OROutcome RailACCESS Model ROI calculator
How much ACCESS Model revenue are you leaving on the table?
Medicare's ACCESS Model (live since July 5, 2026) pays a fixed annual allowed amount per aligned beneficiary across four clinical tracks — up to $420 per patient, per year — and withholds half of the Medicare portion of the Outcome-Aligned Payment (OAP) until outcomes are reconciled. Use CMS-published rates and your own panel to size the opportunity.
Your patient panel Defaults are illustrative
Enter eligible Medicare patients per clinical track, and how many are enrolled today. The pre-filled counts are placeholders, not benchmarks — estimates are fine.
| Track | Eligible | Enrolled today |
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Assumptions Yours to set
Defaults are illustrative starting points, not benchmarks or predictions. Adjust every value to match your own population and performance data.
$0 projected per patient, per year
That's $0/year in projected ACCESS revenue not being captured under these inputs.
Opportunity 1 · Unenrolled patients
$0
Projected revenue from patients you could enroll but haven't.
Opportunity 2 · Performance upside
$0
Additional Medicare-portion payment earned in your scenario.
At risk today
$0
Medicare-portion payment your enrolled panel would forfeit at current attainment, under CMS's published below-threshold formula.
Payout curve Below-threshold payout follows CMS's published formula, not an assumption of ours. A participant whose OAR is below the 50% Outcome Attainment Threshold earns (OAR ÷ OAT) × the full OAP amount, and the resulting Clinical Outcome Adjustment — defined as 1 − (OAR ÷ OAT) — is capped at a 50% reduction, so the earned share never falls below 50%. Source: CMS, ACCESS Model Request for Applications v1.1 (updated 02-12-2026), pp. 28–31, including CMS's three worked examples; read against primary 2026-07-25. Corrected 2026-07-26: this tool previously applied the proportional factor only to the withheld half and described the curve as unpublished. Both were wrong, and the arithmetic was wrong in the direction that flattered us — it overstated the earned share by up to 25 percentage points in the middle of the sub-threshold band. One residual we flag rather than resolve: the RFA states the adjustment against the "full OAP amount" while the payment amounts PDF (p.3) states it against the "Medicare paid amount"; this tool applies it to the Medicare portion, which is the smaller-divergence reading. Illustrative projection only — do not use for contractual or financial planning.
Methodology & sources
- Payment rates are CMS-published annual allowed amounts per beneficiary (Initial Period, Effective Period Jul 5, 2026 – Dec 31, 2027): eCKM $360, CKM $420, MSK $180, BH $180. Allowed amounts include the 80% Medicare payment and 20% beneficiary coinsurance (which participants may waive by adopting a uniform policy, consistent with model requirements). Rural eCKM/CKM beneficiaries add $15.
- MAC corroboration (added 2026-07-11): the first MAC-published operational fee schedule (First Coast Service Options, dated 06/30/2026) lists the OAP billing codes at per-month allowed amounts that annualize to these rates exactly — eCKM initial $30.00/mo (=$360/yr), CKM $35.00 (=$420), MSK $15.00 (=$180), BH $15.00 (=$180); follow-on $15.00/$17.50/$7.50 (=$180/$210/$90), no MSK follow-on code. OAP amounts appear flat national (no locality pricing) on that schedule. It is a fee schedule only: it carries allowed amounts, not reconciliation rules — the below-threshold formula above comes from the RFA (p.28), not from this schedule.
- Payment mechanics: CMS pays monthly; the sum of monthly payments may not exceed 50% of the Medicare portion. The remaining 50% is withheld and reconciled after the 12-month care period. If ≥50% of your aligned beneficiaries meet all outcome targets (the Outcome Attainment Threshold), you earn 100% of payment. Below that, you earn (OAR ÷ OAT) of the full OAP amount, with the Clinical Outcome Adjustment capped at a 50% reduction (RFA v1.1 pp. 28–31). Two further mechanics from the same section, both in the participant's favour: reconciliation is semi-annual, and CMS applies only one of the two downward adjustments per reconciliation period — the larger of the Clinical Outcome Adjustment or the Substitute Spend Adjustment — never both, to prevent compounding penalties.
- Opportunity 1 (unenrolled) = (achievable enrollments − current enrollments) × projected per-patient revenue at your scenario OAR. Includes coinsurance (unless waived), which is beneficiary-paid and not outcome-contingent.
- Opportunity 2 (performance) = currently enrolled patients × (earned share of the Medicare-portion OAP at scenario OAR − earned share at current OAR), where the earned share is CMS's published curve above. Medicare-portion dollars only.
- Headline per-patient figure = (Opportunity 1 + Opportunity 2) ÷ (newly enrolled + currently enrolled patients) — a blended projection across both gaps, single Initial-Period care year.
- Not modeled: Follow-On Period rates (eCKM $180 / CKM $210 / BH $90; MSK has none — roughly half the Initial rates), the Substitute Spend Adjustment (defined as 1 − (SSR ÷ SST) and capped at a 25% reduction, RFA v1.1 p. 29 — not modeled here because the tool has no substitute-spend input; note that only the larger of it and the Clinical Outcome Adjustment applies in any reconciliation period), the multi-track discount (currently 0% — ACCESS OAP Billing Guidelines §XIII, read 2026-07-26, which supersedes the 5% in the Payment Amounts PDF p.4; CMS states it “may adjust this discount in the future”), beneficiary attrition/unalignment, and clinician-side Standard Co-Management payments (billed per review by co-managing clinicians — separate codes with locality-adjusted pricing and a first-month onboarding modifier; not ACCESS-participant OAP revenue).
- Comparison arm: ACCESS is a model test with a randomized control group. The CMS Eligibility API can return a control-group result, and CMS requires Participants to display fixed, unmodifiable language to that beneficiary. Year-1 randomization is 90:10 intervention-to-control (RFA v1.1, pp. 39–40); CMS may adjust or eliminate it in later years, so this is a year-1 constraint and figures derived from it should not be run forward.
- Sources: CMS, ACCESS Model Payment Amounts and Performance Targets, Effective Period Jul 5, 2026 – Dec 31, 2027 (cms.gov/priorities/innovation/files/access-payments-amts-perf-targets.pdf); CMS, ACCESS Model Request for Applications v1.1, updated 02-12-2026, pp. 28–31 for the payout curve, the two adjustment caps and the semi-annual reconciliation cadence (cms.gov/priorities/innovation/files/access-rfa.pdf); First Coast Service Options, ACCESS model HCPCS G-code allowed amounts, 06/30/2026 (medicare.fcso.com/fees/access-model-hcpcs-g-code-allowed-amounts).
Honest limits. Outcome Rail is in active development and onboarding design partners; it is not yet generally available. Product capabilities are built against CMS's ACCESS reporting Implementation Guide, which is currently in DRAFT status.
Disclaimer: This calculator provides illustrative projections based on published CMS payment amounts for the ACCESS Model Effective Period (July 5, 2026 – December 31, 2027). Actual payments depend on beneficiary eligibility and alignment, outcome attainment, the Clinical Outcome Adjustment, the Substitute Spend Adjustment, data reporting compliance, geographic adjustments, and other model requirements. Enrollment and attainment defaults are illustrative placeholders, not benchmarks, forecasts, or representations about any product's effect on outcomes. This is not a guarantee of revenue, reimbursement advice, or legal advice. CMS may update rates and rules. Not affiliated with or endorsed by CMS.