By Marilee Benson

CMS just announced the biggest Medicare opportunity for digital health in a decade. Here’s what it means for you.

1. For the first time, CMS is opening a real payment pathway for health tech – not just EMRs

Until now, Medicare incentive programs have been the domain of certified EHR vendors. Meaningful Use, Promoting Interoperability – if you weren’t an EMR, you were on the outside looking in.

ACCESS changes that.

The Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model is a 10-year program that pays for outcomes in chronic disease management using technology-enabled care. Not just EMRs. Digital health apps. Remote monitoring platforms. Telehealth. Coaching and behavioral support tools. If you build technology that helps people manage chronic conditions, there’s now a federal reimbursement path that didn’t exist six months ago.

This is the first CMS incentive program with a broader impact for health tech beyond certified EMR technology. That’s not a small thing – it’s a fundamental shift in who gets to participate in Medicare payment models.

Action step: Review the four clinical tracks (early cardio-kidney-metabolic, cardio-kidney-metabolic, musculoskeletal, behavioral health) and determine which ones your product could support. If you touch chronic conditions like hypertension, diabetes, obesity, chronic pain, depression, or anxiety – this applies to you.

2. If commercial reimbursement has been a grind, this is your answer

Let’s be honest: getting paid for digital enabled chronic care has been painful. Payer-by-payer negotiations. Inconsistent coverage. Pilot programs that go nowhere. Commercial coverage for remote monitoring has been contracting, not expanding.

ACCESS offers something different: a sustainable, decade-long federal payment pathway to 26 million Medicare fee-for-service beneficiaries.

The payment model is outcome-aligned – providers get paid for hitting clinical targets (blood pressure reduction, A1C control, validated patient-reported outcomes), not for logging activities or minutes. Patient cost-sharing is waived, which removes a major enrollment friction point. And referring providers can bill a co-management payment of approximately $100 per year per patient for staying involved in care coordination.

For digital health companies that have been fighting for reimbursement, ACCESS is the first scalable path to recurring Medicare revenue.

And the opportunity may extend beyond Medicare. When CMS creates a reimbursement pathway, commercial payers often follow. ACCESS could be the proof point that unlocks broader coverage.

The timeline:

• January 12, 2026: Applications open
• April 1, 2026: First deadline
• July 1, 2026: Model launches
• Rolling applications through 2033

Action step: Model the revenue opportunity. How many of your current or potential customers serve Medicare FFS populations? What would outcome-aligned payments look like for your product at scale? Start building the business case now.

3. Providers will ask one question: What’s your interoperability strategy?

Here’s the requirement that’s getting buried in the coverage: participants must integrate with a Health Information Exchange (HIE) or similar trusted network to allow referring clinicians to access updates securely.

This isn’t optional. CMS expects bidirectional data exchange with primary care practitioners and ACOs. Future rulemaking may require FHIR-based APIs or TEFCA-aligned exchange standards.

What does bidirectional actually mean? It means you can’t just send a PDF report back to a doctor via secure mail and call it a day. You need to receive referrals. Ingest medication lists. Consume patient history. Share care plans electronically at key milestones – treatment initiation, completion, and clinical progress points.

If your app is a data island, or integrations take months, you could be locked out of this opportunity.

Providers evaluating tech partners for ACCESS will ask one question: How are you handling the interoperability requirements? If you don’t have an answer, you’re not in the conversation.

For health tech vendors who enable chronic care management, TEFCA is the only way to scale nationwide access to clinical data. The vendors who figure this out first will win the deals.

Action step: Map your current data exchange capabilities. Can you receive clinical data, or do you only send it out? Do you have HIE (regional or state) connections? A national network or TEFCA strategy? If the answer is “no” or “I don’t know,” that’s your gap.

4. Outcomes reporting is your job, not the provider’s

ACCESS is an outcomes-based model. CMS will determine payment based on the overall share of an organization’s patients who meet their defined outcome targets, compared to a minimum threshold that increases each year.

That means you need to measure results – and you need to build that capability into your product.

If you’re expecting providers to figure out how to track outcomes on their behalf, you’ve already lost. They have enough to do. The reporting infrastructure needs to be baked into your application. How are you going to demonstrate that a patient’s blood pressure dropped 10 mmHg? Has their A1C improved? Have their depression scores moved in the right direction?

Participants must report required measures to CMS using standards-based APIs. CMS will release an implementation guide with additional details, but the expectation is clear: if you want to get paid for outcomes, you need to prove outcomes.

Action step: Inventory the outcomes you can currently measure and report. Blood pressure? A1C? Weight? Pain scores? PHQ-9 for depression? Identify the gaps between what you track today and what ACCESS will require. That’s your product roadmap.

5. Don’t be a month late

CMS is moving fast. The ACCESS Model was announced on December 1, 2024. Applications open January 12, 2026. The first deadline is April 1. Launch is July 1.

Things are also still evolving. Payment amounts haven’t been finalized. Key details on risk adjustment methodology and technical requirements are still being clarified. The FDA’s companion TEMPO pilot for enforcement discretion on certain digital health devices is running in parallel.

You don’t want to be reading about this a week after something important changed.

Three things to do now:

1. Audit your data exchange capabilities. Can you receive clinical data, not just send it? Do you have an HIE integration path? A TEFCA strategy?
2. Assign someone to track CMS rulemaking. The ACCESS Model Interest Form will keep you notified of updates. Someone on your team should own this.
3. Talk to your interoperability partner. The vendors who are ready when applications open will have a significant head start.

Further Reading

Deep dives on the model:

• Trey Rawles’ analysis on ACCESS – comprehensive breakdown of the payment mechanics, market sizing, and investment implications (paid newsletter)
• ATI Advisory: Unpacking ACCESS – overview of the model structure and next steps for providers and tech vendors
• Coral Health Advisors: What You Need to Know About ACCESS – analysis of how ACCESS fits with existing digital care programs
• Modern Healthcare: CMS puts digital health into the spotlight with ACCESS Model – reactions from health tech CEOs on what the model means for the industry

Interoperability context:

• Brendan Keeler’s Health API Guy – essential reading on healthcare interoperability, TEFCA, and CMS policy
• TEFCA Overview from ASTP – the federal framework for nationwide health information exchange

Primary sources:

• CMS ACCESS Model page – official program overview
• ACCESS Technical FAQ – detailed answers on requirements, timelines, and participation
• ACCESS Model Interest Form – sign up for updates

Not Sure Where You Stand?

Most of the health tech leaders we talk to aren’t starting from zero – they’re trying to figure out which of these shifts actually affects their roadmap, and how urgently.

That’s exactly what our Interop Workshops are for.. No pitch, no pressure – just a quick conversation to help you sort signal from noise. We’ve been doing this work since before TEFCA had a name.

Request an invite to a Zen Interoperability Workshop by emailing us at info@zenhealthcareit.com.

Want to go deeper?

Book a free 15-minute call with a Zen interoperability expert