The Model

Two ways Medicare pays for the same outcome.

A plan's Star Rating on the Medicare Advantage side; MIPS, shared savings, and the ACCESS payment on the Original Medicare side. The same diabetes and blood pressure measures move both. How each rail pays is on the details page; this page lets you set your own inputs and watch the number.

Change any input by slider or by typing; the (?) beside each explains it, its formula, and its source. Nothing you type leaves your browser. The result is an estimate at your inputs, not a promise of any rating, payment, or savings.

Slide the inputs. Watch the rating, the savings, and the incentive revenue move.

Defaults come from published CMS, KFF, and CDC figures where one exists and are labeled as examples where one does not.

Start from your public record
CMS participant list as of October 7, 2026 · Hudson Valley Medicare claims, 2024 data year · searches stay in your browser; nothing is sent or logged
Who holds the contract?
Essentials
Patients whose home readings reach the care team. In the Medicare Advantage view the panel mixes plan members and Original Medicare patients; the ACCESS share below splits them.
The driver: HbA1c below 7.5 percent or a 1-point drop; systolic pressure below 130 or a 15-point drop; LDL-C and weight targets. It sets the ACCESS outcome factor and, while linked, the Star lift and the MIPS gain.
Needs a Part B-enrolled participant with a physician medical director, and an Original Medicare patient: plan members cannot be aligned. Aligned patients are billed under ACCESS codes only, so each one leaves the remote monitoring billing line, or the bonus line in the Medicare Advantage view.
Type 2 diabetes, chronic kidney disease, and cardiovascular disease qualify for CKM at $420 a year in the initial period; prediabetes, hypertension, or obesity alone for eCKM at $360. CMS pays 80 percent, the 2 percent sequester applies, and half of the Medicare portion waits for reconciliation against the outcome threshold and the substitute-spend threshold.
More inputs
Medicare Advantage contract
An assumption, not a CMS conversion: a contract’s Stars are scored measure by measure against cut points CMS sets after the year ends. Scales with the target share while linked; override it and the link keeps your ratio. Ceiling: the nine diabetes and blood pressure measures carry 21 of roughly 85 weight points, so one star on each is +0.25, two stars +0.49, before improvement measures and the reward factor; the slider stops at 0.6.
2026 KFF averages: $381 individual plans, $466 employer plans, $318 special needs plans; state range roughly $91 to $621.
Set by your value-based contract with the plan. Zero if the plan keeps it all.
Admissions and savings
Not linked, on purpose: triage catches this year's crisis whether or not the patient reaches target. Use your own readmission baseline; the default is a placeholder.
Replace with your average Medicare payment per inpatient stay.
A capitated network or an ACO keeps a share; a fee-for-service practice outside an ACO keeps none. Set to zero in that case.
Why the long-term cascade is not in the admissions number
HbA1c, blood pressure, LDL, weight atherosclerosis coronary disease, heart attack (MI), heart failure, stroke, kidney failure hospital admissions
Two mechanisms on two clocks. This year: triage on home glucose, pressure, and weight catches the hyperglycemic crisis, the hypertensive urgency, and the fluid gain before they become an admission. That is the rate above. Over years: the same control shrinks the cascade behind most diabetes admissions. In the UKPDS, every 1-point lower HbA1c went with 14% fewer heart attacks, 16% less heart failure, 12% fewer strokes, 37% fewer microvascular complications, and 21% fewer diabetes-related deaths. Glucose alone is not the whole lever: trials of intensive glucose lowering cut non-fatal heart attacks by about 17% and did not move stroke or mortality, while treating glucose, blood pressure, lipids, and weight together (Steno-2) added a median 7.9 years of life and 8.1 years before the first cardiovascular event. That bundle is the ACCESS CKM target set, and five of the six weight-3 Star measures on a diabetes patient. It is paid through the quality measures and the outcome factor, so it stays out of the admissions number to avoid counting it twice.
Three Rails

The same verified record, three ways it turns into dollars.

Rail 01 · The plan

Star Rating bonus

The plan's overall rating sets its benchmark and its rebate share. A member with diabetes can count toward six weight-3 measures, and a monitored diabetes panel bears on every one of them.

  • 4.0 stars and above+5 pts benchmark
  • Double-bonus counties+10 pts
  • Rebate share, 4.5 and up70%
  • Rebate share, 3.5 to 4.565%
  • Rebate share, below 3.550%
Rail 02 · The ACCESS participant

Outcome-aligned payment

A Part B-enrolled organization with a physician medical director aligns its diabetes, kidney, and cardiovascular patients to the CKM track and is paid per patient, with half of the Medicare share withheld until CMS reconciles outcomes and substitute spending.

  • CKM, initial 12 months$420 / yr
  • CKM, follow-on 12 months$210 / yr
  • eCKM, initial 12 months$360 / yr
  • Rural add-on, eCKM and CKM+$15
  • Musculoskeletal (MSK) and behavioral health (BH) tracks (secondary lines)$180 / yr
Rail 03 · The clinician

Fee-for-service and MIPS

Outside ACCESS, the clinician bills remote physiologic monitoring for the same patients, and the diabetes and blood pressure quality measures move the MIPS score that adjusts every Part B payment.

  • MIPS adjustment range−9% to +9%
  • Remote monitoring codesmonthly, per patient
  • Referring-clinician co-management$30 / service
  • Co-management capabout $100 / yr
  • ACCESS and FFS, one patient, one participantnever both

CMS keeps the rails apart. For an aligned patient, the ACCESS participant and its affiliates bill only the ACCESS codes during the care period; clinicians outside the participant still bill Medicare as usual, including the co-management service. A Medicare Advantage member's outcomes count toward the plan's Stars. One record can serve all three because it is written once, in the standard each program reads.

Variable Reference

Every input: what it means, where it comes from, and how it enters the math.

The same text sits behind the (?) marks. The formulas are the ones this page runs. Sources open in a new tab.