CMS LEAD Model: Frequently Asked Questions

LEAD is designed to achieve four primary objectives:

LEAD offers two prospective, per-beneficiary per-month (PBPM) capitated payment structures designed to move practices away from fee-for-service (FFS) toward value-based payment:

LEAD offers two distinct risk-sharing tracks: 

No. LEAD and the Medicare Shared Savings Program (MSSP) are mutually exclusive. An ACO and its Participant TINs cannot simultaneously participate in LEAD and MSSP or the ACO Primary Care FLEX Model. 

Vytalize models both pathways—including MSSP BASIC, MSSP Enhanced, LEAD Professional, and LEAD Global—against each practice’s patient mix, prior savings history, and cost profile to identify the program and risk level most likely to generate savings in 2027.

LEAD introduces several significant benchmarking improvements over ACO REACH and MSSP: 

• No rebasing: LEAD maintains consistent benchmark base years across all 10 performance years, eliminating the “ratchet effect” that historically penalized ACOs for successfully lowering costs.

• No benchmark penalty for higher-spending ACOs: Under ACO REACH, ACOs whose patients spent above the regional average faced a downward benchmark adjustment. Under LEAD, this penalty is removed.

• Accountable Care Prospective Trend (ACPT): LEAD uses a trending methodology that allows benchmarks to grow faster than actual realized spending when ACOs collectively lower costs, preserving long-term savings incentives.

• Convergence over time: Over the 10-year period, benchmarks for both higher-spending and lower-spending ACOs gradually converge away from individual historical spending, rewarding improvement rather than baseline efficiency alone.

• AI-based risk adjustment by 2029: CMS has announced a transition to AI-driven risk adjustment methodology beginning in 2029.

The Administrative Add-On is a monthly capitated payment equal to 1.5% of an ACO’s total benchmark.¹ It is available to higher-spending ACOs—those with per-beneficiary spending above the regional average—to support investment in care coordination infrastructure and primary care capacity. 

Critically, the Administrative Add-On is not counted as a performance year expenditure and is not subject to repayment, making it a genuine structural advantage for practices that have historically faced unfavorable benchmark math in prior models. 

LEAD was specifically designed to improve the financial equation for practices caring for Medicare’s most complex patients. Key structural advantages include: 

• Removal of the negative benchmark adjustment: Practices with above-regional-average spending no longer receive a downward benchmark penalty, removing a major disincentive that existed under ACO REACH. 

• Concurrent risk adjustment for high-needs beneficiaries: Rather than setting risk scores based on prior-year diagnoses, LEAD applies the CMMI HCC Concurrent Risk Adjustment Model V2, which uses current-year diagnoses to capture rapidly escalating costs—such as acute crises, rapid decline, or end-of-life care—in real time.⁵

• Lower alignment minimums: ACOs with at least 40% high-needs aligned beneficiaries qualify for a minimum alignment threshold of 800 beneficiaries in PY 1 (scaling to 1,600 by PY 5), compared to the standard minimum of 5,000.³ ⁴

• 1.5% Administrative Add-On for higher-spending ACOs (see above). 

• Expanded alignment pathways and benefit waivers tailored to high-needs and dually eligible populations. 

CMS-Administered Risk Arrangements (CARA) is a voluntary specialist engagement initiative available exclusively to LEAD ACOs in the Global Risk Option. It enables ACOs to establish episode-based risk arrangements (EBRAs) with specialty care Preferred Providers using Episode-Based Cost Measures (EBCMs). 

CARA offers two configuration options: 

Vytalize models both MSSP and LEAD against each practice’s patient population, cost profile, and prior savings history—then places groups in the program and risk option that best fits. Whether a practice is new to value-based care and best positioned for MSSP BASIC or LEAD Professional, or an experienced ACO ready for LEAD Global with full capitation, Vytalize meets practices where they are. 

Vytalize’s support system includes seamless EHR integration, evidence-based clinical recommendations at the point of care, and an innovative financial model that rewards high-quality care. 

Vytalize Health has published a series of resources to help providers, partners, and their teams stay informed on the LEAD Model:

• The CMS LEAD Model: What Primary Care Providers Need to Know—A practical overview of how the model works, what payment options are available, and what it means for your practice.

• A New Path in Value-Based Care: Understanding CMS’s LEAD Model Alongside MSSP—A side-by-side comparison of LEAD and MSSP to help practices identify the program best suited to their goals and patient population.

• LEAD and Your Most Complex Patients: Key Changes to Know for 2027—A focused look at the structural advantages LEAD introduces for higher-spending practices and those serving dually eligible or high-needs beneficiaries.

You can also visit the official CMS LEAD Model page for regulatory updates and application materials.

No. If your doctor or practice joins the LEAD Model, your Medicare coverage and benefits remain completely unchanged.  

Yes, absolutely. You retain full freedom to see any Medicare-enrolled physician, specialist, hospital, or supplier of your choice, at any time, regardless of whether they participate in the LEAD ACO. 

Your provider’s participation in LEAD is about how CMS pays for and coordinates your care behind the scenes. It does not change your rights as a Medicare beneficiary.