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Guide Guide: Payment & Care Delivery Innovation (PCDI) for Providers

We’ve created this guide to bring MassHealth PCDI information to providers. This guide highlights key sections to help providers become familiar with PCDI changes and concepts. Providers can scroll through areas or click on the “quick links” below to view specific content.

Table of Contents

Provider communication and education

1.2 million MassHealth managed care eligible members

Overview

MassHealth is focused on strategies that bring awareness of PCDI changes to the provider community. Providers will need information about how and when these changes will affect them. This includes information on

  • Network contracting choices
  • Payments and accountability
  • Administrative changes
  • Changes for members

MassHealth will develop communication tailored to specific provider groups, including:

  • Primary care providers
  • Hospitals
  • Behavioral health providers
  • Community Partners
  • Specialists and other providers

We will use a variety of communication strategies and methods to share information with providers, including

Resources and Information Collaboration Strategies
Robust online resources and tool kits for providers Work with ACOs and MCOs to provide consistent messaging
Enhanced EVS messaging Work closely with provider associations
Webinars Proactive messaging to specific provider groups
In-person trainings Knowledgeable MassHealth staff, available to answer provider questions as needed
Provider bulletins  
MassHealth regulations  
Message text (POSC)  

Provider Training Events and Forums

Effective March 1, 2018, MassHealth’s PCDI introduced new health plans to MassHealth’s managed care eligible members. These options include re-procured managed care organizations (MCOs), new Accountable Care Organizations (ACOs), and Community Partners (CPs). 

Phase I:  Awareness  October 31-December 28, 2017
Phase II:  Operations January 9-April 24, 2018
Phase III:  Community Partners Program  September 6 - 20, 2018
   

View the webinar and in-person training schedule

To enroll in a webinar or an in-person session, register at the MassHealth Learning Management System (LMS) via www.masshealthtraining.com and create your profile. Once you are registered, select the preferred course date and time available.

For questions, please contact the MassHealth Customer Service Center by email at providersupport@mahealth.net or by phone at 1-(800) 841-2900.

MassHealth Eligibility Verification System (EVS)

Enhanced EVS for PCDI Includes plan and contact information

MassHealth will enhance the Eligibility Verification System (EVS) messages so providers know:

  • Which type of health plan, including ACOs, a member is enrolled in

  • Who to contact for billing questions

EVS will also have messages with contact information for behavioral health services for the member’s health plan. This will include contact information for behavioral health vendors. See below for quick reference guides and screenshots. 

Upcoming webinars dedicated to EVS enhancements will be available for providers. More information on provider webinars is included on this page in the Provider Training Events and Forums section above.

Additional Resources for MassHealth Eligibility Verification System (EVS)

2018 health plan options

New health plan options

Effective March 1, 2018, MassHealth’s PCDI initiative is offering new health plans options to MassHealth members eligible for managed care. These managed care options will include new Accountable Care Organizations (ACOs) in addition to re-procured managed care organizations (MCOs) and the Primary Care Clinician (PCC) Plan.

Managed care eligible members are:

  • Younger than age 65, without any third-party insurance coverage (including Medicare)
  • Living in the community (not in a nursing facility)
  • Enrolled in one of the following MassHealth coverage types:
    • Standard
    • CommonHealth
    • CarePlus
    • Family Assistance

Members who are not affected by the PCDI changes are those who receive MassHealth coverage through:

  • Fee-for-service
  • One Care plans
  • Senior Care Options (SCO) plans
  • Program of All-Inclusive Care for the Elderly (PACE) organizations

Introducing Accountable Care Organizations (ACOs)

An ACO is a provider-led health plan that holds participating providers financially accountable for both cost and quality of care for members. ACOs are composed of groups of primary care providers (PCPs) to whom members are attributed. In an ACO, the PCP and their team are responsible for working with the member and the ACO’s network of providers to help coordinate care and connect the member with available services and supports.

There are three types of ACOs.

  • Accountable Care Partnership Plans 
  • Primary Care ACOs 
  • MCO-Administered ACOs
Accountable Care Partnership Plans

In this type of ACO, a network of PCPs works with just one MCO to create a full network that includes PCPs, specialists, behavioral health providers, and hospitals. PCPs plan and coordinate care to meet the needs of the member.

Primary Care ACOs

In this type of ACO, a network of PCPs has joined together into an ACO to provide integrated and coordinated care for members. The ACO contracts directly with MassHealth and uses the MassHealth provider network of specialists and hospitals. Members who enroll in a Primary Care ACO receive behavioral health services through the Massachusetts Behavioral Health Partnership (MBHP).

MCO-Administered ACOs

In this type of ACO, a network of PCPs may contract with one or multiple MCOs, and use the MCO provider networks to provide integrated and coordinated care for members. MCO-Administered ACOs are not presented as an enrollment option for members because they will be attributed through their relevant MCO.

MCO and PCC Plans

MassHealth will continue to offer the Managed Care Organization (MCO) and Primary Care Clinician (PCC) health plans

Managed Care Organizations (MCOs)

MCOs are health plans run by insurance companies that provide care through their own provider network that includes PCPs, specialists, behavioral health providers, and hospitals. Care coordinators are employed by the MCO.

Primary Care Clinician (PCC) Plan

In the PCC Plan, primary care providers are called primary care clinicians (PCCs). The MassHealth network of PCCs, specialists, and hospitals delivers services. The Massachusetts Behavioral Health Partnership (MBHP) provides behavioral health services.

MassHealth contact matrix – 2018 managed care health plans

This document provides a list of the medical and behavioral health contact information and member ID card images for all 2018 MassHealth managed care health plans.

Additional Resources for MassHealth contact matrix – 2018 managed care health plans

Additional provider information

Special Assignment Designed to keep members with their PCP whenever possible

Member Assignment and Noticing

Effective March 1, 2018, current members will be assigned to an ACO, MCO, or the PCC Plan based on each member’s PCP relationship in mid-October, 2017. This process, known as special assignment, is designed to keep members with their PCP whenever possible. If a member prefers to follow providers other than their PCP, the member should find out what plans those providers are contracted with. The member should then contact MassHealth Customer Service for assistance enrolling in a plan that is in their service area and has their preferred providers.

  • Member noticing begins—November 13, 2017

  • Member enrollments effective—March 1, 2018

  • Plan Selection Period—March 1, 2018, to May 31, 2018

  • Fixed Enrollment Period—June 1, 2018, to February 29, 2019

ACO Primary Care Exclusivity

If a primary care practice is participating in an ACO, its providers can only see MassHealth managed care eligible members who are enrolled in their ACO. A primary care practice can participate in only one ACO. MassHealth is performing a special assignment process to keep members with their PCP wherever possible.

Referral Circles 

Primary Care ACOs will use the MassHealth network for specialty services. They have the option of defining a Referral Circle, a subset of the MassHealth network for whom referral requirements are waived for members in the Primary Care ACO. If a member’s hospital or specialist is part of the Referral Circle of the member’s Primary Care ACO, the member will not need a referral to receive services from that hospital or specialist.

Accountable Care Partnership Plans and MCOs may have preferred networks within their overall networks that have modified authorization requirements. For more information on these potential arrangements, talk to the health plans you have contracted with.

Referrals

Referrals are required for certain specialty services in both the PCC Plan and Primary Care ACOs. The requirements for referrals for all other plans are subject to the requirements of the health plan in which the member is enrolled.

Specialists and Payment and Care Delivery Innovation

Specialists can be contracted with multiple health plans at the same time and can provide services to members in any of the health plans they are contracted with.

Additional Resources for Additional provider information

Information for PCPs, specialists, hospitals, and behavioral health providers

MassHealth has created fact sheets to help providers understand the PCDI changes as they are introduced over the coming months. Providers can use these fact sheets as a quick desk reference. To view the facts sheets please click on the PCDI resources for providers link below.

 

Additional Resources for Information for PCPs, specialists, hospitals, and behavioral health providers

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