Program Details

Name of Payment Reform Program
  Accountable Care Organization
Organization Name
Program Contact Name
  Elisa Pena
Program Contact Email
Program Contact Phone
Program location(s)
  Only in this market
Market(s) (Ctrl-Click for multiple states)
  CA, CO, CT, GA, IN, KY, ME, MO, NV, NH, NY, OH, VA, WI
Lines of business
  Fully-insured commercial
Other line of business
  Federal Employee Program
Stage of implementation
  Full implementation (e.g. available to all intended/applicable providers and members)
Date of Implementation
  November 1, 2012
Payment reform model alignment
  Non-FFS-based Shared-savings with quality
Base payment methodology
Other base payment methodology
  In addition to the FFS payment, the provider receives additional incentives to coordinate the care: • FFS Prudent Buyer fee • Care Management fee for providing coordination services • Shared Savings The provider needs to pass the quality set for ACO to be eligible to receive shared savings.
Participating provider types
  Primary care physicians
Other types of providers
  Not applicable
Related outcomes for policies on non-payment for specific services associated with complications that were preventable or services that were unnecessary
Performance measures used
Other performance measures
  Our ACO program measures quality care through established benchmarks and the Physician Quality Metrics.
Type(s) of benefit and/or provider network design features that create member incentives or disincentives to support the payment reform program
  No active steerage
Other features
  In markets where there is an adequate network of patient-centered care providers(CO, ME and WI), we developed and are expanding offerings of narrow and tiered networks built around these providers. These narrow and tiered networks align provider and member incentives through an integrated network and product design.
Information transparency
  We report to our network providers (e.g. hospitals and physicians)
Other information transparency
  The following reports are provided to providers Performance Scorecard ( performance against program metrics) • Care opportunities - (highlighting members with gaps in care • Hot Spotter - members appropriate for care and disease management • Attributed member lists • Inpatient authorization • Financial performance vs. medical cost target
Evaluation and results for program
  Program evaluation by insurer