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) HMO or MA 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 opens new window

TJR EBM Configuration Code Set, PDF opens new window

Maternity Episode-of-care Model

In 2018, Humana expanded its national episode-of-care programs into perinatal services and developed the maternity episode-based model (EBM). Highlights of the maternity EBM include:

  • Designation of the delivering physician(s) as the principal accountable provider(s) (PAPs) under one Tax Identification Number (TIN)
  • Offer of voluntary participation to obstetricians with sufficient episode volume
  • Exclusively for perinatal episodes of patients with Humana commercial coverage
  • Designed for perinatal episodes with low- to medium-risk pregnancies
  • Multiyear program with gain-share opportunity and an option to pursue risk sharing

Learn more about the maternity EBM:

Maternity EBM Overview, PDF opens new window

Maternity EBM Configuration Code Set, PDF opens new window

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 opens new window

Lumbar Spinal Fusion Configuration Code Set, document opens new window

Cervical Spinal Fusion Configuration Code Set, document opens new window

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 opens new window

CABG EBM Configuration Code Set, PDF opens new window