The HealthTech Company Ecosystem
What Medicare Policy Actually Allows vs. What Companies Claim
The HealthTech sector targeting the Medicare population includes a range of companies making claims about their Medicare revenue potential that range from well-grounded to speculative to materially misleading. Some of this misrepresentation is intentional. Much of it reflects a genuine misunderstanding of what CMS pays for, what CMMI models enable, and how long it takes for a policy opening to become a sustainable revenue stream.
The confusion between a policy opening and a reimbursement pathway is the central analytical problem. A CMMI model creates a payment mechanism that operates during the model’s test period, for participants enrolled in the model, in markets where the model runs. It does not create a Medicare benefit. It does not establish a billing code. It does not guarantee that a company providing services within the model will generate sustainable revenue when the model ends or expands to standard Medicare. Companies that describe their CMMI participation as Medicare coverage, or their total addressable market as the Medicare-eligible population without specifying their actual reimbursement pathway, are making claims that investor materials and public company filings occasionally do not support.
This article maps the named company landscape in the HealthTech sectors most relevant to Medicare, assesses the reimbursement reality against company claims, and identifies which organizations are building durable Medicare businesses.
Digital Therapeutics and Chronic Disease Management#
The ACCESS model (MCR-01.04) creates the most direct pathway for digital health companies to participate in Medicare FFS payment since the chronic care management codes were introduced in 2015. ACCESS proposes Part B enrollment for companies delivering evidence-based digital interventions for eligible chronic conditions: diabetes, obesity, hypertension, chronic kidney disease, cardiovascular disease, musculoskeletal pain, and depression and anxiety. The conditions list covers patient populations in the tens of millions. The policy opening is real.
The reimbursement reality is more constrained than the addressable market framing suggests. Part B enrollment as a provider or supplier requires compliance infrastructure that is non-trivial for digital health companies: billing systems, documentation standards, OIG fraud and abuse exposure analysis, state licensure in every market where patients are located, and ongoing audit readiness. The CPT codes applicable to digital health services do not generate reimbursement at rates that support the cost structures of venture-backed companies that built their operating models around employer-sponsored insurance reimbursement. Medicare Part B pays less than commercial insurance for the same services, and the patient population is older, has higher comorbidity burden, and generates per-session costs that differ materially from the commercial populations these companies have been serving. The companies most capable of capturing ACCESS revenue are those that built Medicare-native operating models from the start, not those that built commercial models and are now trying to extend them downmarket.
Omada Health went public in 2025 after building a digital diabetes prevention and chronic disease management platform primarily on employer and commercial insurer contracts. Medicare has been a smaller share of Omada’s total revenue than its investor communications have implied through addressable market framing. The ACCESS model is the clearest pathway to material Medicare FFS revenue for a company with Omada’s clinical evidence base, and Omada has structured its clinical programs around the conditions ACCESS covers. The gap between ACCESS as a policy opening and ACCESS as a revenue event is time: the model is designed for a ten-year participation horizon, and companies expecting quarterly revenue contribution from ACCESS participation are misreading the model’s design.
Hinge Health has built a digital MSK therapy platform on employer and commercial insurance relationships, with Medicare representing a limited share of current revenue despite the Medicare MSK pain population being one of the largest chronic condition populations in the country. The ACCESS MSK track is a genuine opening because Hinge Health has published randomized controlled trial evidence and has FDA-cleared device components that meet the evidence threshold the model requires. The constraint is the same as for Omada: Part B reimbursement rates for digital MSK interventions do not support the cost structure that employer-contract margins have subsidized. Hinge Health’s Medicare expansion, if it follows the ACCESS pathway, will generate revenue at materially lower margins than its commercial book.
Noom occupies an analytically distinct position. Its behavioral weight management platform is relevant to both the obesity track of ACCESS and to GLP-1 management support under the BALANCE model (MCR-01.05). The BALANCE model’s coverage of GLP-1s for obesity and cardiovascular risk reduction creates a population of Medicare beneficiaries on semaglutide or tirzepatide who need behavioral support to optimize therapeutic outcomes. Noom’s behavioral program has clinical evidence for the weight management population. Whether Medicare reimburses that program as an adjunct to GLP-1 therapy depends on how BALANCE specifies the behavioral support benefit, which had not been fully codified in CMS model specifications as of early 2026. Noom’s Medicare revenue potential under BALANCE is real but contingent on specifications that were still being developed.
Primary Care and Value-Based Care Platforms#
The distinction between companies that enable value-based care and companies that take value-based care risk is the most consistently blurred line in how HealthTech companies describe their Medicare positioning. A company that provides analytics, care management software, or risk stratification tools to ACOs is selling technology. A company that participates in two-sided risk contracts and bears shared savings or loss accountability is taking risk. The revenue model is fundamentally different, and investor materials frequently conflate them.
One Medical, acquired by Amazon in 2023, is the most capitalized primary care technology company in the country. One Medical’s concierge membership model was built on commercial and employer populations. Medicare participation has been limited relative to its commercial book, and the Medicare Advantage panel management question, which is whether One Medical can function effectively as a participating PCP in MA networks at the fee schedule rates those networks pay, has not been resolved in a way that demonstrates scalability. Amazon’s acquisition thesis presumably includes a Medicare angle given the size of the population, but One Medical’s operational model, which involves membership fees, extended appointment times, and a primary care experience calibrated for working-age commercial enrollees, does not transfer straightforwardly to a population with different care patterns and lower reimbursement.
Firefly Health operates a virtual-first primary care model with Medicare as a small share of its current patient population. The ACO REACH pathway is the most direct route to meaningful Medicare revenue for a virtual-first primary care organization, because it allows participation in total cost of care risk without requiring a physical care delivery footprint. The evidence on whether virtual-first primary care can generate ACO savings comparable to in-person primary care is limited; the model intuition is that telehealth accessibility improves engagement for patients who would otherwise defer care, but whether that engagement translates to reduced total cost depends on care management sophistication that goes beyond visit frequency.
The companies in this space that are building durable Medicare businesses are those that have taken risk, generated savings data, and built the compliance infrastructure to participate in MSSP or ACO REACH directly rather than as technology vendors to organizations that take the risk. The distinction is visible in public filings: agilon health’s 10-K shows capitation revenue from Medicare Advantage plans and Medicare total cost of care contracts. Privia’s 10-K shows shared savings distributions from MSSP. A company whose 10-K shows technology licensing revenue to health plans and health systems is in a different business, regardless of how its investor presentations frame its Medicare addressable market.
Remote Monitoring and Care Management#
The RPM billing landscape has undergone significant compliance scrutiny since 2022. The CPT codes that constitute the RPM billing stack (99453 for device setup, 99454 for device supply and transmission, 99457 and 99458 for time-based monitoring management) were introduced or expanded between 2019 and 2021, and the billing volumes grew rapidly as companies built RPM programs on the basis that Medicare’s coverage was broad and the documentation requirements were manageable. OIG and CMS data published between 2022 and 2024 documented that RPM billing growth substantially exceeded what patient population growth and clinical adoption rates could explain, and that a significant share of RPM billing failed documentation audits. The OIG placed RPM billing on its high-priority list for improper payment investigation, which is a signal to both compliance officers and investors that the RPM revenue models built on aggressive CPT interpretation are operating on audit exposure rather than sustainable billing foundations.
The 99454/99457/99458 stack remains viable for organizations with genuine clinical programs, documented physician oversight, and compliant time-tracking for monitoring management time. The companies that built Medicare RPM revenue on compliant foundations are distinguishable from those that built it on volume without documentation, though from the outside both look like RPM companies until audit results or enforcement actions make the difference visible.
Current Health, acquired by Best Buy Health in 2022, operates the best-capitalized clinical RPM platform with a hospital-at-home and continuous monitoring focus. The acquisition gave Current Health the balance sheet and distribution infrastructure that independent RPM companies lack, and Best Buy Health’s broader strategy of building healthcare delivery capability through retail relationships positions Current Health differently from pure-play billing-focused RPM companies. The clinical RPM model, in which monitoring is integrated with physician oversight and care escalation protocols, is more defensible under OIG scrutiny than RPM programs that generate device supply billing without clinical management infrastructure.
BioIntelliSense makes FDA-cleared continuous monitoring biosensors that detect vital signs, activity, and clinical signals continuously rather than episodically. The FDA clearance pathway is the important distinction: a device with FDA Class II clearance has demonstrated clinical-grade reliability through a regulatory process that consumer wearables do not undergo, and that regulatory floor determines whether Medicare will cover the device for clinical monitoring purposes. Medicare coverage of a monitoring device is not automatic following FDA clearance, but FDA clearance is a necessary condition for clinical Medicare coverage that consumer-grade devices cannot satisfy. BioIntelliSense’s positioning in the clinical RPM segment depends on whether CMS creates a billing pathway for continuous biosensor monitoring that reflects the clinical value of the monitoring modality, which had not been established in the standard CPT fee schedule as of early 2026.
The Advanced Primary Care Management codes introduced in 2025 created new billing pathways for technology-assisted care coordination in primary care settings. The APCM codes (99424, 99425, 99426, 99427) allow billing for care management activities for patients with multiple chronic conditions, complex chronic conditions, or serious illness when a physician or advanced practice provider establishes a care relationship. The codes are designed to encourage the care management investment that ACO performance requires by making it billable in the FFS system rather than requiring participation in an alternative payment model to access that revenue. Companies that have built care management technology platforms integrated with EHR systems and that have physician partners with eligible patient panels can generate billing through the APCM codes. The companies still building compliant documentation systems as of early 2026 are operating in a gap between code availability and revenue realization.
What Survives the Medicare Revenue Reality Test#
The companies building durable Medicare businesses share a small number of characteristics. They have compliant billing infrastructure, meaning they have invested in the documentation systems, clinician training, and audit readiness that Medicare billing requires rather than assuming that billing scale creates its own documentation. They have FDA clearance or equivalent regulatory standing for their primary product, which distinguishes clinical-grade from consumer-grade positioning in ways that matter to CMS coverage decisions. They are participating in two-sided risk arrangements or billing through established CPT codes rather than depending on CMMI model participation that could be terminated. And they have Medicare revenue that is visible in public filings, which distinguishes companies with actual Medicare billing from companies with Medicare market opportunity that has not yet been converted to revenue.
The red flags in company positioning are visible in public documents for any investor or policy analyst who reads them carefully. Medicare revenue claims based on total addressable market rather than current billing are the most common. CMMI model participation described as equivalent to Medicare coverage is the most consequential misrepresentation, because it affects not just investor perception but also the companies’ own strategic planning, which builds operational models around revenue that will not materialize on the timeline or at the margin the models assume. RPM billing at scale without documented audit infrastructure is the most acute compliance risk, because OIG improper payment enforcement is proceeding.
The companies that will be operating in the Medicare HealthTech space in 2030 are those that have treated compliance as infrastructure rather than overhead, built clinical evidence at the rigor level Medicare coverage decisions require, and developed revenue models that function within the reimbursement rates the Medicare fee schedule actually pays. That is a smaller set than the current HealthTech landscape implies.
Related Reading#
MCR-01_04 ACCESS: Digital Health’s New Medicare Beachhead MCR-06_09 Predictive Analytics for Aging: What the Models Actually Get Right MCR-06_11 Clinical Decision Support and the WISeR Vendor Ecosystem