MassHealth ACO Program Continues to Evolve

MassHealth continues to tweak its sweeping Accountable Care Organization (ACO) program that went live in March.  Specifically, last week MassHealth extended its “continuity of care” deadlines from one month to 90 days (or May 31). And the ACO program is now allowing patients greater flexibility to enroll in an ACO that does not technically serve their geographic area.

Originally, members had 30 days from March 1 for the continuity of their care, meaning they could stay with their existing provider for 30 days to meet scheduled appointments or continue treatments.  Now, under the new rules, MassHealth members who have not yet transitioned to their plan’s in-network providers may continue to see their existing providers until May 31. (This is for medical care; behavioral healthcare always had the May 31 extended deadline.)  Many health plans had this continuity of care period on their own but now this protection is universal.

By partially removing the service area limitations, MassHealth is addressing a significant problem that MHA, many providers, and consumers raised.  The general rule had been that a MassHealth member could not choose an Accountable Care Partnership Plan that did not operate in his or her service area. But beginning April 9, enrollees wanting a primary care physician that is in an Accountable Care Partnership Plan that does not technically serve the area in which the enrollee resides will be permitted to request an exception.  MassHealth says the criteria for granting an exception will be if the patient has an established relationship with the primary care physician or a specific cultural, language, accessibility, or medical need.  Homelessness is also an acceptable exception criteria. MassHealth will notify the member in writing within 30 days of an exception request and the decision is appealable.