Importance of Member Attribution
Member attribution is MassHealth’s process to determine the patient panel for each primary care practice participating in the Primary Care Sub-Capitation Program. A well-maintained member attribution process ensures that members have a primary care home where they have consistent access to high-quality, coordinated care. Member attribution enables primary care practices to understand who is on their panel and actively engage with MassHealth members to improve health outcomes. It also ensures that primary care practices receive sub-capitation payments that accurately reflect the primary care they are delivering to MassHealth members on their panel.
How Member Attribution Works
When a member is enrolled in a MassHealth Accountable Care Organization (ACO), they select or are automatically assigned to a primary care practice site (also known as a PID/SL) within that ACO’s network. Once the member selects or is assigned to a practice site, the member is “attributed” to that practice site. Members will always be notified when assigned to a primary care practice site. This notification may be sent by MassHealth, the member’s health plan, or both.
Typically, a MassHealth member will receive most of their primary care at their assigned practice site. A set of primary care services delivered at this practice site is paid for through the sub-capitation per-member, per-month (PMPM) rate and claims for these services are zero paid (i.e., no additional payment for the services is issued), if they meet the primary care sub-capitation claims logic. For more details, see the section How Practices Get Paid.
A member may also receive primary care services at a location that differs from their assigned practice site. If the member receives primary care from a practice site that shares the same tax identification number (TIN) as their assigned practice site, this primary care is also paid for through the sub-capitation PMPM payment to that TIN, and claims for this care are still zero paid if all other conditions of the sub-capitation claims logic are met. This is because sub-capitation PMPM rates are set at the TIN level. See the section Rate Methodology for more details.
However, if a member receives primary care at a practice site that does not share the same TIN as their attributed practice site, claims for these primary care services will be paid for on a fee-for-service (FFS) basis. Similarly, practice sites participating in the Primary Care Sub-Capitation Program will be paid FFS for any primary care they deliver to MassHealth members that are not attributed to their TIN.
Member Attribution Changes
Member attribution information is updated daily. For MassHealth ACOs participating in the Accountable Care Partnership Plan (ACPP) program, ACOs maintain current member attribution information and share this with MassHealth monthly. For ACOs participating in the Primary Care Accountable Care Organization (PCACO) program, MassHealth maintains current member attribution directly in its systems and shares member to practice site information with PCACOs daily.
Sub-capitation payments are sent prospectively each month and are based on a recent snapshot of member attribution to the practice site. In the following months, ACOs may adjust sub-capitation payments to reflect any changes to practice member attribution that occurred over past months.