promote functional and lifestyle medicine care approaches (e.g., nutrition, psychological, and physical activity) not currently covered under Original Medicare to support more conventional care. Mandatory or Voluntary? Voluntary. Announced or Implemented? Announced. Participants and Stakeholders: Organizations that provide whole-person functional or lifestyle medicine services directly to patients or partner with other organizations to deliver services. CMS has included a list of potential applicant organizations here. Payment: $100 million total budget to fund up to 30 cooperative agreements. Time Frame and Important Dates: Notice of Funding Opportunity (NOFO) will be released in early 2026. The first cohort will begin participation in September 2026, and a second cohort will begin in 2027. The agreements will be funded for a three-year performance period to collect quality and cost data on whole-person functional or lifestyle medicine interventions.
Make America Healthy Again: Enhancing Lifestyle and Evaluating Value-Based Approaches Through Evidence (MAHA ELEVATE)
Purpose: WISeR is aimed at reducing waste, fraud, abuse and low-value care in Original Medicare for select items and services by enhancing the prior authorization and pre-payment review processes using advanced technologies, including artificial intelligence (AI) and machine learning (ML). CMS will partner with technology vendors experienced in AI/ML-assisted prior authorization to review services identified as particularly vulnerable to inappropriate use, subject to final review by licensed clinicians. See list of covered items and services at Appendix A here. Mandatory or Voluntary? Voluntary, although providers in model states must choose to submit a prior authorization request or go through a post-service, pre-payment review. Announced or Implemented? Implemented, but only in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. Note that services involving skin or tissue substitutes are limited to states with an active local coverage determination (LCD) as of November 21, 2025. Participants and Stakeholders: Healthcare providers and suppliers as well as technology vendors experienced in AI/ML-assisted prior authorization. The six vendors have been selected. Payment: In a departure from prior authorization laws that generally restrict payment based on coverage determinations, the vendors will receive a percentage of the expenditures associated with averted wasteful, inappropriate care as a result of their reviews. That percentage is adjusted based on the vendor participant’s performance on measures related to the process, including provider experience. The model does not change Medicare payment rates to providers. Time Frame and Important Dates: January 1, 2026-December 31, 2031.
Wasteful and Inappropriate Service Reduction Model (WISeR)
Purpose: Under TEAM, selected acute care hospitals in specified Core-Based Statistical Areas (CBSAs) are held accountable for both the cost and quality of care for Medicare beneficiaries undergoing one of five surgical procedures (joint replacement, hip replacement, spinal fusion, coronary artery bypass graft and major bowel procedures) from the surgical event through 30 days after hospital discharge. TEAM also incorporates care coordination expectations, requiring participants to refer patients to primary care services to support continuity of care and improved recovery outcomes. Mandatory or Voluntary? Mandatory, though an additional 10 hospitals have accepted voluntary election letters. Announced or Implemented? Implemented. Participants and Stakeholders: CMS has released its list of over 700 participating hospitals paid under the Inpatient Prospective Payment System (IPPS) and located in the selected CBSAs. Payment: Hospitals continue to bill Medicare fee-for-service as usual, but CMS compares total episode costs against a risk-adjusted target price (e.g., no risk/lower reward) and reconciles payments based on performance. Strong cost and quality performance can result in bonus payments, whereas higher spending relative to the target may require repayments. Time Frame and Important Dates: January 1, 2026-December 31, 2030.
Transforming Episode Accountability (TEAM)
Increasing Organ Transplant Access (IOTA)
Purpose: IOTA is a two-sided risk, alternative payment model intended to maximize the use of deceased donor kidneys; improve quality of care and care coordination before, during and after kidney transplantation; and identify and assist living donors through the donation process. Mandatory or Voluntary? Mandatory for eligible kidney transplant hospitals in CMS selected donation service areas. Announced or Implemented? Active. Participants and Stakeholders: CMS has released its list of 103 kidney transplant hospitals located in half of the donation service areas. Eligible kidney transplant hospitals are non-pediatric kidney transplant hospitals with an active kidney transplant program performing an average of 11 or more kidney transplants in baseline years before the start of model. Payment: Positive payment adjustments (upside risk) only in Performance Year (PY) 1, but potential for upside or downside risk beginning in PY 2 based on final performance scores assessing the number of kidney transplants, the organ offer acceptance rate ratio and the post-transplant composite graft survival rate. Performance-based payment with maximum upside risk payment of $15,000 per transplant for high performers and maximum downside risk payment of $2,000 per transplant for low performers. Time Frame and Important Dates: July 1, 2025-June 30, 2031
Purpose: ASM is a two-sided risk, alternative payment model that automatically applies to eligible specialists in selected geographic areas. Focusing on specialist accountability for the management of high-cost, high-variation conditions, including chronic heart failure and low back pain, ASM will evaluate participants based on cost, quality, care improvement activities and interoperability. CMS aims to reduce avoidable hospitalizations, limit low-value services, and promote more efficient, coordinated, and evidence-based ambulatory specialty care. Mandatory or Voluntary? Mandatory for those who meet CMS participation criteria. Announced or Implemented? Announced, though program design was finalized in the calendar year (CY 2027 Medicare Physician Fee Schedule Final Rule on October 31, 2025. Participants and Stakeholders: CMS has released its list of approximately 6,600 participating specialists who meet CMS participation criteria. Under this program, participating specialists are required to maintain a contractual arrangement with at least one primary care provider (PCP). Note that the linked list is preliminary and the final list will be published in summer 2026. Payment: Performance-based adjustments to Medicare Part B payments. Time Frame and Important Dates: January 1, 2027-December 31, 2031. Payment adjustments will occur through 2033.
Ambulatory Specialty Model (ASM)
Purpose: LEAD is positioned as the successor to the Accountable Care Organization (ACO) REACH model, with the CMS Innovation Center emphasizing an expanded role for ACOs and more durable, predictable payment structures. Under LEAD, the CMS Innovation Center aims to refine benchmarking methodologies, increase the use of prospective payments, and introduce new policy flexibilities intended to support long-term investment in population health. This model will focus on prevention, stronger care coordination, and greater patient empowerment, signaling a continued shift toward value-based arrangements that reward proactive, longitudinal management of complex populations. Mandatory or Voluntary? Voluntary. Announced or Implemented? Announced. Participants and Stakeholders: Will likely include current ACO Reach model participants and other ACOs, current Original Medicare providers that have historically not participated in ACOs and healthcare providers servicing underserved populations. Payment: ACOs and preferred providers can select from voluntary risk-sharing options, will receive capitated payments and be paid based on episode-based risk arrangements, called CMS Administered Risk Arrangements (CARA), in addition to quality payments. Time Frame and Important Dates: A forthcoming Request for Applications (RFA) is expected in March 2026.
Long-Term Enhanced ACO Design Model (LEAD)
Purpose: The new ACCESS model tests outcome‑aligned payments for technology-enabled chronic care and provides a reimbursement framework that can help providers adopt remote monitoring devices and AI-enabled applications in routine practice. ACCESS will focus on four clinical tracks: 1) early cardio-kidney-metabolic conditions such as hypertension or obesity, 2) cardio-kidney-metabolic conditions such as diabetes and heart disease, 3) musculoskeletal conditions, and 4) behavioral health conditions. Mandatory or Voluntary? Voluntary. Announced or Implemented? Announced. Participants and Stakeholders: Must be Medicare Part B-enrolled organizations to apply as a participant. More information about participant requirements and responsibilities is available here. Applications will be reviewed on a rolling basis. Payment: ACCESS will use Outcome-Aligned Payments (OAPs), which are recurring payments for managing a patient’s qualifying condition, with payments tied to achieving measurable health outcomes. OAP amounts and performance targets are here. Time Frame and Important Dates: Will launch on July 5, 2026 and run for 10 years. For more information on the U.S. Food and Drug Administration's (FDA) TEMPO Pilot launched in collaboration with ACCESS, click here.
Advancing Chronic Care with Effective, Scalable Solutions (ACCESS)
Purpose: Launched by the FDA in collaboration with the CMS ACCESS model, TEMPO is intended to expand safe access to digital health tools for cardio-kidney-metabolic, musculoskeletal and behavioral health conditions, each representing four clinical use areas aligned to chronic disease management. The FDA will exercise enforcement discretion for certain requirements, such as premarket authorization and investigational device requirements, while manufacturers offer their devices for use within the ACCESS model and collect real-world data demonstrating the device's performance. Mandatory or Voluntary? Voluntary. Will accept up to about 10 manufacturers for each of the four clinical areas. Announced or Implemented? Announced. Will operate as a pilot once participating manufacturers are selected. Participants and Stakeholders: Manufacturers of digital health devices, particularly if such devices have not yet obtained premarket authorization or remain investigational. TEMPO is also relevant to ACCESS participants that will partner with manufacturers to participate in that CMS payment model. Time Frame and Important Dates: Statements of interest were due January 2, 2026. Manufacturer selection is slated for early 2026. Duration of this pilot is to be determined, but expected to last multiple years. Click here to return to ACCESS model.
Technology-Enabled Meaningful Patient Outcomes for Digital Health Devices (TEMPO)
MAHA ELEVATE
Purpose: Under BALANCE, CMS will negotiate pricing and coverage terms with participating manufacturers on behalf of state Medicaid agencies and Medicare Part D plans. Mandatory or Voluntary? Voluntary for manufacturers, state Medicaid agencies and Part D plans. Announced or Implemented? Announced. Participants and Stakeholders: State Medicaid agencies and Part D plans. In addition, manufacturers of GLP-1 receptor agonist drugs used for weight management and metabolic health improvement are eligible if they market or expect to market an eligible product by January 1, 2027. Payment: Subject to negotiated pricing and coverage for these products that would generally be statutorily excluded from coverage otherwise. Time Frame and Important Dates: Manufacturers interested in participating in the model were due to respond to the Request for Applications by January 8, 2026. CMS also announced plans to implement a new Medicare GLP-1 payment demonstration beginning in July 2026, which will serve as a short-term bridge to the model.
Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE)
Purpose: GUARD intends to assess whether an alternative approach to calculating inflation rebates for certain Part D drugs and biological products can reduce Medicare program spending while maintaining or improving enrollee access and quality of care. Under the model, manufacturers would be required to pay a GUARD Model Rebate when a drug’s Medicare net price exceeds an applicable international benchmark, with rebates triggered when U.S. prices are higher than prices paid in comparable countries. Mandatory or Voluntary? Mandatory (as proposed). Announced or Implemented? Announced. Participants and Stakeholders: Manufacturers of certain drugs included in the Medicare Part D Drug Inflation Rebate Program, with a focus on sole-source drugs and sole-source biologics in specified therapeutic categories and subject to proposed inclusion and exclusion criteria. Payment: Manufacturers would use an alternative calculation for rebates under Medicare Part D. Time Frame and Important Dates: January 1, 2027-December 31, 2031, with rebate invoicing and reconciliation continuing into 2033.
Guarding U.S. Medicare Against Rising Drug Costs (GUARD)
Purpose: GENEROUS aims to ensure ensure fair and reasonable drug prices under Medicaid through CMS-led negotiations with drug manufacturers. Manufacturers would provide supplemental rebates to participating states for drugs included in the model to align Medicaid net prices with international benchmarks. Mandatory or Voluntary? Voluntary. Announced or Implemented? Announced. Participants and Stakeholders: State Medicaid agencies approved for participation by CMS and drug manufacturers with an active Medicaid Drug Rebate Program agreement. Medicaid agencies must enter into Supplemental Rebate Agreements through the State Plan Amendment process and implement management, operational and system requirements to support the model. Will also need to align coverage policies with Medicaid managed care organizations (MCOs). Payment: Manufacturers would be required to pay a Medicaid supplemental rebate to participating states. Time Frame and Important Dates: January 2026 for five years. CMS is aiming to have all manufacturer participation agreements executed before June 30, 2026. Participating Medicaid agencies must enter into agreements with the manufacturers before August 31, 2026.
GENErating cost Reductions fOr U.S. Medicaid (GENEROUS)
Purpose: GLOBE is designed to test whether an alternative approach to calculating Part B inflation rebates for certain separately payable drugs and biological products can reduce costs for Medicare fee-for-service beneficiaries and the Medicare program while preserving or enhancing quality of care. Manufacturer rebates would be triggered when a drug's price exceeds an applicable international benchmark derived from prices paid in comparable countries. Mandatory or Voluntary? Mandatory (as proposed). Announced or Implemented? Announced. Participants and Stakeholders: Manufacturers of high-expenditure, Part B rebatable drugs, limited to single-source drugs and sole-source biological products that fall within one of seven USP Drug Classification categories – antigout agents, antineoplastics, blood products and modifiers, central nervous system agents, immunological agents, metabolic bone disease agents, and ophthalmic agents – and that exceed $100 million in annual Medicare Part B fee-for-service allowed charges. CMS proposes excluding drugs with HCPCS Level II codes when payment is based on a negotiated maximum fair price, and it is seeking comment on other inclusion and exclusion criteria. Payment: Manufacturers would use an alternative calculation for rebates under Medicare Part B. Time Frame and Important Dates: October 1, 2026 through 2031, with rebate invoicing and reconciliation continuing into 2033.
Global Benchmark for Efficient Drug Pricing (GLOBE)
