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Regulations amended for PCDI

Changes to MassHealth regulations related to PCDI

As part of the PCDI initiative, MassHealth is contracting with accountable care organizations (ACOs), entities that are held financially responsible for the cost and quality of care to assigned member populations. 

There are three types of MassHealth ACOs:

  1. Accountable Care Partnership Plans
  2. Primary Care ACOs
  3. MCO-Administered ACOs. 

MassHealth  has revised 4 of its regulations as part of the PCDI initiative:

  1. 130 CMR 450.000: Administrative and Billing Regulations (All Provider)
  2. 130 CMR 501.000: MassHealth General Policies
  3. 130 CMR 508.000: MassHealth Managed Care Requirements
  4. 130 CMR 610.000: MassHealth Fair Hearing Rules

These regulatory changes reflect the new ACOs and their managed care impacts, for compliance with federal regulations, and related matters.

130 CMR 450: Administrative and Billing Regulations

130 CMR 450.000 sets forth the administrative and billing regulations applicable to MassHealth providers and services.

Specific PCDI changes to 130 CMR 450 include the following:

  • Amendment to regulation regarding coverage types to account for new managed care enrollment options and to make provisions align between sections, where appropriate.
  • Amendment to managed care regulation to add Accountable Care Partnership Plans and Primary Care ACOs to the list of managed care enrollment options and improve readability and organization
  • Description of how billing and administrative requirements apply to Accountable Care Partnership Plans and Primary Care ACOs. 
  • Addition of a set of requirements governing Primary Care ACOs and primary care providers (PCPs) who participate in Primary Care ACOs. 
  • New definitions of ACO, Accountable Care Partnership Plan, behavioral health contractor, MCO-Administered ACO, and  Primary Care ACO. 
  • Modification of the definitions of managed care, MCO, and MassHealth managed care provider.
  • Removal of requirement related to physician and nurse practitioner service area in criteria for who is eligible to be a PCC in the PCC plan and Participating PCP in a Primary Care ACO. 

130 CMR 501.000: MassHealth General Policies

130 CMR 501 defines terms and describes general requirements governing the MassHealth program.

Regulatory changes reflect the new ACOs and their managed care impacts.

Specific PCDI changes to 130 CMR 501 include: 

  • New definitions
    • ACO
    • Accountable Care Partnership Plan
    • Behavioral health contractor
    • MCO-Administered ACO
    • Primary Care ACO. 
  • Modification of the definitions of managed care, MCO, and MassHealth managed care provider. 

130 CMR 508.000: MassHealth Managed Care Requirements

130 CMR 508.000 sets forth MassHealth’s managed care requirements. Regulatory changes reflect the incorporation of the new ACOs into the managed care delivery options available to MassHealth members. They also make associated programmatic changes related to the MassHealth managed care delivery system. Specific PCDI changes to 130 CMR 508 include: 

  • Addition of Accountable Care Partnership Plans and Primary Care ACOs to the list of managed care enrollment options; 
  • Description of managed care requirements with respect to Accountable Care Partnership Plans, Primary Care ACOs, and MCO-Administered ACOs, including assignment, enrollment, disenrollment, and appeals;
  • Reorganization of existing provisions related to assignment, enrollment, and disenrollment for clarity.
  • Revision of certain provisions related to enrollment in a managed care provider outside the member’s service area.
  • Clarification of language related to member assignment to a managed care provider.
  • Addition of language regarding copayments for members enrolled in MassHealth’s behavioral health contractor and copayment policies for the MassHealth behavioral health contractor, to align language with other managed care provider copayment language

130 CMR 610.000: MassHealth Fair Hearing Rules

130 CMR 610.000 governs the MassHealth administrative appeal process for applicants, members, and providers. 

Specific PCDI changes to 130 CMR 610 include: 

  • Addition of Accountable Care Partnership Plans to the definition of managed care contractor. As a result, requirements governing appeal of managed care contractor decisions now apply to Accountable Care Partnership Plans. 
  • Modification of the provision describing time limits for responding to a member’s appeal of a managed care contractor decision to conform with federal rules.
  • Conforming changes to amendments to the 130 CMR 508 regulations including: addition of appeal for denial of member’s request to transfer out of the member’s MCO, Accountable Care Partnership Plan, or Primary Care ACO.
  • Revision of appeal for denial of enrollment in an out of area provider.
  • Clarification of language regarding appealable actions that may be the subject of a fair hearing provisions

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