This week, our In Focus section reviews the draft waiver agreement between the Centers for Medicare & Medicaid Services (CMS) and the Governor of Vermont, the Green Mountain Care Board (GMCB), and the Vermont Agency of Human Services (AHS) to form an all-payer accountable care organization (ACO) model in Vermont. The agreement, if approved by all parties, would implement ACO assignment targets, outcomes and quality milestones, and would require Vermont to keep all-payer and Medicare-specific total cost of care growth per beneficiary below annual growth rate thresholds. The all-payer model (APM) encourages alignment across Medicare, Medicaid, and commercial payers, moving toward next generation ACO models with all-inclusive population-based payments. Vermont and CMS have reached preliminary agreement on the draft waiver, with state and federal officials conducting further review at this time.