MassHealth ACO Resources

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.


  • 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