CARA offers episode‑based contracting for specialists, including a fall‑prevention bundle
April 22, 2026 | Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS), Executive, Federal
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Zachary Howard, legal lead for the CMS Administered Risk Arrangements (CARA), described CARA as a voluntary initiative inside the LEAD model that allows lead participant ACOs—particularly those in the global risk option—to contract directly with specialists for episode‑based arrangements.
"CARA contains three key components," Howard said: (1) a data initiative that provides reports to identify preferred providers and potential episodes; (2) performance adjustment mechanisms tied to quality measures, negotiable between ACOs and specialists and ranging from 10 to 100 percent; and (3) the RISE (Resilience and Independence in a Safe Environment) Age‑in‑Place episode, a bundled episode focused on fall prevention and activities of daily living for Medicare beneficiaries.
Howard explained CARA offers a default participation option—where CMS provides episode definitions and data and ACOs may only set discounts/premiums and select performance measures subject to CMS review—and a "Max Flex" option where ACOs may more substantially customize episodes and partner with external vendors to construct alternative episode methodologies.
Participation requires ACOs to use the 4i digital platform to select episodes, identify preferred providers, negotiate target prices and enter EBRA contracts; specialists will continue to bill fee‑for‑service and be reconciled against target prices with concurrent settlement.
Howard clarified timing during Q&A: CARA episodes will start triggering and the payment mechanics will operate in performance year 2028; 2027 is intended for LEAD participants to research, select and negotiate potential CARA participation and episode designs.
CMS emphasized that more detailed guidance, data feeds and timing will be published later to support ACOs interested in CARA.
"CARA contains three key components," Howard said: (1) a data initiative that provides reports to identify preferred providers and potential episodes; (2) performance adjustment mechanisms tied to quality measures, negotiable between ACOs and specialists and ranging from 10 to 100 percent; and (3) the RISE (Resilience and Independence in a Safe Environment) Age‑in‑Place episode, a bundled episode focused on fall prevention and activities of daily living for Medicare beneficiaries.
Howard explained CARA offers a default participation option—where CMS provides episode definitions and data and ACOs may only set discounts/premiums and select performance measures subject to CMS review—and a "Max Flex" option where ACOs may more substantially customize episodes and partner with external vendors to construct alternative episode methodologies.
Participation requires ACOs to use the 4i digital platform to select episodes, identify preferred providers, negotiate target prices and enter EBRA contracts; specialists will continue to bill fee‑for‑service and be reconciled against target prices with concurrent settlement.
Howard clarified timing during Q&A: CARA episodes will start triggering and the payment mechanics will operate in performance year 2028; 2027 is intended for LEAD participants to research, select and negotiate potential CARA participation and episode designs.
CMS emphasized that more detailed guidance, data feeds and timing will be published later to support ACOs interested in CARA.
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