MassHealth Primary Care Sub-Capitation: Care Delivery Transformation

Supporting primary care providers in meeting new care delivery expectations that promote team-based, integrated care and improve patient access.

Intro to Clinical Tiers

Practices that participate in the primary care sub-capitation program must meet a set of minimum care delivery standards. Practices also receive increased payment for providing more advanced services in the primary care setting. Practices attest that they meet the criteria for one of three “clinical tiers” based on the set of criteria outlined below.  MassHealth adjusts sub-capitation rates to reflect these tiers through the clinical tier enhanced payment. Clinical tiers differ from the quality metrics that apply to all MassHealth Accountable Care Organizations (ACOs). MassHealth monitors primary care quality through its ACO quality metrics.  The Primary Care Sub-Capitation Program does not include any new quality metric requirements above what is already required of an ACO-participating practice.

For more information about ACO quality metrics, please refer to the relevant ACO contract (Accountable Care Partnership Plan Contract Appendix Q, Primary Care Accountable Care Organization Contract Appendix B.

Clinical Tier Criteria

Participating practices are categorized as Tier 1, Tier 2, or Tier 3 based on meeting the following criteria. Those marked with a (*) can be provided by the Accountable Care Organization (ACO) associated with a given practice and those marked with (†) can be met virtually. 

See below for an overview of the tier criteria. Full details and descriptors of each criterion can be found in the, ACO Contract Appendix on the Primary Care Sub-Capitation Program: PDF | Word

Tier	Requirements
Tier 1	A. Care Delivery Requirements Traditional primary care Referral to specialty care Oral health screening and referral Behavioral health (BH) and substance use disorder screening BH referral with bi-directional communication, tracking, and monitoring BH medication management Health-Related Social Needs (HRSN) screening*† Care coordination*† Clinical Advice and Support Line*† Postpartum depression screening Use of Prescription Monitoring Program Long-Acting Reversible Contraception (LARC) provision, referral option B. Structure and Staffing Requirements Same-day urgent care capacity Video telehealth capability No reduction in hours Access to Translation and Interpreter Services C. Population-Specific Requirements Practices serving Enrollees 21 years of age or younger shall: Administer, at a minimum, BH, developmental, social, and other screenings and assessments as required under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Screen for SNAP and WIC eligibility Establish and maintain relationships with local Children’s Behavioral Health Initiative (CBHI) Coordination with MA Child Psychiatry Access Program (MCPAP) and MA Child Psychiatry Access Program for Moms (M4M) Fluoride varnish for patients ages 6 months up to age 6
Tier 2	Tier 2 Practices shall meet all Tier 1 requirements above and all Tier 2 requirements below to achieve this Tier Designation A. Care Delivery Requirements Brief intervention for BH conditions Telehealth-capable BH referral partner B. Structure and Staffing Requirements E-consults available in at least three (3) specialties After-hours or weekend session† Team-based staff role Maintain a consulting independent BH clinician† C. Population-Specific Requirements Practices serving Enrollees 21 years of age or younger shall: On-site staff with children, youth, and family-specific expertise Provide patients and their families who are eligible for SNAP and WIC application assistance Practices serving Enrollees ages 21-65 shall: Offer at least one (1) type of LARC Active Buprenorphine Availability† Active Alcohol Use Disorder (AUD) Treatment Availability†
Tier 3	Tier 3 Practices shall meet all Tier 1 & 2 requirements above and all Tier 3 requirements below to achieve this Tier Designation A. Care Delivery Requirements The practice shall fulfill at least one of the following three requirements: Clinical pharmacist visits† Group visits† Designated Educational Liaison for pediatric patients† B. Structure and Staffing Requirements E-consults available in at least five (5) specialties After-hours or weekend session Three team-based staff roles Maintain a consulting BH clinician with prescribing capability† C. Population-Specific Requirements Practices serving Enrollees 21 years of age or younger shall: Full-time, on-site staff with children, youth, and family-specific expertise Offer at least one (1) type of LARC Active Buprenorphine Availability† Practices serving Enrollees ages 21-65 shall: Offer multiple types of LARC Capability for next-business-day Medication for Opioid Use Disorder (MOUD) induction and follow-up†

Practice Attestation and Auditing

Participating practices must complete the Practice Tier Designation Attestation form in the corresponding ACO contract appendix (ACPP Appendix K or PCACO Appendix D) to attest whether they meet the criteria for Tier 1, Tier 2, or Tier 3, and practices must fulfill all care model requirements of their attested tier. Each ACO is responsible for maintaining up-to-date Practice Tier Designation Attestation forms for their primary care practices. Tier attestation occurs at the site level. For the purposes of the Primary Care Sub-Capitation Program, a “site” refers to a unique, 10-digit alpha-numeric “Practice Identification Service Location (PID/SL)” that represents a single practice site.

Tier designations are effective until the end of each calendar year. All participating practices can change their tier designation for the next calendar year through MassHealth’s annual tier designation change process. For more information on this timing, see the section Timeline of Activities for ACOs and Providers.

MassHealth conducts an audit process to monitor compliance with the tier designation requirements of the Primary Care Sub-Capitation Program. Practices that are selected to participate in the audit receive materials and an online audit questionnaire.

Clinical Tier Enhanced Payment

To support practices in meeting the criteria listed above and to incentivize them to advance their capabilities, each clinical tier is associated with an enhanced payment. This clinical tier enhanced payment is added to the adjusted historical base rate for each member attributed to a practice. Enhanced payments vary by clinical tier and by member age, as outlined in the table below. These standardized values are not inclusive of the practice-specific base rate and do not represent the full PMPM payment to practices participating in the sub-capitation program. For more details on how clinical tier enhanced payments factor into the overall Sub-Capitation PMPM rate, see the section Rate Methodology.

2024 Clinical Tier Enhanced Payments (component of PMPM rate)	Pediatric Members (age 0-21)	Adult Members (age 21+)
Tier 1	$5.20	$4.16
Tier 2	$7.28	$6.24
Tier 3	$13.52	$10.40