The Centers for Medicare and Medicaid Services (CMS) has
announced significant policy and operational changes to the
Achieving Healthcare Efficiency through Accountable Design (AHEAD) Model, effective January 1, 2026. AHEAD is a voluntary, multi payer, state total cost of care model launched in 2023. Participating states include Maryland, cohort 1; Connecticut, Hawaii, Vermont, cohort 2; and Rhode Island and sub-state regions in New York, cohort 3 (2028).
AHEAD is comprised of three components:
- Advanced funding for states
- Hospital Global Budgets
- Primary Care AHEAD (PC AHEAD).
States are responsible for managing beneficiaries’ health care costs across Medicare, Medicaid, and commercial payers. The model holds states accountable for primary care investment targets, population health and quality outcomes.
Key changes to the AHEAD Model include:
- Extended Timeline: All AHEAD cohorts now run through December 31, 2035.
- Introduction of Geo AHEAD: Starting in 2028, CMS will implement geographic attribution for Medicare FFS beneficiaries in AHEAD regions not currently aligned with other CMS value-based care programs.
- Policy Mandates for States: Participating states must implement a minimum of two policies focused on promoting choice and competition in their healthcare markets during the model’s implementation period. Policy options include:
- Promoting choice (states choose one option):
- Implement Medicaid site neutrality
- Improve access to new and/or additional modes of care delivery via telehealth
- Advance prescription drug price transparency
- Free up provider movement by banning non-compete clauses
- Promoting competition (states choose one option):
- Change scope of practice restrictions (including for both Physician Assistants and Nurse Practitioners)
- Remove certificate of need requirements for all non-hospital settings
- Expand access to care by revising network adequacy provisions in compliance with federal requirements
- Expand contracting flexibilities by repealing any-willing-provider laws
- Hospital Budget Changes: States with existing hospital rate-setting authority will no longer be allowed to design their own Hospital Global Budget (HGB) methodologies for Medicare FFS, CMS will standardize it.
Geographic-Based ACO Program (Geo AHEAD)
The Geo AHEAD program is a new geographic based ACO track within AHEAD that includes geographically-based alignment, expanding TCOC accountability to otherwise unattributed Medicare fee-for-service (FFS) beneficiaries within AHEAD regions. The model includes two four-year contract periods between 2028 and 2035.
Model participants (“Geo Entities”) include non-provider led organizations (e.g., health plans, technology companies), Hospital Global Budget (HGB) providers, and Primary Care AHEAD (PC AHEAD) providers. The model utilizes two-sided risk arrangements and allows entities to submit discounted bids relative to a CMS-established TCOC benchmark.
The model reflects CMS’s evolving priorities: prevention, competition, and flexibility in care delivery.
CMS is expected to release further guidance regarding eligibility for assignable beneficiaries under the Geo AHEAD program prior to its launch in 2026. Specific details are not yet available.
Please reach out to AHCA’s Population Health Policy Analyst, Rohini Achal or Nisha Hammel, Vice President, Reimbursement Policy & Population Health with any questions.