CMMI payment models signal broader Medicare reimbursement shifts

CMS’s Center for Medicare & Medicaid Innovation (CMMI) was busy during the last two months of 2025, announcing a number of new models designed to improve healthcare and keep costs in check. Some address specific priorities of President Donald Trump or HHS Secretary Robert F. Kennedy Jr.

New models scheduled for implementation over the next year will join the previously announced TEAM (Transforming Episode Accountability Model) and Ambulatory Specialty Model (ASM), which are mandatory episode-based payment models for, respectively, hospitals and physician specialists in selected markets.

TEAM began Jan. 1, while the ASM is set to start in 2027. Also underway at the onset of 2026 is the WISeR (Wasteful and Inappropriate Service Reduction) Model, which will test a more extensive use of prior authorization in traditional Medicare.

Amid all the new models, “CMMI could be an incredibly consequential avenue to implement what should probably be done legislatively — or at least through uniform notice-and-comment rulemaking,” Michael Baker, director of healthcare policy with the center-right think tank American Action Forum, wrote in a blog post.

New models addressing chronic disease management

The voluntary ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model is an effort to reimburse technology-enabled care for preventing and managing chronic disease in traditional Medicare.

Participants in the model will include technology vendors and Medicare Part B providers. To take part, providers must agree to designate a Medicare-enrolled medical director whose role will be to ensure care quality and compliance with model requirements.

Payments will be based on the share of patients who meet defined outcomes within the designated clinical tracks (e.g., cardio-kidney-metabolic conditions). Referring clinicians can bill for a new payment covering documented review and coordination activities.

Technology that is expected to be covered in the model includes telehealth, wearable monitoring devices, and health and wellness apps. Clinical consultations, care coordination and medication management are among the services that will be reimbursable, as is lifestyle and behavioral support.

A companion model to ACCESS is being introduced by the Food and Drug Administration. Known as the TEMPO (Technology-Enabled Meaningful Patient Outcomes) Pilot, it will adjust the agency’s enforcement protocols to better ensure the availability of digital health devices that can be included in ACCESS.

A separate program, the voluntary MAHA ELEVATE (Make America Healthy Again: Enhancing Lifestyle and Evaluating Value-Based Approaches Through Evidence) Model, will test up to 30 evidence-based proposals for whole-person functional or lifestyle medicine interventions that can be used in traditional Medicare. Health systems and accountable care organizations (ACOs) are among the entities invited to apply to participate.

The National Association of ACOs (NAACOS) said ACOs likely “will be interested in pursuing this opportunity to build on their local efforts to help advance preventive and integrative care strategies that could shape future Medicare payment policies.”

Drug pricing models using international benchmarks

A pair of proposed mandatory models incorporate an international pricing benchmark for drug manufacturers, an approach favored by Trump dating back to his first term.

The GLOBE (Global Benchmark for Efficient Drug Pricing) Model would replace the inflation-based metrics that currently determine rebates in Medicare Part B, instead tying rebates to international prices. Drugs proposed for inclusion in the model are designated single-source products with Part B allowed charges exceeding a specified threshold over a year-long period. Any drug for which Medicare negotiates the price under the Inflation Reduction Act will be excluded from the model.

Parallel to GLOBE, the GUARD (Guarding U.S. Medicare Against Rising Drug Costs) Model is an attempt to reduce out-of-pocket costs in Medicare Part D by requiring manufacturer rebates when the price of the drug exceeds a baseline derived from prices paid by comparable countries.

Over the five-year time frame for the models, CMS projects Medicare savings of $11.9 billion for GLOBE and $14.1 billion for GUARD. As proposed mandatory models, both are subject to a notice-and-comment period that ends Feb. 23.

A voluntary demonstration, the BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth [sic]) Model gives manufacturers of GLP-1 drugs the option to negotiate with CMS on pricing and coverage terms in Medicare Part D and Medicaid. Terms up for negotiation include coverage criteria and the availability of accompanying lifestyle support programs. Part D plans and state Medicaid programs can opt in to the model if they agree to use the negotiated terms.

The new models join another pilot announced earlier in 2025, the GENEROUS (GENErating cost Reductions fOr [sic] U.S. Medicaid) Model, which is voluntary for manufacturers and seeks to bring most-favored-nation drug pricing to Medicaid.

Accountable care after ACO REACH

The LEAD (Long-term Enhanced ACO Design) Model for ACOs marks the next phase of CMS’s accountable care efforts that began with the ongoing Medicare Shared Savings Program and continued with several defunct models and most recently with ACO REACH (Realizing Equity, Access and Community Health). Designed to promote the concept of direct contracting in Medicare, REACH is set to conclude its four-year run at the end of 2026.

CMMI says a focus of the LEAD model will be incorporating rural and independent physicians through accommodations such as flexible benchmarking and add-on payments to help them get a foothold in accountable care.

One way the agency hopes LEAD will apply lessons learned in ACO REACH is by better facilitating ACO contracting with physician specialists. CMS plans to manage those arrangements, ostensibly removing some of the administrative burden from the providers.