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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.

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. The PCDI changes will affect providers in a number of ways, including

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

MassHealth communications are tailored to specific provider groups, including

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

MassHealth uses 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
Provider bulletins Message text (POSC)
MassHealth regulations  

Key Actions for Provider communication and education

MassHealth Eligibility Verification System (EVS)

Enhanced EVS for PCDI Includes plan and contact information

MassHealth has enhanced the Eligibility Verification System (EVS) messages so providers know

  • Which type of health plan a member is enrolled in

  • Who to contact for billing questions

EVS now has messages with contact information for behavioral health services for the member’s health plan. 

 

Additional Resources for MassHealth Eligibility Verification System (EVS)

Health plan options

Health plans

On March 1, 2018, MassHealth’s PCDI initiative offered new health plan options to MassHealth members eligible for managed care. These managed care options include Accountable Care Organizations (ACOs) plans in addition to re-procured managed care organizations (MCOs) plans 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

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 are 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 – Managed care health plans

This document provides a list of the medical and behavioral health contact information and member ID card images for all 2019 MassHealth managed care health plans

Additional Resources for MassHealth contact matrix – Managed care health plans

Additional provider information

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. 

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. 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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