Technology, reporting, and connected-device infrastructure for organizations participating in the CMS ACCESS Model
Many organizations preparing to participate in the CMS ACCESS Model have questions about meeting the ACCESS application checklist particularly the technology, reporting, and connected-device requirements CMS expects applicants to demonstrate.
What is the CMS ACCESS Model?
The ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model
is a national payment model operated by the Centers for Medicare & Medicaid Services (CMS). ACCESS shifts Medicare payment from fee-for-service to outcome-aligned payments for organizations that manage chronic conditions using technology-supported care.
Under ACCESS, participating organizations are paid based on measurable improvement in patient outcomes, such as symptom improvement, functional gains, or control of blood pressure—rather than the volume of services delivered. Organizations preparing to participate must understand and meet specific ACCESS technology requirements related to outcome measurement, care coordination, reporting, and device support.
What is Healthfully’s role in ACCESS?
Healthfully is an enabling technology provider for ACCESS participants.
Healthfully does not provide clinical care, does not enroll beneficiaries, and does not submit ACCESS applications on behalf of organizations. Instead, Healthfully supplies the technology, workflows, and reporting infrastructure organizations need to:
- Support preparation of compliant technology sections for CMS ACCESS applications. See ACCESS application checklist
- Capture required outcomes and PROMs with fidelity
- Coordinate care with primary and referring providers
- Submit required data to CMS using standards-based APIs
- Support connected devices for applicable tracks
Healthfully is designed to integrate and work alongside existing EMRs and EHRs, not replace them.
Who should use Healthfully for ACCESS?
Healthfully supports organizations planning to participate in ACCESS, including:
- Virtual Behavioral Health programs
- Virtual Musculoskeletal (MSK) care providers
- Cardio-metabolic and hypertension programs
- ACO-adjacent specialty organizations
- Technology-enabled chronic care programs
If your organization is preparing an ACCESS application or planning to launch under ACCESS, Healthfully provides application-ready technology support. Healthfully is designed to complement existing EMRs and care delivery models, not replace them.
See ACCESS application checklist.
ACCESS Tracks Healthfully Supports
Healthfully is designed to support the following ACCESS clinical tracks:
Depression and anxiety
PROM-based symptom improvement
Required measures: PHQ-9, GAD-7, WHODAS 2.0 (12-item)
Chronic musculoskeletal pain
Functional improvement and pain reduction
Validated MSK PROMs (e.g., pain and function instruments)
Hypertension, diabetes, CKD, ASCVD
Outcome improvement and control
Home blood pressure monitoring using validated devices
Support for additional CMS ACCESS tracks as they come online
What technology does CMS expect ACCESS Participants to have?
ACCESS Participants are responsible for demonstrating that they can:
Collect validated Patient-Reported Outcome Measures (PROMs) with strict fidelity. See PROMs requirements, diabetes, CKD, ASCVD
Track outcomes longitudinally (baseline → follow-up → completion)
Share electronic care updates with PCPs and referring clinicians
Submit required measures to CMS using standards-based APIs
Use FDA-cleared connected devices where applicable (e.g., blood pressure)
Maintain HIPAA compliance and audit-ready documentation
CMS defines what must be reported, but does not provide the software, workflows, or device infrastructure required to operationalize these requirements.
How Healthfully supports ACCESS requirements
Patients choose how they want to stay in touch. Healthfully does the rest.
Web & App Access
Healthfully provides:
Locked-fidelity PROM instruments required by ACCESS
Automated cadence and reminders
Scoring, version control, timestamps, and audit logs
Care Coordination and Clinical Updates
Healthfully supports:
Standardized ACCESS care-update templates
Secure electronic delivery (e.g., Direct Secure Messaging)
Delivery evidence and audit trails
CMS Reporting Enablement
Healthfully supports:
Assembly of required outcome data
Submission to CMS using standards-based APIs
Schema versioning, validation, and error handling
See how Healthfully supports specific reporting requirements in ACCESS application checklist
Connected Devices (for eCKM and CKM Tracks)
Healthfully offers devices through established device and connectivity partners, supporting:
FDA-cleared home blood pressure monitoring
Cellular connectivity (no smartphone or Wi-Fi required)
Automatic data transmission with source and timestamp preservation
See how Healthfully supports specific device requirements in ACCESS application checklist. Device manufacturing and FDA clearance remains with the original device manufacturers
ACCESS Application/Proposal Support
Healthfully supports organizations in preparing the technology and reporting sections of their ACCESS applications by providing:
CMS-safe technology descriptions
Architecture and responsibility diagrams
PROM and reporting documentation
Device strategy language (if applicable)
Applicant organizations retain sole responsibility for application submission, certifications, and clinical attestations.
ACCESS Application Checklists (By Track)
Healthfully maintains track-specific ACCESS application checklists:
Musculoskeletal ACCESS Application Checklist
Early Cardio-Kidney-Metabolic ACCESS
Behavioral Health ACCESS Application Checklist
Cardio-Kidney-Metabolic ACCESS Application Checklist
Healthfully maintains track-specific ACCESS application checklists:
- Required PROMs
- Care coordination expectations
- Device considerations
- CMS reporting requirements
Getting Started with Healthfully for ACCESS
Organizations preparing for ACCESS participation can:
- Review general ACCESS application checklist
- Review the relevant track-specific checklist
- Assess current PROM, reporting, and device readiness
- Engage Healthfully for application support and implementation planning
- Healthfully provides technology documentation, workflows, and reporting infrastructure to support ACCESS participation. Applicant organizations remain solely responsible for application submission, attestations, and clinical delivery.
Organizations may contact Healthfully to request application-ready technology documentation
This checklist and supporting guidance are maintained by Healthfully, a healthcare technology platform that supports organizations participating in the CMS ACCESS Model. Healthfully is not affiliated with, endorsed by, or acting on behalf of the Centers for Medicare & Medicaid Service