Humana has developed episode-based models (EBM) for episodes of care related to total joint replacement (hip and/or knee), maternity, spinal fusion (lumbar and/or cervical) and coronary artery bypass grafting.

Total Joint Replacement Episode-of-care Model

In 2016, Humana piloted its first episode-based model (EBM) for elective total hip or knee joint replacement (TJR) in select states. The program has been available nationwide since 2018. Highlights of the TJR EBM include:

  • Designation of the orthopedic surgeon(s) as the principal accountable provider(s) (PAPs) under one Tax Identification Number (TIN)
  • Offer of voluntary participation to orthopedic surgeons with sufficient episode volume
  • Exclusively for TJR episodes of patients with Humana Medicare Advantage (MA) health maintenance organization (HMO) or preferred provider organization (PPO) coverage
  • Multiyear program with gain-share opportunity and an option to pursue risk sharing

Learn more about the total joint replacement EBM:

TJR EBM Overview, PDF

TJR EBM Configuration Code Set, PDF

Spinal Fusion Episode-of-care Model

In 2019, Humana further expanded its national episode-of-care programs into spinal fusion services and developed the spinal fusion episode-based model (EBM). Highlights of the spinal fusion EBM include:

  • Designation of the orthopedic surgeon(s) as the principal accountable provider(s) (PAPs) under one Tax Identification Number (TIN)
  • Offer of voluntary participation to orthopedic surgeons with sufficient spinal fusion (lumbar and/or cervical) episode volume
  • Separate programs for lumbar and cervical spinal fusions
  • Exclusively for spinal fusion episodes of patients with Humana Medicare Advantage (MA) HMO or MA PPO coverage
  • Multiyear program with gain-share opportunity and an option to pursue risk sharing

Learn more about the spinal fusion EBM:

Spinal Fusion EBM Overview, PDF

Lumbar Spinal Fusion Configuration Code Set, PDF

Cervical Spinal Fusion Configuration Code Set, PDF

Coronary Artery Bypass Grafting (CABG) Episode-of-care Model

In 2020, Humana added a national cardiac episode-of-care program and developed the coronary artery bypass grafting (CABG) episode-based model (EBM). Highlights of the CABG EBM include:

  • Designation of the cardiothoracic surgeon(s) as the principal accountable provider(s) (PAPs) under one Tax Identification Number (TIN)
  • Offer of voluntary participation to cardiothoracic surgeons with sufficient episode volume
  • Exclusively for CABG episodes of patients with Humana Medicare Advantage (MA) HMO or MA PPO coverage
  • Multiyear program with gain-share opportunity and an option to pursue risk sharing

Learn more about the CABG EBM:

CABG EBM Overview, PDF

CABG EBM Configuration Code Set, PDF