ACCESS-Aligned: What Health Plans Will Start Asking Vendors

On July 5th, CMS launched the ACCESS Model, a 10-year voluntary Medicare payment test paying for outcomes across four chronic care tracks. Alongside it, CMS shipped a full replication kit for the private payer market, and 14 of the largest health plans in the country signed the ACCESS Aligned Payer Pledge, covering 165 million member lives across Medicare Advantage, Medicaid, and commercial coverage, committing to offer ACCESS-Aligned arrangements by January 1, 2028. The surprise: the questions health plans will start asking vendors about outcome thresholds, defined care periods, and coordination with other providers start showing up in RFP language as early as this fall, whether or not the plan running the evaluation signed the pledge.

In this episode of the Upward Growth Podcast, Ryan Peterson walks through what ACCESS-Aligned means for health tech vendors selling into health plans, and what the evaluation question set will look like over the next 24 months. The episode goes one level deeper on why ACCESS-Aligned language lands in Q4 RFPs, unpacks the PE-side diligence patterns Ryan has been hearing over the last two weeks, and lays out what to do between now and the end of Q3 if your outcome story is not ready.

What you'll hear:

• What ACCESS-Aligned means, why the four principles are the anchor, and how the replication kit (sample provider agreement, standardized G-codes, CMS-hosted FHIR API) compresses private payer adoption timelines
• Why plans that never signed the pledge, and may not have Traditional Medicare business at all, end up asking the same questions in their vendor evaluations
• Which health tech categories just got elevated (cardio-kidney-metabolic, MSK, behavioral outcome measurement, care coordination, outcome measurement infrastructure), and which got deprioritized
• How ACCESS-Aligned reaches your buyer across Medicare Advantage (via the MA signatories), Medicaid (via Centene), and self-insured employer (via CVS Health)
• The 18-month timeline of milestones to watch, starting with when CMS publishes the sample provider agreement
• The specific instructions for vendors between now and the end of Q3, and why the repositioning window closes mid-2027

Read the full analysis in the Upward Growth newsletter: What the ACCESS Model Signals About Where CMS Wants Outcome-Based Chronic Care to Go

About Upward Growth: Upward Growth is a health plan market advisory firm. We work with health tech vendors, investors, provider organizations, and management consultancies on how health plans actually buy, operate, and make decisions. 

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Connect with Ryan on LinkedIn: https://www.linkedin.com/in/ryan-peterson-1a20866/

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Transcript

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This is the Upward Growth Podcast, and this week's episode pairs with the article that came out on July 14th titled What the Access Model Signals About Where CMS Wants Outcome Based Chronic Care to Go. And that article is live on our Substack at Upwardgrowth.substack.com. Today I'll be walking through which health tech categories just got re-rated, the specific channels this reshapes over the next 24 months, and why this framework starts showing up in every plan's RFP language as early as this fall, whether or not that health plan running the evaluation signed the pledge. If you sell chronic care to a health plan, or if you invest in a company that does, your buyer's evaluation criteria just got repriced. On July 5th, CMS launched the Access Model. It's a 10-year voluntary Medicare payment test paying participants for outcomes across four chronic care tracks. Two of them are cardio kidney metabolic, split between early conditions like hypertension and prediabetes, and advanced conditions like diabetes and CKD. The other two are musculoskeletal chronic pain and behavioral for anxiety and depression. And payment rates run $90 to $420 per beneficiary per year, with half held back until outcome reconciliation. Now there's a second piece to the July 5th launch. Around the Medicare test, CMS also shipped a full replication kit for the private payer market. It includes four principles that define what makes a chronic care management access aligned, a sample provider agreement structure, standardized billing codes for each track, and a CMS-hosted FIRE API for outcome measurement that both participants and aligned payers can plug into. Most of that ships in phases through late 2026 and 2027. Then there's the payer pledge. In February, 14 of the largest health plans in the country signed something called the Access Aligned Payer Pledge. Humana, United Healthcare, Cigna, CVS Health, Centeen, Devoted, and 7 Blues plans. Together they cover about 165 million member lives across Medicare Advantage, Medicaid, and commercial coverage. And they publicly committed to offer chronic care payment arrangements aligned with the model's core principles by January 1st, 2028. So what CMS shipped on July 5th is a reference architecture for outcome-based chronic care, and a substantial share of the private payer market has publicly committed to build against it. The way that reshapes what you actually experience selling into the market is not something you will feel in January 2028. It's actually something you're going to feel with health plan conversations as early as this fall. Let me go one level deeper than the article did. And here's why the frameworks show up in every plan's RFP language as early as this fall, even if a plan never signed the pledge. It comes down to what CMS actually built and who signed on to use it. Prior CMMI tests were bespoke Medicare experiments, each with their own contract structure, its own measurement methodology, its own reporting requirements. Vendors watched them come and go, investors mostly ignored them, and consultancies earned some fees on the ones that stuck. But the private payer market never picked up on most of them because there really wasn't much to pick up. Each test was too custom to replicate. What CMS built around access is a full replication kit. The four principles are the anchor. They are predictable recurring payments, accountability for clinical improvement or control, flexibility and care delivery that facilitates technology-enabled care, and coordination with primary care and referring clinicians. Every access aligned private payer arrangement written over the next three years traces back to those four principles. Then the operational collateral wraps up around them. See a sample provider agreement means the contract language does not have to be rebuilt from scratch. Standardized codes for each track means that the claims plumbing already exists. A federally hosted fire API means the payer does not have to stand up its own outcome measurement infrastructure. The whole build gets outsourced to the federal government. The measurement infrastructure, the contract language, the actuarial work to price and arrangement, all of it becomes a plug-in kit a plan can adopt off the shelf. Now there's a fair caveat worth naming. Signatories are not committed to copy the model verbatim. Each one does retain discretion on which conditions they target, which outcomes they measure, and which vendors they work with. It's a commitment and offer an access aligned option, not a uniform contract each signatory will execute. Read strategically, that distinction changes very little. When Cigna and United Healthcare start asking their vendors about access aligned principles during the next RFP cycle, competitor plans are going to be borrowing that question set within the year. And so the framework becomes the market's evaluation lens, regardless of whether the plan running the evaluation signed on or even has traditional Medicare business at all. Which health tech categories actually got repriced by all this? Well, that's the question we're spending a few minutes on, because it's the piece that most directly changes what your buyer thinks your product is worth. It broke into a group that got more valuable to health plan buyers this month and a group that got less valuable, starting with the ones on the way up. The clearest winner here is longitudinal chronic condition management with outcome accountability, particularly the cardio kidney metabolic stack. If you manage a chronic condition end-to-end and you can prove outcome performance over a defined care period, Access just validated your category. The label alone doesn't earn it, but what it does earn is a longitudinal accountability for outcomes against a public threshold, with technology-supported care as the delivery method. The second lift went to behavioral outcome measurement. The anxiety and depression track puts behavioral outcomes on the same footing as physical health outcomes for the first time. G codes and API infrastructure turn outcome reporting into an administrative workflow instead of a research project. Behavioral health has been the least mature category in the outcomes-based conversation for years, and so having a public federal target to measure against changes that across every plan procurement cycle. Care coordination and multi-vendor attribution moved up too. Access penalizes participants up to 25% if their aligned members are receiving duplicate services from other providers during the care period. To defend against that, you have to know who else is touching your member and what they've billed for. When private payers copy that clause, and they will, they'll need the same visibility. Attribution, care coordination, and multi-vendor claims analytics are more valuable across MA, Medicaid, and commercial lines than they were the week before Access launched. MSK got a lift as well. For years it's been treated as commodity priced and volume-driven work. Then Hinge Health and Omada went public and the market validated the outcome-based digital MSK thesis. Access now puts the same category on the same footing as cardiometabolic inside the federal framework. And outcome measurement infrastructure is the layer everyone needs these categories to run on top of. Every plan that intends to align by January 1st, 2028 needs a measurement layer to do it. Most don't have one built at the scale access aligned reporting is going to require, and the plans that try to build it themselves on their own timeline face a much harder job than the ones that partner. Now for the categories that got deprioritized. Point solutions without a longitudinal outcome story are the first ones to lose ground. If you can't tie your work to a specific outcome threshold measured across the defined care period, your buyer is now discounting you against a competitor who can. Simple as that. Engagement only pitches are the next group that are losing ground. 40% engagement is a features conversation against a framework that pays for outcomes. Your buyers will make that comparison out loud the next time that they are comparing vendors, even if they were willing to accept engagement metrics just a year ago. And the third group is coding focused revenue capture plays, and this is a piece I've been writing about for months. CMS has systematically been pulling risk adjustment arbitrage tools out of Medicare Advantage. Access is the flip side of that same policy strategy. Margin is moving from coding to outcomes, and that shift now has this public framework, standardized billing codes on the way, and the January 2028 deadline attached to it. So how does this actually reshape what health plan buyers are wanting to purchase as soon as the next quarter? That answer breaks up differently depending upon which line of business you sell into, so let's walk through each of them. Medicare Advantage first. The MA signatories on the pledge collectively touch tens of millions of MA lives. Their commitment to align starts affecting MA vendor selection in 2026 and 2027, well ahead of the deadline. If you sell into any of their MA books, the four access aligned principles start showing up in their evaluation criteria as soon as the next quarter. And as we've been talking about, many of these MA plans have already been running a gate with their CFO on outcomes-based evidence since 2025. And that gate just picked up a public federal benchmark to point at. So it's a real tailwind for vendors who already have the evidence and a real problem for those who don't. Next up is Medicaid, and Medicaid runs through Centeen. Centeen holds the largest share of National Medicaid managed care at just under 18% as of Q1 of this year. And their commitment to align doesn't stay in their commercial or MA books. It becomes the template their state Medicaid MCO relationships eventually inherit, because the infrastructure to run these arrangements doesn't cleanly split by line of business. State Medicaid agencies haven't published anything referencing access by name yet, but that's not really where this is going to show up first. It shows up first at the MCO level, which is where the real replication happens. The third channel here is commercial and self-insured employer, and that's going to run through CVS Health. CVS owns CareMark plus a retail pharmacy footprint and a clinical services stack. That combination sits inside vendor selection at most of the largest self-insured employer relationships in the country. So any employer relationship CVS touches is now in the orbit of the pledge. What to watch here is how access aligned payment structures start landing inside self-insured employer contracts through CVS's stack over the next 24 months. If you sell to employer channels through a national PBM or a health services partner, watch for how they start scoping outcomes work over the next four quarters. Here's the pattern I'm hearing on my end over the last couple weeks. Diligence conversations that used to lead with how do you measure engagement? are increasingly asking, what's your outcome accountability story against a public threshold, particularly access. And on the PE side, the question landing more in early diligence is whether the target's product actually maps to one of the four access tracks or one of the adjacent tracks most likely to be added next. The likely next ad tracks are COPD and substance use disorders. Neither of those questions was in the standard early diligence set three months ago. There's one more pattern worth naming. When plans stand up access aligned arrangements, they consolidate around a smaller set of vendors per condition category. They don't spread the work across today's long tail of point solutions. So that kind of consolidation is what plans always do when they operationalize a complex network strategy. And so which side of the consolidation your product sits on gets decided in the next 12 to 18 months. Speaking of the next 18 months, let's take a couple minutes to look at how this plays out. The frame is what we look for and how to read it when it shows up. The first move over the next two to three quarters is CMS publishing the sample provider agreement and finalizing the standardized billing codes for each track. That's when the plugin gets real. Once the sample agreement is out there, plans that sign the pledge stop building alignment mechanics from scratch and start copying. That compresses the timeline for private payer replication. Second, roughly Q1 to Q2 of 2027, the first access aligned private payer contracts get signed by pledge plans. And once one of the big pledge plans publicly signs an access aligned arrangement with a specific vendor, every peer plan and every peer vendor is going to be reading that contract in the shape of what's coming for them. Third, mid-2027 through late 2027. That's when the buying conversation across MA and Medicaid books actually shifts. Non-signatory plans borrow that question set and start utilizing it against vendor evaluations. And that's when you start seeing consolidation on a curated group of partners per condition category in the deals that actually get signed. The vendors that had repositioned in the back half of 2026 are the ones that might be getting those early consolidation invites. For your watch list over the next quarter, two things are worth tracking. First, when CMS publishes the sample provider agreement, that's the milestone that makes replication cheap. Once it's public, the clock is running on private payer replication. Two, how buyer conversations start changing across MA and Medicaid and Q4 2026. If your team is in the middle of vendor evaluations, pay attention to where language like outcome threshold starts showing up in the questions that you get asked this fall compared to what you were getting earlier this year. That's going to be the earliest signal of the buying motion shifting underneath your feet. If you sell chronic care into health plans, here's what's worth doing between now and the end of Q3. Sit down with your product and marketing team and figure out whether what you sell maps to how access defines an outcome. Saying you improve outcomes isn't going to be enough anymore. What matters is whether you can point to a specific threshold on a specific condition measured over a defined care period and prove your product moves it. If you can, the next 18 months are working in your favor, and you should be leading with that in every buyer conversation between now and the end of 2027. If you can't, the repositioning window is open and it starts closing the middle of 2027. Look, here's why this can't wait. Health plan buyers have been raising the bar on outcomes evidence for two years already. What Access does is put a deadline on that shift. Fourteen of the largest health plans in the country have publicly committed to a specific framework on a specific timeline backed by CMS. That means when the pledge signatories start scoring vendors against Access Aligned Principles, every other plan borrows the same questions. Whether they've signed the pledge, whether they participate in the model, whether they have any traditional Medicare business at all, doesn't matter. Every plan you sell into is going to start looking at your outcome story through this framework. And that starts happening this fall, not in 2028. If your outcome story isn't ready for that framework by Q4, you're going to feel it in the buying conversations you're already having. Alright, that's it for this episode. And if you found it useful, shoot us a note at info at upwardgrowth.com and let us know. We read everything that comes in. And if the show is earning a slot in your week, follow or subscribe on Apple Podcasts or Spotify and leave a rating so the next listener can find the show as well. I'm Ryan Peterson. Here's to Upward Growth.