All You Need To Know About The CMS Lead Model

The CMS Lead Model starts in January 2027 and runs for 10 years through December 2036. Medicare built this program to replace ACO Reach and open doors for providers who got shut out of earlier models. Rural clinics, small practices, and doctors treating complex patients can now join. The old requirements that blocked them are gone.

What makes LEAD different is simple. The financial targets stay fixed for all 10 years. Previous programs changed these targets every few years, which made it hard for providers to plan or invest in better care systems. LEAD also pays upfront money to help smaller organizations build the infrastructure they need.

How LEAD Works Differently

LEAD keeps the same financial benchmarks through 2036. Older accountable care programs had a problem where successful ACOs got penalized. When they improved care and saved money, CMS would lower its targets the next year. That meant good performance actually hurt future earnings.

LEAD fixes this by offering:

• Monthly payments to cover patient care costs instead of waiting for year-end savings
• Two risk levels so organizations can choose what fits their size and experience
• Lower patient minimums so smaller practices qualify
• Direct payments for building care coordination systems in rural areas

Providers pick between 100% global risk or 50% professional risk. Global risk means taking on all Medicare costs for patients. Professional risk covers only outpatient and physician services. Smaller groups usually start with professional risk to learn the model before taking on full financial responsibility.

Who Gets Covered Under LEAD

The CMS Lead Model targets patients who struggle to manage their health alone. This covers homebound individuals, people with both Medicare and Medicaid coverage, and those in areas where healthcare is hard to access.

CMS built LEAD after reviewing why ACO Reach struggled with certain patient groups. Standard methods for assigning patients to ACOs did not work well for people with multiple chronic conditions. LEAD uses better risk scoring to account for how sick patients are when setting payment rates.

Some states are testing a dual-eligible pilot within LEAD. These patients have Medicare and Medicaid, but the two programs usually do not talk to each other. That creates gaps in care. The pilot aligns payments so providers get rewarded for coordinating both coverage types.

Payment Options in the Model

ACOs in LEAD get paid monthly per patient instead of billing for each service. This is called capitation. The amount depends on how sick the patients are and what services they need.

Two main payment paths are available:

• Primary care capitation that covers prevention, checkups, and managing ongoing health issues
• Total care capitation that includes hospital stays, specialist visits, and all Medicare Part A and B services

There is also something called CARA, which stands for Coordinated ACO Risk Arrangements. This lets ACOs partner with specialists on specific care episodes. The first one covers fall prevention. More episodes will be added later. CARA uses a digital system to make contracts between ACOs and specialists easier to set up.

Eligibility Requirements

Current ACO Reach participants can move directly into LEAD. New applications open in March 2026 through the CMS application portal.

Organizations that can apply:

• Medicare providers who have not joined an ACO before
• Federally Qualified Health Centers and Rural Health Clinics
• Independent doctor practices in rural or underserved locations
• Provider groups where many patients have both Medicare and Medicaid

The accountable care program lowered the bar for entry. Smaller practices that could not meet old patient volume requirements can now qualify under the new minimums.

What Patients Get From LEAD

LEAD lets providers build programs around what their patients actually need. Funds go toward managing diabetes and heart disease, stopping falls before they happen, and making sure different doctors share information.

Starting in 2029, ACOs can help patients pay for Part D prescription drug premiums. Many people skip medications because they cannot afford the copays. Subsidizing these costs helps patients take their medicines as prescribed.

Patients still choose any Medicare provider they want. LEAD does not create restricted networks or limit where people can get care. The model adds telehealth services and care navigators to help patients without taking away existing options.

The Bigger Picture

Medicare wants all beneficiaries connected to an accountable care relationship by 2030. Right now, about 14.3 million people get care through an ACO. LEAD expands this to groups who could not participate before.

The 10-year commitment matters because building better care systems takes time. Hiring care coordinators, buying data analytics tools, and training staff require upfront investment. Shorter programs did not give providers enough time to see returns on that spending. Many successful ACOs left earlier models when their benchmarks got cut after performing well.

LEAD bets that stable, long-term benchmarks will keep high-performing organizations in the program and encourage new ones to join.

Managing LEAD Participation With Better Technology

ACOs joining LEAD need platforms that handle data tracking, patient risk assessment, and quality reporting. Persivia offers platforms specifically built for organizations managing the total cost of care under value-based payment models.

These platforms track which patients are assigned to your ACO and calculate how sick each person is. They flag which patients need extra help and send quality data to CMS. Your staff spends time on patient care, not filling out spreadsheets. Persivia handles the technical work for ACOs at every stage of LEAD participation with analytics, care coordination tools, and quality tracking.