CMS payment models
Six models decide who carries
the risk through 2036.
ASM, TEAM, CJR-X, ACCESS, LEAD and CARA get used interchangeably and they are not interchangeable. Three are mandatory and three are not. They start in different years, and only some of them reach musculoskeletal care at all. Every figure below links to the CMS page it came from.
Mandatory. Episode-based. The surgical lane.
No opt-out. These decide what a joint replacement, a fusion, or a low-back-pain episode is worth, and to whom.
Ambulatory Specialty Model
Clock
Jan 1 2027 – Dec 31 2031 (five performance years)
Reach
Two cohorts. Heart failure: cardiology. Low back pain: anesthesiology, pain management, interventional pain management, neurosurgery, orthopedic surgery, PM&R. Eligibility is historical attribution of at least 20 heart-failure or low-back-pain episodes a year, in roughly one quarter of CBSAs and metropolitan divisions.
The part people miss
Scored on four categories built on the MIPS Value Pathways framework: quality and cost per clinician, improvement activities and interoperability at the group level. Part B adjustment runs −9% to +9% in the first two years and widens to −12% to +12% by the last. CMS currently lists the participant count as N/A; the mandatory geographies are published as a spreadsheet, not a list of names.
The CMS model page →Transforming Episode Accountability Model
Clock
Jan 1 2026 – Dec 31 2030 (five performance years)
Reach
Five surgical episodes on a 30-day window.
The part people miss
Its musculoskeletal episodes are hip, knee and ankle replacement, hip fracture surgery and spinal fusion (the other two are cardiac bypass and major bowel surgery). It does not reach shoulder, foot or hand. Anyone selling a whole-body musculoskeletal story into TEAM is selling past the model boundary.
The CMS model page →Comprehensive Care for Joint Replacement, expanded
Clock
Finalized in the FY2027 IPPS rule; most IPPS hospitals from January 2028
Reach
Hip, knee and ankle replacement episodes, inpatient or outpatient, nationwide.
The part people miss
The episode runs 90 days after discharge and includes post-discharge physical therapy, which is what makes post-acute adherence a hospital financial exposure rather than a clinical preference. That is three times TEAM’s 30-day window.
The CMS model page →Voluntary. Population-based. The chronic-care lane.
You opt in. These pay for care between visits, for prevention, and for technology-supported care that CMS says Medicare payment rules have held back.
Advancing Chronic Care with Effective, Scalable Solutions
Clock
Live since July 5 2026, ten-year model
Reach
Conditions affecting more than two thirds of people with Medicare — hypertension, diabetes, depression, and chronic musculoskeletal pain, which is a named track.
The part people miss
For participants it replaces fee-for-service billing with a recurring payment tied to measurable outcomes, and it requires them to name a physician Clinical Director responsible for clinical oversight. The payment follows the outcome; the accountability sits with a named physician.
The CMS model page →Long-term Enhanced ACO Design
Clock
Jan 1 2027 – Dec 31 2036
Reach
The ACO REACH successor, aimed deliberately at smaller, independent and rural practices and at organizations new to accountable care.
The part people miss
Ten performance years is the longest period CMS has ever tested, and the design point is a window without rebasing. ACOs whose costs run above their regional average can also receive a 1.5% administrative add-on, paid up front. The bet is that ACOs will invest differently when the benchmark stops moving under them.
The CMS model page →CMS-Administered Risk Arrangement
Clock
Voluntary for LEAD ACOs in the Global Risk Option; CMS’s tentative timeline puts the first performance year in 2028
Reach
Episode bundles negotiated between a LEAD ACO and its specialist partners.
The part people miss
CMS supplies the episode data, pricing information and reconciliation, so the ACO and the specialist negotiate a target price without building the machinery themselves. If fee-for-service spending lands under the target, the specialist is paid the difference; over it, the specialist repays. The fact sheet also describes RISE, a falls-prevention episode delivered at home by occupational therapists, physical therapists and nurses — a federal payment mechanism pointed at prevention in the home.
The CMS fact sheet (PDF) →What actually follows from the table.
Three consequences that survive contact with a finance committee.
A locked model is a need, not a grievance
ASM is mandatory with no opt-out. A practice inside an ASM geography cannot lobby its way clear; it can only arrive prepared. That converts the conversation from “you are being paid less” into “you are about to carry two-sided risk on low-back-pain episodes and be scored on interoperability you do not currently produce.” The four scoring categories are infrastructure questions, and they have a deadline.
What a specialist actually has to produce →The episode boundary is the sales boundary
TEAM’s musculoskeletal episodes are hip, knee and ankle replacement, hip fracture surgery and spinal fusion. It does not reach shoulder, foot or hand. CJR-X is hip, knee and ankle replacement only, on ninety days, with therapy inside the window. Any claim that a musculoskeletal product is “aligned with the mandatory models” is only true for the joints those models name, and a hospital finance team knows exactly where that line falls.
The health-system read →Two of these models put a named human on the hook
ACCESS requires a physician Clinical Director responsible for clinical oversight. CARA puts a specialist’s payment at risk on the episode. Neither pays for accuracy on its own; both attach the money to someone accountable. That is the same structure the attestation record exists to produce, and it is why the payment rail and the governance rail are the same rail.
Why the signature is the unit →Honest edges
What this page does not know.
- CARA target prices are negotiated between each ACO and its specialists rather than posted as a fee schedule, the fact sheet publishes no RISE payment amounts, and CMS calls its timeline tentative. Any revenue figure built on CARA today is a model, not a rate.
- CMS lists the ASM participant count as N/A. Headcount figures circulating in trade coverage are secondary reporting, not a CMS number, and are not repeated here.
- ASM is finalized, but updates to it were proposed in the CY2027 Physician Fee Schedule, with comments due by 11:59 PM on September 14, 2026. The CY2027 final rule decides those updates; the model itself was never up for relitigation.
- Being in a model is not the same as being in a geography. ASM selects by CBSA and metropolitan division, and CMS publishes those areas as a spreadsheet — check it before assuming exposure either way.
- This page is a reference, not advice. Every figure links to the CMS page it came from so it can be checked rather than trusted.
Two of these models put an accountable human on the hook.
ACCESS requires a physician Clinical Director. CARA puts a specialist’s payment at risk on the episode. Neither pays for accuracy on its own. Bring one synthetic output to the sandbox and watch the record that a named clinician signs.