offered by

Guide MassHealth Community Partners (CP) Program

Behavioral Health (BH) and Long-Term Services and Supports (LTSS) Community Partners (CPs) work with Accountable Care Organizations (ACOs) and Managed Care Organizations (MCOs) to provide care management and care coordination to certain members identified by MassHealth, ACOs, or MCOs. BH CPs will provide care management and care coordination to certain members with significant behavioral health needs, including Serious Mental Illness (SMI) and addiction. LTSS CPs will provide LTSS care coordination and navigation to certain members with complex LTSS needs, such as children and adults with physical disabilities, developmental disabilities and brain injuries.

Members enrolled in an ACO or MCO will be able to participate in the CP program. CPs are not available to members in the PCC Plan or in MassHealth’s fee-for-service program (e.g., members who are dually-eligible for MassHealth and Medicare) unless the member is affiliated with the Department of Mental Health’s Adult Community Clinical Supports program. Where members have other state agency or provider supports, CPs will coordinate with those supports and will supplement but not duplicate the functions provided by them.

When the program is fully implemented, MassHealth anticipates that

• BH CPs will support approximately 35,000 MassHealth members, and
• LTSS CPs will support approximately 20,000 – 24,000 MassHealth members.

Objectives

  • Support members with significant BH needs and complex LTSS needs to help them navigate the BH and LTSS healthcare systems in Massachusetts.
  • Improve member experience and continuity and quality of care by holistically engaging members with significant BH needs (SMI, and addiction) and complex LTSS needs.
  • Create opportunity for ACOs and MCOs to leverage the expertise and capabilities of existing community-based organizations serving populations with BH and LTSS needs.
  • Invest in the continued development of BH and LTSS infrastructure (e.g. technology, information systems) that is sustainable over time.
  • Improve collaboration across ACOs, MCOs, CPs, and community organizations addressing the social determinants of health, and BH, LTSS and physical health care delivery systems in order to break down existing silos and deliver integrated care.
  • Support values of Community First[1], recovery principles, independent living, and promote cultural competence.

[1] Community First is a policy agenda that seeks to empower and support people with disabilities and elders to live with dignity and independence in the community by expanding, strengthening, and integrating systems of community-based long-term supports that are person-centered, high in quality and provide optimal choice.

Supports Provided by Community Partners

BH CPs perform comprehensive care coordination and care management, including

  • Outreach and engagement
  • Comprehensive assessment and ongoing person-centered treatment planning
  • Care Coordination and care management, including across medical, behavioral health, long-term services and supports, social services and services provided by other state agencies
  • Support for transitions of care
  • Medication reconciliation support
  • Health and wellness coaching
  • Connection to social services and community resources

LTSS CPs are experts in LTSS and perform the LTSS component of care coordination, including

  • Outreach and engagement
  • LTSS care planning including providing informed choice of services and providers
  • Care team participation
  • LTSS care coordination, including social services and services provided by other state agencies
  • Support for transitions of care
  • Health and wellness coaching
  • Connection to social services and community resources

CPs will not be responsible for authorizing services for members. All Person Centered Treatment Plans and LTSS Care Plans must be approved and signed by the member's PCP or PCP Designee. Providers of services that require prior authorization should continue to submit authorization requests to Accountable Care Partnership Plans, MCOs and MassHealth, as applicable. Providers should refer to MassHealth or managed care contracts, regulations, bulletins, and provider manuals, as appropriate, for all applicable requirements for their respective programs and MassHealth services.

How Members are Identified for Assignment to a Community Partner

  • MassHealth will identify members for the program based on service utilization history.  Members identified by MassHealth will be assigned to a Community Partner in the member’s area.
  • Each assigned member will receive a letter from MassHealth in the mail and will be contacted by Community Partner staff who will explain the program.  Letters will be mailed in July and on an ongoing basis to newly assigned members approximately quarterly.
  • Members may request a different Community Partner in their area or may decline to participate in the program at any time.
  • Members who are not identified by MassHealth or assigned to a Community Partner may request to participate in the program beginning in January 2019 by submitting a request to the member’s MCO or ACO.  The member’s MCO or ACO will determine whether to assign the member to a CP.

Program Implementation Timeline

  • June 2018 - MassHealth identifies members for the Community Partners Program based on service utilization data.
  • July 2018 – Community Partners Program begins.  Community Partners begin supporting members identified by MassHealth.
  • Ongoing – MassHealth continues to identify members for the Community Partners Program on a quarterly basis.
  • January 2019 - ACOs and MCOs begin accepting referrals for the Community Partners Program.  More information about how to make a referral is forthcoming.  This information will be available prior to January 2019.

What this Means for Providers

CP Supports are designed to work in partnership with other MassHealth programs and services.  Providers of MassHealth services and programs will be expected to perform functions per regulations, agency guidance, and contracts with ACOs/MCOs, where applicable. CPs will coordinate with providers and supplement but not duplicate functions performed by providers. CPs will be a resource and support for coordinating with the ACO and MCO.  For example, a CP may support integration by ensuring appropriate information sharing between ACOs, MCOs, PCPs and providers and by coordinating services, including additional social services, through a single care plan. 

Behavioral Health Community Partners

  • Behavioral Health Network, Inc.
  • Behavioral Health Partners of Metrowest, LLC
    Including Advocates, Inc.; South Middlesex Opportunity Council; Spectrum Health Systems, Inc.; and Wayside Youth and Family Support, Family Continuity (FCP), Inc.
  • McInnis Health Group/Boston Health Care for the Homeless Program
    Including Bay Cove Human Services, Inc.; Boston Public Health Commission; Boston Rescue Mission, Inc.; Casa Esperanza, Inc.; Pine Street Inn, Inc.; St. Francis House; Victory Programs, Inc.; and Vietnam Veterans Workshop, Inc.
  • The Bridge of Central Massachusetts, Inc. d.b.a. Central Community Health Partnership 
    Including AdCare; Alternatives Unlimited, Inc.; LUK, Inc.; and Venture Community Services
  • The Brien Center for Mental Health and Substance Abuse Services, Inc.
  • Clinical and Support Options, Inc.
  • Community Counseling of Bristol County
  • Community Healthlink, Inc.
  • Community Care Partners, LLC
    Including Vinfen Corporation; Bay Cove Human Services, Inc.; and Bridgewell, Inc.
  • Eliot Community Health Services, Inc.
  • High Point Treatment Center, Inc. d.b.a Coordinated Care Network
    Including Brockton Area Multi Services, Inc. (BAMSI); Bay State Community Services, Inc.; Child & Family Services, Inc.; Duffy Health Center; and Steppingstone, Inc.
  • Innovative Care Partners, LLC 
    Including Center for Human Development; Gandara Mental Health Center, Inc.; and Service Net, Inc.
  • Lowell Community Health Center, Inc. 
    Including Lowell House, Inc.
  • Northeast Behavioral Health Corporation d.b.a. Lahey Health Behavioral Services
  • Riverside Community Care, Inc. d.b.a Riverside Community Partners
    Including Brookline Community Mental Health Center, Inc.; The Dimock Center, Inc.; The Edinburg Center, Inc.; Lynn Community Health Center, Inc.; North Suffolk Mental Health Association, Inc.; and Upham’s Corner Health Center
  • Southeast Community Partnership 
    Including South Shore Mental Health Center, Inc. Gosnold, Inc., and Family Continuity
  • South Shore Mental Health Center, Inc.
    Including Spectrum Health Systems, Inc.
  • Stanley Street Treatment and Resources (SSTAR), Inc. 
    Including Greater New Bedford Community Health Center, Inc.; HealthFirst Family Care Center, Inc.; and Fellowship Health Resources, Inc.

 

Long-Term Services and Supports Community Partners

  • Alternatives Unlimited d.b.a. Central Community Health Partnership
    Including AdCare; the Bridge of Central Massachusetts, Inc.; LUK, Inc.; and Venture Community Services, Inc.
  • Boston Medical Center Corporation d.b.a. Boston Allied Partners
    Including Boston Senior Home Care, Inc.; Central Boston Elder Services; and Southwest Boston Senior Services, d.b.a Ethos
  • LTSS Care Partners, LLC
    Including Vinfen Corporation, Bay Cove Human Services, Justice Resource Institute, Boston Center for Independent Living, Mystic Valley Elder Services, Somerville Cambridge Elder Services, and Boston Senior Home Care, Inc.
  • Elder Services of Merrimack Valley, Inc. d.b.a. Merrimack Valley Community Partnership
    Including Northeast Independent Living Program
  • Family Service Association
  • Innovative Care Partners, LLC 
    Including Center for Human Development; Gandara Mental Health Center, Inc.; and Service Net, Inc.
  • Seven Hills Family Services, Inc. d.b.a Massachusetts Care Coordination Network 
    Including Advocates, Inc.; Boston Center for Independent Living, Inc.; HMEA; Baypath Elder Services, Inc.; and Brockton Area Multi Services, Inc. (BAMSI)
  • WestMass Elder Care, Inc. d.b.a. Care Alliance of Western Massachusetts
    Including Greater Springfield Senior Services, Inc.; Highland Valley Elder Services, Inc.; LifePath, Inc.; Elder Services of Berkshire County, Inc.; Stavros Center for Independent Living; Adlib, Inc.; and Behavioral Health Network, Inc.
  • Greater Lynn Senior Services d.b.a. North Region LTSS Partnership
    Including Bridgewell, Inc. and Northeast Arc, Inc.

An Introduction to MassHealth Long Term Services and Supports and Other Covered Services

 

This Guide provides basic information about and gives context to the range of State Plan LTSS and Other Covered Services. MassHealth intends for this Guide to be a resource for care managers, care  coordinators, and physician offices within Accountable Care Organizations (ACOs, including Accountable Care Partnership Plans, Primary Care ACOs, and MCO-Administered ACOs) and Managed Care Organizations (MCOs), as well as Community Partners (CPs), and providers as they serve MassHealth members who may benefit from LTSS or Other Covered Services.

Additional Resources for An Introduction to MassHealth Long Term Services and Supports and Other Covered Services

September PCDI Provider Training Schedule

Feedback

Did you find what you were looking for on this webpage? * required
We use your feedback to help us improve this site but we are not able to respond directly. Please do not include personal or contact information. If you need a response, please locate the contact information elsewhere on this page or in the footer.
We use your feedback to help us improve this site but we are not able to respond directly. Please do not include personal or contact information. If you need a response, please locate the contact information elsewhere on this page or in the footer.

If you need to report child abuse, any other kind of abuse, or need urgent assistance, please click here.

Feedback