From Pilots to Paychecks: Why CMMI’s New Models Matter for Risk Adjustment and Quality

The CMS Innovation Center (CMMI), created by the Affordable Care Act (ACA) in 2010 under Section 1115A, designs, tests, and scales payment and service‑delivery models that improve quality while lowering cost across Medicare, Medicaid, and CHIP, launching 50+ models to date, from ACOs to bundled payments. Recently, they released a flurry of new models, and understanding these models and their potential impact are important because they directly change how revenue is earned, how patient complexity is recognized, and how performance is measured and published.

1) 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 $100M in 30 three‑year cooperative agreements to test whole‑person interventions for those enrolled in original Medicare, such as nutrition, physical activity, sleep, stress, that are not currently covered by original Medicare. The model is voluntary, launches September 1, 2026 with a second cohort in 2027, and will issue a Notice of Funding Opportunity in early 2026. Proposals must include nutrition or physical activity components and can come from a wide array of organizations (CBOs, health systems, FQHCs, rural clinics, academic sites, etc.).

Impact: Although ELEVATE is grant‑funded (not claims‑paid), CMS will generate cost and quality evidence that can shape future coverage and models. Expect heightened attention to measurable outcomes (e.g., function, biometrics) and real‑world effectiveness; inputs that, if later scaled, could influence condition coding expectations and quality benchmarks tied to prevention.

2) 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 beginning July 2026 that tests Outcome‑Aligned Payments (OAPs) for technology‑supported care for those enrolled in original Medicare across four tracks: early cardio‑kidney‑metabolic, CKM (e.g., diabetes, CKD, ASCVD), musculoskeletal pain, and behavioral health (depression/anxiety). The model pays recurring amounts tied to patients achieving outcomes versus activities, with an initial application deadline of April 1, 2026 for a July 2026 start; later applications may start January 1, 2027. Referring clinicians who co‑manage patients may earn ~$100 per beneficiary per year. CMS will publicly report risk‑adjusted outcomes. More importantly, ACCESS expects interoperable data sharing (e.g., integration with HIEs, electronic care‑plan exchange) and will reconcile payments against risk‑adjusted outcomes, pushing RA/QI to standardize data capture, close gaps, and ensure numerators/denominators are accurate across systems.

FDA linkage (TEMPO) model: The FDA’s TEMPO pilot allows up to ~40 digital‑health manufacturers to seek enforcement discretion (e.g., premarket review) while collecting real‑world data in alignment with ACCESS, creating a coordinated path from evidence to reimbursement. Statements of interest opened January 2, 2026.

Impact: ACCESS is explicitly outcomes‑based, with performance risk‑adjusted and publicly visible, pushing participants to master accurate baseline assessment, longitudinal data capture, and stratified outcomes reporting. Successful programs will align HCC capture (to reflect patient complexity) with condition‑specific targets (e.g., A1c, BP, PHQ‑9), improving both RAF integrity and quality performance. For enablement partners with strengths in risk adjustment, data integration, and engagement, ACCESS rewards closing clinical gaps that move the needle on outcome denominators. ACCESS expects interoperable data sharing (e.g., integration with HIEs, electronic care‑plan exchange) and will reconcile payments against risk‑adjusted outcomes, pushing standardized data capture, care gap closure, and ensuring numerators/denominators are accurate across systems.

3) LEAD: The Successor to ACO REACH—Longer Horizon, 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 CMS test to date. LEAD aims to lower barriers to ACO participation, especially for small/rural practices and specialized/high‑needs providers, with improved benchmarking, enhanced cash‑flow flexibility, and patient‑centric tools; RFA opens March 2026. CMS material and expert briefings indicate global (100/100) and professional (50/50) risk options, and a planning phase to pilot Medicaid integration in two states. LEAD also will focus on better serving coordinated care for high-needs patients, such as those dually eligible for Medicare and Medicaid, and those who are homebound or home limited.

Impact: Expect updated risk adjustment and benchmarking to better reflect complexity and reduce adverse selection, alongside prevention‑focused quality measures and stronger expectations for coordinated, accountable care. Accurate diagnosis capture and closing care‑gap measures (e.g., chronic disease control, avoidable utilization) will be central to sustaining favorable benchmarks and shared‑savings yield. LEAD explicitly seeks to draw in smaller, independent, rural practices and organizations serving high‑needs patients (including homebound and duals), with improved tools and flexible cash flow, altering attribution, networks, and outreach strategies that underlie both risk adjustment and quality.

4) 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 / pre‑payment review for a defined list of low‑value or FWA‑prone services in six states from Jan 1, 2026–Dec 31, 2031. CMS will use AI/ML plus clinical review through participating tech companies; providers can seek prior auth or accept pre‑payment review. Early documentation identifies ~17 service categories (e.g., epidural steroid injections, certain stimulators, skin/tissue substitutes). It tests the use of enhanced technology in original Medicare to decrease certain wasteful (low-value) services shown to have little to no clinical, evidence-based benefit. Technology companies participating in the model will help streamline the review of medical necessity for select items and services earlier in the claims process to: 1) reduce inappropriate utilization, 2) lower spending in Original Medicare, 3) expedite decision making and (4) ease provider administrative burden.

Impact: While not a risk‑bearing model, WISeR may curb overuse that inflates costs without improving outcomes, indirectly affecting utilization profiles that feed benchmarking and quality measures (e.g., procedure rates, complications, avoidable care). Organizations should tighten coverage criteria documentation and ensure that medically appropriate alternatives are offered to protect patient experience and quality. WISeR applies tech‑enabled prior authorization to a defined set of services (e.g., epidural steroid injections, certain nerve stimulators, skin/tissue substitutes), aiming to curb overuse and fraud/waste while preserving appropriate care. Expect shifts in orthopedic, pain, sleep, and wound‑care pathways that influence episode counts and complication rates used in benchmarking.

Next Steps in Developing a Roadmap for Success

CMS is linking payment to measurable outcomes, strengthening risk adjustment/benchmarking for complex populations, and spotlighting prevention and low‑value care reduction. Success will require: (1) precise diagnosis capture and clinical data integration; (2) member engagement that moves clinical endpoints; (3) interoperable, transparent outcomes reporting; and (4) operational readiness for utilization management guardrails like WISeR.

• Map measures to money. For each model, list the metrics that drive payment and where risk adjustment is applied; align documentation and measure logic accordingly (e.g., ACCESS track‑specific endpoints).
• Tighten diagnosis capture. Focus on CKM, MSK pain, and behavioral health categories. Ensure persistence, specificity, and clinical corroboration match outcome targets.
• Stand up outcomes dashboards. Build track‑level views (baseline → target → current), stratified by risk, and validate against model definitions. Be sure to incorporate social determinants of health (SDOH) as part of stratification, since it is a major cost and outcome driver.
• Track referral patterns and outcomes, and pay attention to closure of the referral loop, including for those intended to address SDOH.
• Prepare a WISeR playbook. If operating in the six pilot states, codify medical‑necessity checklists and pre‑service documentation for the 17 service categories to minimize denials and rework.
• Check data infrastructure and status of interoperability initiatives. Confirm HIE connections, EHR data fields, and device/RPM feeds support ACCESS reconciliation and public reporting.

Conclusion

The mandate is clear with these new CMMI models: capture diagnoses accurately, standardize interoperable data flows, and engage patients in ways that move condition‑specific endpoints. Organizations that operationalize this now by building track‑level dashboards, tightening documentation, and preparing for WISeR guardrails will outperform as ACCESS, LEAD, and MAHA ELEVATE mature. In short, the winners will code and document completely and accurately, prove what improved, and make prevention and coordinated care pay.

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.

 

Dawn Carter, BSBA, MHA, CPC, CRC, CPMA, CDEO, CPCO, AAPC Fellow
Sr. Director, Health Policy and Regulatory Affairs
Centauri Health Solutions, Inc.