Your top questions on LEAD & MA changes — answered

This FAQ is based on our March 25, 2026 webinar "Taking the LEAD on CMS Policy Updates for VBC Excellence" and has been updated to reflect policy finalization through April 8, 2026.

Note:‍ The application process for LEAD is expected to be competitive – meeting eligibility criteria does not ensure acceptance. Current ACO REACH PY 2026 participants may submit abbreviated applications, but acceptance is also not guaranteed.

LEAD Model Design

Q1: With the participation at TIN level for LEAD, will Market Leaders still favor the model?

A: Yes, if they have infrastructure to improve underperformers and value 10-year stability over cherry-picking flexibility. Hybrid Alignment allows mid-year TIN additions.

LEAD uses whole-TIN for Participant Providers, which is a change from REACH's TIN/NPI flexibility. This could affect organizations that relied heavily on cherry-picking individual providers.

MSSP has always used whole-TIN, and the most successful ACOs have infrastructure to improve underperforming providers rather than excluding them. LEAD gives you 10 years of benchmark stability to work with underperformers and bring them up to standard.

The strategic question: Would you rather have TIN/NPI flexibility with a 4-year model that might change, or whole-TIN with 10-year stability to invest in provider engagement?

If you select Hybrid Alignment in LEAD, you CAN add TINs mid-year. Acquire a practice in Q1, assess performance for 6 months, then add their TIN mid-year if performing well. This approach gives you some strategic control.

Note on specialists: TIN-level participation combined with LEAD's attribution approach may increase specialist involvement in attribution for multi-specialty organizations compared to MSSP and REACH. This is because when primary care clinicians account for ≤10% of allowed charges for qualified E&M services, selected specialists are included in attribution calculations.

Bottom line: For Market Leaders with strong infrastructure, the 10-year stability is worth more than cherry-picking flexibility. For organizations whose strategy was built on selective inclusion, MSSP Enhanced (also whole-TIN, no benchmark discount) may be better.

Q2: If a clinic is in REACH because they only have mid-level clinicians, is LEAD the logical next option?

A: Yes. LEAD allows NPs, PAs, and CNSs to be Participant Providers and drive beneficiary alignment.

Starting in 2025, MSSP allowed NPIs from nurse practitioners, physician assistants, and clinical nurse specialists to contribute to beneficiary alignment. LEAD continues this approach – you don't need physicians to drive attribution.

If your clinic is primarily NPs and PAs:

• They CAN be Participant Providers in LEAD
• They CAN drive beneficiary alignment
• Your clinic qualifies

The logical path: If you're in REACH now with mid-level clinicians and it's working, LEAD is the natural next step. The question is whether you go LEAD Global (100% risk, same as REACH Global) or LEAD Professional (50/50 risk, lower exposure).

Verify: Make sure you meet beneficiary minimums. Standard is 5,000, but if 40%+ of your population is High Needs, you can qualify with as low as 800.

For High Needs ACOs (>40% High Needs beneficiaries):

• 800 aligned beneficiaries in PY1
• Including 500 claims-based aligned in at least one base year (2024-2026)

For Newly Entering ACOs:

• 1,000 aligned beneficiaries in PY1
• Including 600 claims-based aligned in at least one base year (2024-2026)

Q3: What's the difference between LEAD's Prospective vs Hybrid Alignment?

A: Prospective = locked attribution for 12 months (simpler). Hybrid = monthly voluntary alignment updates + mid-year TIN additions (more flexible, more complex).

Prospective Alignment:

• Beneficiary list set before performance year starts
• No updates during the year (except drops for loss of eligibility)
• Cannot add TINs mid-year
• More predictable/stable (like REACH)

Hybrid Alignment:

• Voluntary alignment updated monthly: Beneficiaries can voluntarily align to your existing ACO providers each month, adding new beneficiaries throughout the year
• Claims-based alignment runs once mid-year: When you add new TINs mid-year, CMS runs a claims-based alignment to attribute beneficiaries to those newly added TINs
• One-way attribution: You can add beneficiaries during the year (via voluntary or mid-year claims-based runs), but cannot drop them once aligned 

Choose Prospective if: You value stability, have established network, want simpler operations

Choose Hybrid if: You're growing network, want mid-year TIN additions, have IT infrastructure for monthly roster changes, want to maximize attributed population growth

Important: Mid-year TIN addition is ONLY available with Hybrid Alignment, not Prospective.

MA 2027 Final Rate Announcement

Q4: If the provider documented something in the note but the biller didn't submit the claim, is there no possibility of retrospective chart review to submit missed codes under the new guidelines?

A: Correct. Starting 2027, diagnoses must be on submitted claims (encounter-linked). Chart review alone can't add them. This policy was FINALIZED April 6, 2026 in the MA 2027 Final Rate Announcement.

Pre-2027: Provider documents → biller misses code → health plan's retrospective chart review finds it → counts for risk adjustment

2027+ (FINALIZED): Provider documents → biller misses code → chart review finds it → CANNOT submit because it wasn't encounter-linked → doesn't count

The only way to capture: Provider documents it AND it appears on a submitted claim for that encounter.

Operational impact: Revenue cycle must be tighter. Workflow: document → code → submit → verify, all in real-time. No more retrospective cleanup.

Exception: If a beneficiary switches MA plans mid-year, their documented diagnoses from the old plan's chart reviews can transfer to the new plan, even if unlinked. This continuity provision prevents beneficiaries from losing their documented chronic conditions during plan transitions. This is the only scenario where unlinked chart review diagnoses may still count.

Q5: Please give a concrete example of something that would have counted, that will no longer count from 2027 and forward

A: Any diagnosis documented in medical record but not on submitted claims (AWV HCCs forgotten by biller, telehealth visit notes, hospital discharge summary notes).

Example 1 – Annual Wellness Visit:

• Old: Provider documents CHF, diabetes, COPD in AWV note → biller codes AWV but forgets HCC diagnoses → chart review pulls them from the note → they count
• New (2027+): Same scenario → chart review finds them in the note → they don't count (weren't on claim)

Example 2 – Telehealth Visit:

• Old: Provider documents conditions → bills simple E/M with no diagnoses → chart review pulls from note → they count
• New (2027+): Chart review finds them → they don't count (not encounter-linked)

Example 3 – Hospital Discharge:

• Old: Discharge summary documents conditions → health plan reviews records → they count even if not on claims
• New (2027+): Not on submitted claims = don't count

Example 4 – Audio-Only Telehealth (Different Rule):

Unlike Examples 1-3 (which are about billing issues), audio-only telehealth has a separate exclusion:

• Old: Phone call with patient → document chronic conditions → bill on claim → counts for risk adjustment

• New (2027+): Phone call with patient → document chronic conditions → bill on claim → doesn't count because CMS excludes all diagnoses from audio-only encounters

Why this matters: You can't "fix" this with better billing. Audio-only telehealth encounters simply don't count for risk adjustment starting 2027, regardless of documentation or coding quality.

The pattern: Diagnosis only in the medical record but not on the submitted claim won't count anymore.

Biggest shift: You have to get it right during the encounter when the claim is generated. No more fourth-quarter cleanup.

Q6: How will these changes impact organizations who currently participate in ACO?

A: MA changes don't directly affect MSSP/LEAD performance, but they create workflow alignment if you serve both Traditional Medicare and MA patients.

For Traditional Medicare ACO patients (MSSP/LEAD): The MA Final Rate Announcement changes don't directly affect MSSP or LEAD benchmarks or performance. These use Traditional Medicare claims data, not MA risk scores.

However – indirect operational impact:

If you serve both Traditional Medicare ACO patients AND Medicare Advantage patients, the MA changes create alignment:

Pre-2027: Two different HCC capture strategies

• Traditional Medicare ACO: Real-time capture on claims (prospective)
• Medicare Advantage: Retrospective chart review cleanup allowed

2027+ (FINALIZED): Both require the same thing

• Traditional Medicare ACO: Real-time capture ✓
• Medicare Advantage: Real-time capture ✓

Your workflows converge. One HCC capture process works for both populations instead of managing parallel systems.

Bottom line: If you're in an ACO and contract with MA plans, MA changes make your life simpler in the long-term. You're optimizing for the same behaviors across both populations.

Operational & EHR Considerations

Q10: It seems like a lot of these changes are mainly about documenting correctly in structured EMR fields, is that right? 

A: Yes. This is an EHR optimization + clinical workflow problem, not just a billing problem.

What needs to happen:

1. Structured data fields (not free text)

• Problem list updated in real-time
• ICD-10 codes populated correctly
• Links to encounter (not floating in notes)

2. Workflow integration

• Pre-visit: Flag HCC gaps before patient walks in
• During visit: Provider reviews/confirms diagnoses
• Post-visit: Coder verifies everything on claim

3. Templates optimized for HCC capture

• Smart prompts, not click fatigue
• "Patient has diabetes - last documented 18 months ago, confirm still active?"
• AWV templates that systematically review chronic conditions

The mistake many organizations make: Thinking that this is a billing department problem. It's a clinical workflow problem with billing implications.

Your physicians need:

• Actionable templates directly in the EHR that make HCC capture easier (not burdensome)
• Real-time feedback on documented vs coded
• Quality dashboards showing HCC capture rates

Bonus: If you build this for MA, it directly benefits ACO performance too. Same infrastructure, dual benefit.

Important timing note: With the MA Final Rate Announcement (April 6, 2026), the encounter-linked diagnosis requirement is now finalized policy for 2027. This is no longer proposed – it's happening.

Provider types & eligibility

Q11: Is this for senior living operators or more so physician groups?

A: Both can participate with different roles. Physician groups = Participant Providers. Senior living = Preferred Providers (post-acute coordination).

Physician groups / primary care practices:

• Most natural fit for LEAD/MSSP
• Drive beneficiary attribution
• Accountable for total cost of care

Senior living operators (SNFs, assisted living, CCRC):

• Participate as Preferred Providers in LEAD (not Participant Providers)
• Don't drive attribution, but share in savings/losses
• Focus: Post-acute care coordination with ACOs

Real-world model:

• ACO led by physician group (150 doctors)
• Partners with 3 SNFs as Preferred Providers
• ACO shares financial risk with SNFs for post-acute utilization
• SNFs benefit from reducing readmissions, shortening stays, improving outcomes

For senior living operators specifically:

The question: Are you clinically integrated enough to take risk?

• If you employ physicians/NPs: Could potentially lead your own ACO or be Participant Provider
• If you're primarily housing + non-clinical services: Preferred Provider partner (important to continuum, not driving attribution)

LEAD advantage: CMS is testing CARA (episode-based payments), which could let ACOs engage post-acute providers through episode payments—more aligned with how senior living operates.

Model Transitions

Q12: How should organizations choose their next value-based care model whether they’re starting from scratch or transitioning from a program like PCF? 

A: PCF infrastructure transfers to ACO models. Start with MSSP Track 1 (upside-only) to test performance before taking downside risk.

PCF terminating early was frustrating for practices who made real investments.

Good news: Your PCF infrastructure transfers to ACO models. You built care management capabilities, risk stratification, chronic disease workflows – those don't go to waste.

Your options depend on:

Panel size:

• 5,000+ Medicare beneficiaries → MSSP or LEAD viable
• 800-5,000 → LEAD only (if 40%+ High Needs)
• Under 1,000 → Join someone else's ACO or wait for different model

For High Needs ACOs (>40% High Needs beneficiaries):

• 800 aligned beneficiaries in PY1
• Including 500 claims-based aligned in at least one base year (2024-2026)

For Newly Entering ACOs:

• 1,000 aligned beneficiaries in PY1
• Including 600 claims-based aligned in at least one base year (2024-2026)

Risk appetite:

• Low risk, building capability → MSSP Track 1 (upside-only)
• Moderate risk, proven performance → MSSP Enhanced (75% shared savings/losses)
• High risk, want maximum upside → LEAD Global (100% up/down)

Considerations for former PCF practices:

Start with MSSP Track 1 (upside-only) to test ACO performance without downside risk. You already built infrastructure through PCF. Use Year 1 to see if you can consistently hit benchmarks. If yes, move to MSSP Enhanced or LEAD in Year 2-3.

If you're confident in your performance: LEAD offers population-based payments (PBPM) that can support infrastructure and care delivery – similar to PCF's model but tied to total cost of care accountability. However, don't rush into two-sided risk (LEAD or MSSP Enhanced) – unlike PCF, you're accountable for total cost of care with shared savings/losses at year-end. Make sure you can consistently perform against benchmarks before taking on downside risk.

Alternative: Look at Making Care Primary (MCP) launching in 2026. It's PCF/CPC+ successor and might feel more familiar. But you can't do MCP + MSSP simultaneously (after the first 6 months).

Q13 How should organizations in REACH think about their next step whether moving to LEAD, MSSP, or something else, and when do they need to decide? 

A: REACH ends Dec 31, 2026. LEAD applications are due May 17, 2026. MSSP applications begin May 2026. Decide by Q2 2026.

Updated Key Dates (as of April 8, 2026):

• REACH ends: December 31, 2026
• LEAD RFA released: March 31, 2026
• LEAD applications due: May 17, 2026 for January 1, 2027 start
• LEAD Letter of Interest deadline: April 20, 2026 (if not ready to apply)
• LEAD Implementation Period: September 15 - December 31, 2026 (optional for accepted applicants)
• LEAD performance starts: January 1, 2027
• MSSP annual application: Begins May 2026

You need to decide NOW if targeting a 2027 start. Internal decision-making should happen immediately – building business cases, modeling scenarios, assessing readiness.

Three pathways:

1. Transition to LEAD (Global or Professional)
2. Move to MSSP (Track 1, Enhanced, or ACO PC Flex)
3. Exit ACO participation

Decision framework:

• Consistently saving 12-16%+ gross → Consider LEAD Global
• Saving 5-10% → MSSP Enhanced likely better net results
• Saving <5% or breaking even → MSSP Track 1 or exit

REACH participants: You're eligible for abbreviated LEAD application - simpler process if you're in good standing with CMS program requirements.

Not ready for 2027? Submit a Letter of Interest by April 20, 2026 to be notified about future LEAD cohorts.

Q14: When is the LEAD application deadline, and what options exist for organizations that aren’t ready to apply yet? 

A: Apply by May 17, 2026 for Jan 1, 2027 start. If not ready, submit Letter of Interest by April 20, 2026 for future cohorts.

LEAD RFA released: March 31, 2026

Application deadline: May 17, 2026 for ACOs wanting to start January 1, 2027

Application portal: https://app.innovation.cms.gov/LEAD/IDMLogin

Letter of Interest: If you're interested in LEAD but not ready to apply for 2027, you can submit a Letter of Interest (LOI) by April 20, 2026. CMS will use LOIs to:

• Gauge interest in future application cycles
• Inform planning for subsequent cohorts
• Notify LOI submitters when future application windows open
• Provide information about application support resources

Abbreviated applications: Current ACO REACH participants in PY 2026 can submit abbreviated applications (simpler process).

Implementation Period: Accepted applicants can participate in optional Implementation Period from September 15 – December 31, 2026 to prepare for January 1, 2027 launch.

Application scoring: CMS will assess applications across 5 key domains:

1. Organizational readiness
2. Revenue sources and payment arrangements
3. Beneficiary and caregiver experience
4. Data and health information
5. Preventive care

CMS will also consider cross-cutting factors such as financial stability, operational capability, and program integrity risk. While prior ACO performance is not a formal scoring category, it is considered – applications should clearly describe prior experience and operational capabilities.

Bottom line: If you want to start LEAD on January 1, 2027, you need to apply by May 17, 2026 – that's 5+ weeks from today (April 8). If that timeline is too tight, submit an LOI by April 20 to stay informed about future cohorts.

Apply here: https://app.innovation.cms.gov/LEAD/IDMLogin 

Q15: Can an organization apply to both LEAD and MSSP?

A: Yes. You can apply to both, then choose based on LEAD acceptance (decisions come before MSSP window closes).

Yes, and this could be a smart strategy for REACH ACOs as a backup.

Apply to LEAD by May 17, then apply to MSSP when the window opens (late May). LEAD acceptance notifications come in summer/early fall – before you need to finalize MSSP participation – so you can choose based on LEAD acceptance.

Important: Final participation requires non-overlapping provider participants. You cannot have the same TIN participating in both LEAD and MSSP simultaneously. This means:

• Option 1: Choose one model for all your providers (withdraw the other application)
• Option 2: Split your organization into separate cohorts with different TINs – some TINs in LEAD, others in MSSP (requires separate operations, governance, etc.)

For most organizations, Option 1 (choose one) is simpler. Option 2 only makes sense if you have distinct provider groups that can operate independently.

Submitting initial applications to both doesn't lock you in – you finalize provider participant lists closer to the January 1, 2027 start date.