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 will change 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 will start 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