Key Terms
- ACO: Accountable Care Organization
- Capitation Payment: PMPM (per member per month) monthly payments based on patient attribution
- Primary Care Entity (PCE): MassHealth defines a PCE as a Tax ID Number (TIN)
- PID/SL: Provider ID and Service Location; MassHealth defines a PID/SL by site/practice location
- Redetermination of Eligibility: the process by which MassHealth verifies that patients are still eligible for benefits. The continuous coverage requirement was paused due to the federal public health emergency.
PCP Cap
- Effective 4/1/2023, PCPs have changed from a Fee For Service (FFS) payment to a Primary Care Sub-Capitation payment PMPM (per member per month)
- The Primary Care Sub-Capitation is paid at the TIN level otherwise known as the Primary Care Entity (PCE)
- WellSense pays the Primary Care Sub-Capitation to each PCE/TIN
- There are two components of Primary Care Sub-Capitation:
- Base monthly cap: based on the TIN/PCE’s unique historical claims experience trended forward
- Tier payment: Based on the tier attestations
- Tiers are intended to reflect the type of integrated primary care / level of services offered at a given primary care site
- Payment is tied to tiers (Tier 1 = lower payment, Tier 3 = Higher payment)
- It is important that all providers continue to submit claims for services that fall under the primary care sub-capitation program
- The Sub-Capitation payment process and timing can be found in the Wellsense Primary Care Sub-Capitation program announcement, here
- Please click here to view CPT codes included in the PCP cap
Tiering Audits
- MassHealth started Tiering audits July 2023
- Up to 25% of practices annually
- Will be mainly remote through reporting and document review
- MassHealth will provide 30 day notice for audit response
- Deficiencies will require a remediation process in collaboration with the ACO and WellSense
- Potential 6-9 month remediation process
- If remediation does not rectify, PID/SL is no longer eligible for prospective payment/tiering program
Key Links
- WellSense Primary Care Sub-Capitation pages https://www.wellsense.org/providers/ma/sub-capitation
- WellSense Care Management pages https://www.wellsense.org/members/ma/manage-your-health/care-management-program
- MassHealth has created a new landing page for Community Health Centers and the MassHealth ACO Primary Care Sub-Capitation Program.
- Available Primary Care Providers and MassHealth ACOs starting April 1, 2023 | Mass.gov
- To search for all current MassHealth primary care providers and ACOs, click here
- For more information about ACOs click here
Important Documents
The Tiering support page on the BILHPN website is live!
This will be the central resource for PCP Tiering. As a privacy measure, this webpage is secure so that only BILH network employees can view these resources. To access this page users must have a BILH email (MAH.org, MAH.harvard.edu, BILH.org, BIDMC.harvard.edu, or Lahey.org) The following emails will not be able to access these resources: yahoo, Gmail, comcast, Verizon, Hotmail . If you or your practice does not know your BILH email, please contact Alycia Messelaar at Alycia.Messelaar@lahey.org.
https://www.bilhpn.org/provider-resources/resource-center/masshealth-aco-2023-tiering-requirements/
1. Log into the page by selecting the appropriate email extension that matches your BILH email (mah.org, mah.harvard.edu, bilh.org, BIDMC.harvard.edu, or lahey.org)
2. Type in your BILH email and password
3. Once on the BILHPN home page, click Provider Resources on the top right
4. In the drop-down menu select Resource Center
5. On the left-hand side of the Resource Center page select 2023 MassHealth ACO: Tiering Criteria