Augmented continuity of care policy

For new 2023 ACO members

With the upcoming renewal of the 1115 MassHealth Demonstration Waiver, which authorizes WellSense’s ACO plans, there will be hundreds of thousands of MassHealth members moving between health plans on April 1, 2023.

In response to the large number of new ACO members coming to WellSense from their legacy MassHealth plans, WellSense is implementing an augmented continuity of care policy. Generally speaking, this augmented policy expands our normal 30-day transition period to a 90-day period transition period for these new members.

To help our providers address any concerns regarding patients under an active treatment plan during their transition their new WellSense ACO plan, we have created this guide to our augmented continuity of care policy.

The guide is specific to members newly joining a WellSense ACO plan and covers both medical services (including behavioral health and durable medical equipment) and pharmacy services.

Members joining WellSense as a result of the normal course of business (e.g., are newly enrolled in MassHealth or switch to WellSense for reasons other than the ACO launch) will not be covered by the special policies outlined below. Instead, WellSense’s standard 30-day policy will apply to such new members.

Augmented continuity of care policy for medical, behavioral health and DME services

WellSense will continue to cover established healthcare services initiated with enrollees. This includes established healthcare services administered by providers that are out of WellSense’s provider network (OON). 

This means that WellSense will authorize any established healthcare services for membership enrolled in any of the newly contracted ACOs for up to 90 days after the contract start date of April 1. Providers do not need to submit new prior authorization requests for services approved for coverage by the member’s prior legacy health plan carrier. 

Please note that if a new enrollee is receiving care from an provider that is out of WellSense’s network, that enrollee will be expected to transition to a WellSense in-network provider prior to or by the end of that 90-day period.

All new services beginning on or after April 1 that require prior authorization (PA) will need to be submitted to WellSense for approval. Services for which a prior authorization has already been obtained from the legacy carrier do not require resubmission except to extend the authorization for additional dates of service. For a list of WellSense medical necessity policies and services requiring authorization approval, see below under “Additional resources.”

Pharmacy

Retail pharmacies

Members will have approximately 90 days to transition from their existing pharmacy to an in-network pharmacy. Beginning July 5, members will get denials at OON pharmacies. A list of participating pharmacies can be found on the MassHealth prescriptions page.

Specialty pharmacies

Effective April 1, WellSense will have a new network of specialty pharmacies.  Specialty drug fills are normally limited to the specialty pharmacy network. However, members joining WellSense as a result of ACO expansion taking specialty drugs will have a transition period until July 5 to move their specialty prescriptions to an in-network specialty pharmacy. During this transition period, the member may fill their prescription at any retail pharmacy.

Beginning on July 5, WellSense will deny claims for specialty drug fills from any pharmacy other than an in-network specialty pharmacy

A list of participating specialty pharmacies will soon be made available on the MassHealth prescriptions page.

Unified Pharmacy Product List

Effective April 1, MassHealth (MH) is fully unifying their Unified Pharmacy Product List (UPPL) across all health plans. This means that WellSense will fully align our formulary with that of MassHealth’s. Members joining WellSense as a result of ACO expansion will be granted a staggered transition period regarding prescriptions requiring prior authorization and whether a new prior authorization from WellSense will be required for them. For full details, please visit the Pharmacy transition periods section of the FAQ below.

For questions, please contact WellSense Provider Services line at 888-566-0008.

Additional resources

 

Frequently Asked Questions (FAQ)

Glossary

A state-mandated and WellSense-driven effort to minimize disruption of members’ access to care, particularly care previously established with members’ legacy ACOs.

Approval from a member’s health plan that may be required before that member can get a service or fill a prescription in order for that service or prescription to be covered by the health plan.

The Current Procedural Terminology (CPT) codes represent a uniform language used by doctors and health care professionals for coding medical services and procedures in order to streamline reporting and increase accuracy and efficiency.

A collection of standardized codes that represent medical procedures, supplies, products and services.

Continuity of Care (CoC)

CoC is a state-mandated and WellSense-driven effort to minimize disruption of members’ access to care, particularly care previously established with members’ legacy ACOs.

WellSense has a standing permanent CoC policy which allows new members a 30-day period to transition their care to in-network providers and WellSense prior authorization requirements when necessary. 

For new ACO groups (listed below), WellSense will apply an augmented CoC policy aligned with MassHealth requirements. These requirements state that members enrolled with any of the new ACO groups are entitled to 90-day period to transition their care to in-network providers and WellSense prior authorization requirements.

All further information presented in this section is specific to this augmented policy.

Any services a new WellSense ACO member began with their previous ACO, prior to April 1, 2023 or any service occurring on or after April 1, 2023 (but before July 1, 2023) for which a new WellSense ACO member has received prior authorization from their previous ACO.

Any services for which a new WellSense ACO member initiates prior authorization on or after April 1, 2023 for the first time.

No, the CoC policy only applies to members who are new to WellSense or who are switching between WellSense MassHealth products as a direct result of the new ACO waiver.

WellSense has four new ACOs whose members will be covered by the augmented ACO CoC policy. These include:

  • WellSense BILH Performance Network ACO (Beth Israel Lahey Health)
  • WellSense Boston Children’s ACO (Boston Children’s Hospital and its Pediatric Physicians’ Organization)
  • East Boston Neighborhood Health WellSense Alliance (East Boston Neighborhood Health Center)
  • WellSense Care Alliance (Tufts Medicine and Lowell Community Health Center)

In addition, members from three new provider groups joining the WellSense Community Alliance (BACO) will also be covered by the augmented, 90-day policy.

  • Cape Cod Healthcare Accountable Care Organization
  • Compass Medical, PC        
  • Harvard Street Neighborhood Health Center                              
Members joining WellSense Community Alliance as a result of the normal course of business (e.g., are newly enrolled in MassHealth or switch to WellSense for reasons other than the ACO launch) will not be covered by the 90-day policy. WellSense’s standard 30-day policy will apply to such new members.

No. While prior Authorization requirements may differ between their legacy plans and their new WellSense ACO plan, benefits and covered services are consistent across all MassHealth ACOs. 

Policy impact to claims payments, prior authorizations and other operations

WellSense will honor any unexpired prior authorization that was previously approved by a member’s legacy ACO/health plan (for MassHealth products only). This means that if a member receives a service within 90 days of enrollment for which a previous approval has not expired after April 1, 2023, WellSense will pay the claim. Approved PAs do not need to be resubmitted to WellSense as we are receiving and loading any open PAs from legacy health plans. 

If an approved authorization expires during the 90-day period (e.g, an authorization for dates of service ending on May 15), a new request must be submitted to WellSense if the member needs continuing care after the end date on the authorization.

If the member’s legacy carrier already approved an authorization for the service and dates in question, you do not need to submit a new authorization to WellSense. Otherwise, please follow the instructions in the “Prior Authorization Administration” section below to (1) determine if the service requires prior authorization at WellSense and (2) submit a prior authorization request if it does. 

WellSense will only receive authorizations that were approved by the member’s legacy ACO/health plan. Any open authorization requests (not yet approved or denied) will not be sent to WellSense. In these cases please follow the instructions in the “Prior Authorization Administration” section to (1) determine if the service requires prior authorization at WellSense and (2) submit a prior authorization request if it does.

Prior authorization loading for legacy carriers will apply only to members who are part of the four new ACOs and three new WellSense Community Alliance groups named above. If a member is joining WellSense from a non-MassHealth product (e.g. commercial coverage) or as a result of switching MassHealth plans outside of the new ACO waiver, we will not have access to previously approved authorizations, and the provider will need to submit a new authorization request to WellSense.

WellSense will honor established, active courses of treatment regardless of whether the member’s providers are in WellSense’s network for 90 days after the waiver go-live date. WellSense will work with ACOs to transition members receiving care from an OON provider to an in-network WellSense provider. You should submit a prior authorization to WellSense for these OON services unless you already have an approved OON authorization request from the legacy carrier.

Prior authorization administration

Refer to the prior authorization resources for WellSense services requiring authorization approval and WellSense medical policies (for medical services only).

WellSense delegates prior authorization administration for the following vendors/services:

  • Carelon Behavioral Health for Behavioral Health services
  • eviCore for high-end radiology, genetic testing and musculoskeletal procedures
  • Northwood for durable medical equipment (DME) and prosthetic, orthotics and supplies (POS)*

All of these vendors will honor the CoC policies and procedures outlined in this document.

For a breakdown of which vendor will handle requests for each service type, please refer to WellSense’s MA Prior Authorization Matrix.

*Northwood handles authorizations for DME supplies ordered directly from them. Authorizations for supplies bought by a provider and seeking reimbursement (i.e., buy and bill) are administered directly by WellSense

 None. MassHealth dental is a carve-out administered by the State. All of the current policies, processes and contacts will be the same.

You can submit outpatient and inpatient authorization requests, confirm authorization numbers and check the status of an authorization on the WellSense provider portal.

Pharmacy transition periods

Members joining WellSense as a result of ACO expansion will be granted a staggered transition period regarding prescriptions requiring prior authorization:

  • From April 1-July 4, WellSense is providing a transition benefit that allows members to fill existing prescriptions that would otherwise require prior authorization without the need to submit a request. New prescriptions for drugs marked as requiring prior authorization in our drug list will still need a valid approval from WellSense during this period.
  • From July 5-September 30, WellSense will require one of the following for any prescriptions that require prior authorization on our drug list:
    • An unexpired prior authorization from a member’s legacy ACO
    • A prior authorization from WellSense
  • Beginning October 1, WellSense will cease to honor prior authorizations from legacy ACO plans. Any prescriptions marked as requiring prior authorization in our drug list will then need a valid approval from WellSense.

A list of covered drugs and those that require authorization can be found here.

Members joining WellSense as a result of ACO expansion will have a transition period to move their non-specialty prescriptions to an in-network pharmacy until July 5 (learn more about specialty prescriptions below). Before July 5, WellSense will cover member prescriptions at the pharmacy currently used by the member.

Beginning on July 5, WellSense will deny pharmacy claims from out-of-network pharmacies. It is notable that some retail pharmacies, including Walgreens, are not in WellSense’s pharmacy network.

Find out if a pharmacy is in the WellSense network.

Members joining WellSense as a result of ACO expansion taking specialty drugs will have a transition period until July 5 to move their specialty prescriptions to an in-network specialty pharmacy. During this transition period, the member may fill their prescription at any retail pharmacy.

Beginning on July 5, WellSense will deny claims for specialty drug fills from any pharmacy other than an in-network specialty pharmacy.

Find a list of specialty drugs and specialty pharmacies in the WellSense network.