How it Works

​Patients experiencing one of the medical episodes will schedule office visits and be seen by their physician or mental health provider just as they are today. Providers will file claims as usual and be reimbursed as they are today.  The change comes as providers are now able to input some basic information related to the care they provide into a Provider Portal. Using the portal, providers are able to access reports that show the overall quality of care they delivered during a set time period -- typically one year -- and at what average cost. Medicaid and the private insurers use the information from the portal along with claims data to determine which provider has the most responsibility for a given episode. That provider will be designated the “Principal Accountable Provider (PAP).” At the end of the set time period, each PAP’s average cost per episode will be calculated and compared to “acceptable” and “commendable” levels of costs. If the average cost is above the acceptable level, the provider will pay a portion of the “excess” costs. If the average cost is acceptable but not commendable, there will be no payment changes. If the provider offers high-quality care below the commendable level, then he or she will be eligible to share in the savings with the payer. If you want more details on the state's overall health care transofrmation effort, you can read our State Innovation Plan.

The collaborating partners are using input from providers, patients and others interested in the initiative to design and build infrastructure for the continued waves of new episodes. The goal is to have most episodes of care designed and launched within three to five years.

Here you can find a link to the legislative language submitted by Medicaid that provides a more detailed description of the first wave of episodes, including exclusions, and the payment improvement process.