2023 ACO launch guidance

There are a number of changes starting on April 1 as a result of MassHealth’s renewal of the ACO program. These include:

• Realignment of ACO partnerships
  ACOs are a partnership between provider groups and health plan partners. In some cases, established ACOs are seeing certain providers either joining or leaving the ACO. Other ACOs are changing carrier partners. For WellSense specifically, we have welcomed four new ACOs with provider partners who have switched from their former health plan partner to us. WellSense is also experiencing some changes in the provider groups that we partner with in our WellSense Community Alliance ACO (BACO). A summary of the changes to our ACO structures is summarized in the table below.
  
  Due to these changes, it’s very important to check your patients’ ID cards for updated information. In addition, you should carefully review prior authorization requirements, as they may have changed. More details about how these changes impact prior authorization requirements and continuity of care are available in our Augmented Continuity of Care Policy.

• Primary care sub-capitation
  MassHealth is changing the way primary care providers (PCPs) are reimbursed. Starting on April 1, PCPs will receive a monthly per-member per-month payment rather than fee-for-service payments for primary care services. More information is available on our Primary Care Sub-Capitation Program page.
• Formulary changes
  Effective April 1, MassHealth is fully unifying their Unified Pharmacy Product List (UPPL) across all health plans. New ACO members joining WellSense as a result of the new waiver contracts will be granted a transition period until June 1, 2023, during which they may fill existing prescriptions that may otherwise require prior authorization to pay. To find covered alternatives or which drugs require prior authorization, search the MassHealth drug list. Prior authorization requirements will resume for applicable drugs to continue coverage of existing prescriptions after June 1, 2023. Information on how to submit a prior authorization request is available at on our Prior Authorizations page.
• Community Partners
  MassHealth has re-procured community partners (CPs) for this new waiver. However, some existing CPs are experiencing service area changes, others are leaving the network and some will be merging with another CP organization. This means that you may be working with different CPs than you were before.

At the start of the new ACO period, some members may not be assigned to the correct ACO. In these situations, primary care providers should see patients and bill their current insurer of record normally.

Claims for members covered by a WellSense plan will be paid according to WellSense’s Augmented Continuity of Care Policy.

If the patient is or will be part of the primary care provider’s panel, then they will need to switch ACOs in order to maintain access after the continuity of care period. Members will need to contact MassHealth Customer Service 800-841-2900 (TTY: 800-497-4648) or visit masshealthchoices.com to change plans.

Yes. MassHealth sent letters to ACO patients in early February alerting them to changes to their MassHealth insurance carrier and to their opportunity to change their health plan by letting MassHealth know before March 31, 2023.

After April 1, 2023, members will have a plan selection period until June 3, 2023 to try out their assigned ACO plan and change their ACO plan for any reason.

Starting July 1, 2023, most members will be in a fixed enrollment period. During the fixed enrollment period, members can only change health plans for specific reasons (e.g. member moves out of the ACO service area). 

Certain members will not have a fixed enrollment period and can change their health plan at any time of the year (e.g., children under age 1 or members in DCYF custody). Members must go directly to MassHealth to request health plan enrollment changes as outlined above.

Yes, providers can verify eligibility in several ways:

• Eligibility Verification System
• WellSense Provider Portal
• 888-566-0008 Option 1 (automated phone system)
• NEHEN – State Health Information Exchange (HIE)

Nothing. MassHealth benefits are standard across all carriers.

Your patients will experience a change to their pharmacy network, but MassHealth’s UPPL means that there will also be no difference in their prescription drug benefit. Patients may also experience changes to referral or prior authorization requirements as well as different extras, like free bike helmets.

For more information on WellSense’s member extras and WellSense’s pharmacy network, please visit our Pharmacy page.

Yes. WellSense has three delegated vendors who administer benefits. They are:

• Behavioral Health: Carelon Behavioral Health
  • Phone: 866-444-5155
  • carelonbehavioralhealth.com
• Durable Medical Equipment (DME): Northwood
  • Phone: 866-802-6471
  • northwoodinc.com
• Pharmacy: Express Scripts International
  • Phone: Call WellSense provider services line (888-566-0008 and select Option 4)
  • express-scripts.com/MassHealthPriceaMed

You can contact WellSense Provider Services at 888-566-0008. You can also contact your assigned Provider Relations Consultant or send the Provider Relations team an email at provider.info@wellsense.org.

For behavioral health provider services, please contact 866-444-5155. 

Yes. While there is a lot of overlap between carriers’ networks, they are not exactly the same. You can check WellSense’s various provider directories online to validate whether a particular provider is in-network:
•    Medical providers: Visit WellSense’s Find a Provider page
•    Behavioral health providers: Visit Carelon Behavioral Health’s website
•    Pharmacy: Visit Express Scripts’ website

There will be no changes to dental networks, as dental is a carve-out benefit that is managed by MassHealth.

Vision hardware (like eyeglasses) is also managed by MassHealth. Treatment for medical conditions of the eye are covered by the ACOs, and those networks could change. Please visit WellSense’s Find a Provider page for more information.

We encourage providers to help members transition care to an in-network provider when possible. However, in the case of established relationships, new members joining WellSense as a result of the 2023 ACO launch will be covered by WellSense’s Augmented Continuity of Care Policy. Providers may submit a prior authorization request as outlined in the policy.

Should providers believe that their patients should continue to see an out-of-network provider for established care after July 1, 2023, providers should submit a new prior authorization request to WellSense. WellSense will use the criteria from its Out-of-Network Services Policy to review.

No. None of WellSense’s Medicaid plans require referrals for in-network specialists. If your patient needs to see an out-of-network specialist, then prior authorization is required.