CMS recently announced the Long-term Enhanced ACO Design (LEAD) Model, positioning it as the follow-up to ACO REACH, which sunsets at the end of 2026. This 10-year voluntary model kicks off January 1, 2027, and promises the longest ACO model yet. LEAD isn’t just a REACH sequel – it is breathing new life into the goals of the ACO Primary Care Flex (PC Flex) Model, using a smarter approach to finally pull in those hard-to-reach providers like independents, FQHCs, RHCs, and rural docs serving high-needs patients.

PC Flex: Big Ideas, Tough Execution

PC Flex rolled out in 2025 as a five-year MSSP add-on focused on low-revenue ACOs and rural providers. Its goals were to:

• Provide Stable Funding for Primary Care: Monthly Prospective Primary Care Payments (PPCPs) swapped out FFS for predictable revenue, plus a $250,000 one-time advance to cover startup costs.
• Entice New Entrants to Medicare ACOs: Targeted physician-led groups, FQHCs, and RHCs to grow MSSP participation among smaller players.

But uptake was low – only 24 ACOs signed on, way under CMS’s 130+ target. Why? From our work with participants and industry chatter, a few pain points stood out:

• MSSP Tie-In and Rebasing Risks: ACOs had to start a fresh MSSP agreement, triggering rebasing that scared off ACOs protecting good benchmarks.
• Admin Overload: Spend plans, fund guardrails, and extra repayment setups added hassle for resource-strapped groups and additional financial burden.
• Capitation Jitters: The concept of fee reduction agreements, a mid-year switch to capitation, PPCP eligibility lists and specialist designations……. These factors were overwhelming to some.
• Short Ramp-Up: Tight application timelines and limited buzz left many on the sidelines.

PC Flex had the right ambitions but wasn’t promoted effectively and introduced complexity that scared off some providers that would have benefitted.

LEAD: Same Goals, Better Path Forward

In many ways the LEAD model picks up where PC Flex left off, seeking to entice and engage independent practices, FQHCs, RHCs, rural providers, and high-needs care – but giving providers more time to plan ahead and making some other critical changes: No MSSP requirement, no rebasing, lower alignment thresholds for new entrants.

This evolution is timely, as value-based care continues to shift toward rewarding prevention and coordination over volume. By extending the model to a full decade, LEAD gives organizations the breathing room to invest in infrastructure, like data analytics and care teams, that pay off over time- something PC Flex’s shorter span couldn’t fully support. For providers who’ve hesitated due to past model complexities, this could be the entry point that aligns financial stability with better patient outcomes.

Standout features include:

• 10-Year Stability: No benchmark rebasing for predictable planning – this is perfect for long-haul investments PC Flex’s five years couldn’t match.
• Flexible Risk Tracks: Choose Global (100% upside/downside) or Professional (50%) to ease in.
• Prospective Payments: Up-front capitated payments, supplemented by non-reconciled add-ons for rural providers and reduced alignment minimums
• High-Needs Emphasis: Better risk adjustment for dually eligible and complex patients; beneficiary incentives like Part B cost-sharing help and Part D buy-downs by 2029.
• Medicaid Ties: Pilots in two states for Medicaid integration. This integration will be particularly important given that Medicaid is the primary line of business for FQHCs and RHCs.
• Timeline: LEAD Applications open March 2026, offering more prep time for interested providers than PC Flex’s rollout in 2024.

From our perspective, this model could transform how smaller and rural providers engage with Medicare. We’ve seen in PC Flex how upfront payments can spark real change in care delivery, but only if the framework lets them focus on patients rather than paperwork. LEAD seems poised to deliver that, potentially increasing ACO adoption and driving broader system efficiencies.

What’s Still Up in the Air?

LEAD looks promising, but some program specifications are TBD:

• Trends and Benchmarks: Prospective or retrospective? Blend details?

• Risk Adjustment: How to dodge REACH-style penalties for coding improvements or tougher patients?
• Quality: Measures, weights, withholds?
• Assignment: Sticking with REACH’s methodology  or will there be tweaks for high-needs populations?

COPE Health Solutions will continue to monitor for and analyze details as they become available.

Time to Gear Up

Applications hit in March 2026, so start now:

• Determine which ACO program is right for you? MSSP or LEAD? Why? What will my financials look like in each scenario?
• Check your fit: Rural? High-needs? Efficient or high-cost?
• How mature are my current population health capabilities? Can I handle capitation?

LEAD could be the game-changer PC Flex hoped to be for RHCs and FQHCs and get more providers off the bench. Nonetheless, preparation is key.

How COPE Health Solutions Can Help

We have helped PC Flex ACOs successfully apply, stand up and run the program. Now, we at CHS are ready to help rural providers, FQHCs, and others who’ve watched from the sidelines jump into Medicare ACOs and thrive in LEAD. Whether it’s modeling scenarios, launching your ACO, or optimizing care coordination and population health, we’re here to make it happen.

MSSP and models like LEAD are paying off big. The question is, is your organization leaving opportunity on the table?

Reach out to us at info@copehealthsolutions.com or visit copehealthsolutions.com to chat about your next move.