Program Benefits
MassHealth’s Primary Care Sub-Capitation (Sub-Cap) Program aims to improve health outcomes for MassHealth members by changing how primary care is delivered and funded. The program supports integrated, team-based care and helps build the systems, policies, and technology needed for broader payment reform. The goal of the program is to improve population health outcomes for residents across the Commonwealth.
Benefits to MassHealth Members
- Flexible, patient-centered care: Members receive primary care that is tailored to meet their needs.
- Expanded access to care: Members have better and more convenient access to primary care through telehealth, same day urgent care, and after-hours or weekend appointments.
- Integrated primary care: Members can access the full range of support they need through their primary care practice team including both their primary care provider (PCP), and other members of the clinical team who can support members in addressing issues ranging from behavioral health to reproductive health, and health-related social needs (e.g., nutrition and housing).
Benefits to Providers
- Revenue stability: Primary care practices receive predictable monthly payments based on the size of their MassHealth panel. Payment is not based on visit volume.
- Member engagement: Providers can foster strong, continuous relationships with their MassHealth patient panel, so patients get the care they need to stay healthy.
- Flexibility in decision-making: Providers have more flexibility and control in decision-making and can allocate their resources and time in ways that best meet the needs of their patients. This may include expanding their clinical care team to include care managers, behavioral health professionals, community health workers, and other providers who can best support their patient panel.
- Ability to innovate: Through increased investment in primary care, practices receive support to pursue care delivery innovations, such as team-based care, integrated behavioral health, and services to address their patients’ health-related social needs.
To read more about the program’s benefits and success, see the section Program Impact.
Program History
The Sub-Cap program gives primary care practices more predictable and flexible revenue, so they can build patient-focused care models, instead of relying on billable visits to sustain their practices.
Since the program’s launch, MassHealth continues to evaluate and refine the model to strengthen its clinical and financial impact. This evaluation ensures that the program supports high-quality, team-based primary care while also creating a sustainable payment structure for participating practices and MassHealth.
To support these goals, MassHealth continues to refine how payments are calculated under the sub-capitation model. Initially, rates were based on a prospective per-member per-month (PMPM) amount that relied on fee-for-service (FFS) experience. Over time, MassHealth has moved toward a more population-based payment methodology (PBP) that better separates primary care payment from a practice’s own historical FFS billing patterns.
Effective 1/1/2026, in response to stakeholder feedback and lessons learned from implementation, MassHealth updated the program’s Tier requirements. These updates aim to make the requirements clearer and more operationally feasible. MassHealth will continue to monitor how the Tier structure supports practice transformation, care delivery, and financial sustainability.
Rates Methodology Over the Years
- 2023: MassHealth launched the program using prospective PMPM rates for primary care, based on each practice’s historical FFS experience. Clinical tiers were introduced to encourage greater investment in primary care. For more details, see Care Delivery Transformation.
- 2024: MassHealth increased investment in primary care by improving clinical tier requirements and implementing overall rate increases, with a particular focus on group practices.
- 2025: MassHealth introduced a population-based payment (PBP) methodology to reduce reliance on individual practices’ historical FFS billing patterns. For more details, see Rates Methodology.
- 2026 and beyond: MassHealth is committed to evaluating and refining the sub-capitation methodology to improve the clinical and financial performance of the model. This includes further decoupling primary care payment from practice-specific FFS billing history, monitoring how Tier requirements support practice transformation and sustainability, and increasing the share of ACO total cost of care (TCOC) dedicated to primary care and behavioral health.