Starting in spring 2027, the Centers for Medicare & Medicaid Services will let beneficiaries with heart failure, chronic obstructive pulmonary disease, substance use disorders or nicotine dependence enroll in a disease-management program that pays participating organizations for measurable health gains rather than for individual office visits. The expansion, announced September 15, extends CMS’s existing ACCESS Model to four conditions common among older Americans. The catch is stated plainly in the agency’s own release: the new tracks belong only to Original Medicare. Anyone who instead carries a Medicare Advantage plan cannot enroll, whatever their diagnosis, though CMS notes a private plan may run something comparable on its own.
A Payment Design Built Around Fee-for-Service Claims
The ACCESS Model — Advancing Chronic Care with Effective, Scalable Solutions — already covers high blood pressure, diabetes, chronic musculoskeletal pain and depression, and roughly three out of four Medicare beneficiaries already qualify for at least one existing track. The model pays participating organizations for documented improvements in a patient’s health rather than for each office visit, measuring outcomes against CMS’s fee-for-service claims data. That measurement method is built around Original Medicare’s per-service billing, not the flat monthly payments CMS already sends Medicare Advantage insurers for each enrolled member.
The four tracks CMS is adding start in spring 2027: heart failure, chronic obstructive pulmonary disease, substance use disorders and tobacco cessation, alongside an expansion of the existing musculoskeletal-pain track beyond its initial 12-month care period. CMS Administrator Mehmet Oz framed the additions as a response to patients who were, in his words, “falling through the cracks between appointments,” and pointed to AI-enabled monitoring tools tied to compensation for results rather than volume of services.
Heart failure and COPD support under the model centers on continuous monitoring tied to measurable gains in function, symptom management and quality of life, rather than a fixed bundle of services; CMS describes the design as flexible enough to vary by participating organization as long as the tracked outcomes improve. Tobacco cessation, the fourth new track, is folded in as a stand-alone benefit rather than one attached only to patients with a heart or lung diagnosis, meaning a beneficiary could qualify for it without either condition.
Free download: How to read the Annual Notice of Change, spot the cost, drug and network changes, and decide whether to keep or switch. Get the free 2027 plan-change checklist.
What Newly Eligible Beneficiaries Actually Get
Participating organizations in the ACCESS Model can offer virtual care, health coaching, remote monitoring and connected devices between a beneficiary’s regular doctor visits, integrated with referrals from primary care rather than replacing that care. Enrollment is voluntary and does not change a beneficiary’s Medicare benefits, coverage or choice of provider, and CMS is building a directory at Medicare.gov/ACCESS listing which organizations serve which conditions in which areas, since not every organization will offer every track everywhere.
The substance use disorder track folds in support for opioid, alcohol and other substance use disorders along with co-occurring depression and anxiety, and CMS ties that piece explicitly to the administration’s broader Great American Recovery initiative on addiction. The number of organizations participating at launch stands at 160, a figure CMS says will grow over the model’s ten-year run, which began its performance period in July 2026 covering the original four conditions.
The timing lands inside this year’s annual Medicare enrollment season, when beneficiaries choosing between Original Medicare and a Medicare Advantage plan for 2027 are weighing drug coverage, provider networks and premiums months before the new ACCESS tracks themselves become available. A beneficiary who values the added heart failure or COPD support has to commit to Original Medicare during this fall’s decision and then wait for spring, with no guarantee a participating organization already serves that beneficiary’s area.
A Parallel Track for Advantage Insurers That Isn’t the Same Program
Separately, major health payers covering more than 165 million Americans across Medicare Advantage, Medicaid and private insurance pledged in February 2026 to adopt an outcomes-based payment structure aligned with ACCESS’s principles by January 1, 2028. Signatories include Humana, UnitedHealthcare, Cigna, CVS Health and Centene, insurers that collectively cover a large share of Medicare Advantage enrollment. The pledge commits those payers to adopt similar payment principles inside their own plans; it does not enroll a single Medicare Advantage member in the federal ACCESS Model itself, and it carries no requirement that the four new condition tracks specifically be replicated.
That distinction is the one CMS’s own announcement draws when it notes that Medicare Advantage plans “may offer similar programs” without committing to what those programs contain, when they start, or whether they cover heart failure and COPD on the same terms as the federal model. A Medicare Advantage enrollee with one of the four newly added conditions has no federal directory to consult and no CMS outcome measurement standing behind whatever their insurer chooses to build, leaving the scope of any equivalent benefit entirely up to each plan.
The ten-year window CMS set for ACCESS means the split between what Original Medicare offers directly and what Medicare Advantage insurers offer voluntarily could persist for most of a decade unless CMS extends the model’s design to capitated payment. For now, the agency’s own language is unambiguous: Original Medicare carries the ACCESS Model, and Medicare Advantage’s version of the same coverage question is deferred entirely to a plan a beneficiary already chose without knowing the answer.
Comparing Original Medicare and Advantage on Benefits
Nothing in CMS’s announcement tells a beneficiary already leaning toward Medicare Advantage what that specific plan covers for heart failure, COPD, substance use disorder or tobacco cessation instead. That comparison has to happen plan by plan, during the same enrollment window when premiums, drug formularies and provider networks are already competing for attention. No insurer is required to publish whether its own chronic-condition support matches what Original Medicare enrollees will receive through the federal model.
The 2027 Medicare Open Enrollment Decision Kit is a 42-page decision kit that includes a cost calculator spreadsheet comparing plans on cost, drugs and doctors, a prescription-by-plan comparison, and a provider call script for asking a plan directly what it covers.
See the provider call script and the plan-comparison tools in The 2027 Medicare Open Enrollment Decision Kit.
This article was researched and drafted with the assistance of AI and reviewed by The Money Overview editorial team.
