Any individual receiving benefits during the hospital-determined presumptive eligibility period or the time-limited period while MassHealth investigates and verifies access to qualified and cost-effective private health insurance or the time-limited period while the member is enrolling in such insurance; Any individual receiving Limited coverage; Any individual receiving hospice care, or who is terminally ill as documented with a medical prognosis of a life expectancy of 6 months or less; and Any participant in a Home and Community-Based Services Waiver who is not eligible for SSI and for whom MassHealth is not a secondary payer. MassHealth may permit such individuals to enroll in Managed Care, including the option to enroll with the behavioral health contractor for behavioral health services and receive their medical services through FFS. Managed Care Delivery Systems MassHealth’s Managed Care delivery systems include two categories as described (1) PCCM delivery systems (which includes the PCC Plan and Primary Care ACOs); and (2) MCO-based delivery systems (which includes the MassHealth MCOs and Partnership Plans). Table E below provides an overview of these delivery systems. Table E. Overview of Managed Care Delivery Systems Managed Care PCCM delivery systems MCO-based delivery systems PCC Plan Primary Care MassHealth MCOs Partnership ACOs Non- ACO Non- MCO- (previously (previously Pilot Pilot ACO Administered B ACOs”) A ACOs “Model “Model ACOs”) (previously C ACOs”) “Model PCCM delivery systems: The PCC Plan. The PCC Plan is a managed care option operated by MassHealth. Members enrolled in the PCC Plan are also enrolled in a single Behavioral Health Program (BHP) contractor, which is a Prepaid Inpatient Health Plan (PIHP), for behavioral health coverage. Members enrolled in the PCC Plan access other services from MassHealth’s FFS network, subject to PCC referral and other utilization management requirements. Each member enrolled in the PCC Plan is assigned to a designated primary care provider (a Care “Primary Clinician,” or from among the PCC Plan’s available PCCs, who provides primary “PCC”) care case management. A member’s PCC provides most primary and preventive care and is responsible for providing referrals for most specialty services and for otherwise coordinating the member’s services. PCC Plan members may receive family planning services from any
Any individual receiving benefits during the hospital-determined presumptive eligibility period or the time-limited period while MassHealth investigates and verifies access to qualified and cost-effective private health insurance or the time-limited period while the member is enrolling in such insurance; Any individual receiving Limited coverage; Any individual receiving hospice care, or who is terminally ill as documented with a medical prognosis of a life expectancy of 6 months or less; and Any participant in a Home and Community-Based Services Waiver who is not eligible for SSI and for whom MassHealth is not a secondary payer. MassHealth may permit such individuals to enroll in Managed Care, including the option to enroll with the behavioral health contractor for behavioral health services and receive their medical services through FFS. Managed Care Delivery Systems MassHealth’s Managed Care delivery systems include two categories as described (1) PCCM delivery systems (which includes the PCC Plan and Primary Care ACOs); and (2) MCO-based delivery systems (which includes the MassHealth MCOs and Partnership Plans). Table E below provides an overview of these delivery systems. Table E. Overview of Managed Care Delivery Systems Managed Care PCCM delivery systems MCO-based delivery systems PCC Plan Primary Care ACOs (previously “Model B ACOs”) MassHealth MCOs Partnership (previously “Model A ACOs”) Non- Pilot ACO Pilot Non- ACO MCO- Administered ACOs (previously “Model C ACOs”) PCCM delivery systems: The PCC Plan. The PCC Plan is a managed care option operated by MassHealth. Members enrolled in the PCC Plan are also enrolled in a single Behavioral Health Program (BHP) contractor, which is a Prepaid Inpatient Health Plan (PIHP), for behavioral health coverage. Members enrolled in the PCC Plan access other services from MassHealth’s FFS network, subject to PCC referral and other utilization management requirements. Each member enrolled in the PCC Plan is assigned to a designated primary care provider (a “Primary Care Clinician,” or “PCC”) from among the PCC Plan’s available PCCs, who provides primary care case management. A member’s PCC provides most primary and preventive care and is responsible for providing referrals for most specialty services and for otherwise coordinating the member’s services. PCC Plan members may receive family planning services from any
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