Common use of ACO Pilot Clause in Contracts

ACO Pilot. In state fiscal years 2017 and 2018, MassHealth will contract with ACOs (“Pilot ACOs”) for an ACO Pilot within the PCC Plan; the ACO Pilot is not a separate delivery system or an enrollment option for members. Members in the PCC Plan will not experience fixed enrollment periods for the ACO Pilot, and members will still have access to all PCC Plan benefits and network of providers. Pilot ACOs consist of provider-led entities such as health systems or groups of health care providers that contract with MassHealth to provide care coordination and management and to take financial accountability for cost and quality of care for certain attributed PCC Plan members. Members enrolled in the PCC Plan who are assigned to PCCs that participate with Pilot ACOs will be considered attributed to these Pilot ACOs. MassHealth may establish Referral Circles for Pilot ACOs; Referral Circles are groups of providers within MassHealth’s FFS network, for which MassHealth will eliminate the need for otherwise-required primary care referrals for ACO-attributed members, in order to facilitate increased access and coordinated care. MassHealth will hold Pilot ACOs financially accountable for cost and quality of care through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). MassHealth will contract with Pilot ACOs selectively. Pilot ACOs are not managed care entities under 42 CFR 438. See Attachment L for additional detail on the ACO Pilot. Primary Care ACOs. Primary Care ACOs are managed care options operated by MassHealth using PCCM contractors (“Primary Care ACOs”). MassHealth contracts with Primary Care ACOs to serve as PCCM entities. Primary Care ACOs are not paid directly to provide services. Members enrolled in Primary Care ACOs are also enrolled in MassHealth’s Behavioral Health PIHP for behavioral health coverage and access other services from MassHealth’s FFS network, subject to primary care referral and other utilization management requirements. Each member enrolled in a Primary Care ACO is assigned to a primary care provider from among the Primary Care ACO’s participating primary care providers. Primary Care ACO enrollees may receive family planning services from any provider without consulting their primary care provider or their Primary Care ACO, or obtaining prior approval from MassHealth. The State may limit disenrollment for Primary Care ACO enrollees. Any such limitation will be consistent with 42 CFR 438.56(c). MassHealth may establish Referral Circles for Primary Care ACOs; Referral Circles are groups of providers within MassHealth’s FFS network, for which MassHealth will eliminate the need for otherwise-required primary care referrals for Primary Care ACO enrollees, in order to facilitate increased access and coordinated care. MassHealth will hold Primary Care ACOs financially accountable for cost and quality of care through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). See Attachment O for additional detail on pricing for Primary Care ACOs. Similar to the Center for Medicare and Medicaid Innovation (CMMI) “Next Gen” ACO program and its option for population-based payment, MassHealth may also prospectively pre-pay a Primary Care ACO, at the request of both the Primary Care ACO and the providers. Providers and Primary Care ACOs may choose such arrangements to support greater control of service revenue funds within a coordinated system, to increase accountability for total cost of care, to support up-front investments in infrastructure that supports integrated care delivery, or for other purposes in service of MassHealth’s delivery system goals. Under such a payment mechanism, MassHealth would continue to maintain the FFS network and receive claims from network providers for payments for services, but would reconcile those claims to prepayments for such services. The Commonwealth will submit a proposal for any such payment mechanism to CMS for approval prior to implementation. Primary Care ACOs may be required to implement payment arrangements in their contracts with their participating primary care providers that may include minimum levels and/or frequency of risk sharing. Such arrangements will be consistent with 42 CFR 438.6. MassHealth will contract with Primary Care ACOs selectively. Primary Care ACOs are PCCM entities under 42 CFR 438. Other features of MassHealth’s PCCM delivery systems. MassHealth will maintain responsibility for requirements of the delivery systems not specifically delegated to the PCCMs or PCCM entities (e.g., member communications about the delivery system). MCO-based delivery systems: MassHealth MCOs. MassHealth contracts selectively with Managed Care Organizations (MCOs) that provide comprehensive health coverage, including behavioral health services, to enrollees. Some Direct Coverage services are not provided by the MCOs but are instead covered directly by MassHealth for members enrolled in MCOs. Over the course of the Demonstration, MassHealth anticipates that enrollees will begin to receive certain of these Direct Coverage services from the MCOs. For example, Long Term Services and Supports (LTSS) are anticipated to be phased into MCO covered services during the Demonstration extension period. Members enrolled in MCOs may receive family planning services from any provider without consulting their PCP or MCO and are not required to obtain prior approval from MassHealth. For family planning services provided by MassHealth providers not participating in a member’s MCO network, MassHealth reimburses the provider on a fee-for-service basis and recoups the funds from the MCO. See Attachment O for additional detail on pricing for MassHealth MCOs. MassHealth MCOs are MCOs under 42 CFR 438. The State may limit disenrollment for MCO enrollees. Any such limitation will be consistent with 42 CFR 438.56(c). MCO contracts will include requirements to use alternative payment methodologies and other arrangements described in STC 45 and Attachment Q, to increase accountability for cost and quality of care through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). MCO-Contracted ACOs. MassHealth will select certain qualified ACOs through a competitive selection process, for accountability for services furnished through MassHealth MCOs. These “MCO-Contracting ACOs” will be provider-led entities such as health systems or groups of health care providers that contract with MCOs to provide care coordination and management and to take financial accountability for cost and quality of care for certain attributed MCO enrollees. They are not managed care entities under 42 CFR 438 and there will not be a separate delivery system or enrollment option for MCO enrollees attributed to MCO-contracting ACOs; such individuals will receive services from the MCO service delivery system. MCO enrollees who receive primary care from primary care providers who participate in MCO- contracting ACOs are considered attributed to those ACOs for the purposes of this cost and quality accountability. MassHealth MCO contracts will include requirements for MCOs to contract with MCO-Contracted ACOs using a MassHealth-approved alternative payment contract framework that includes risk tracks and schedules set by the state, which will be broadly consistent with 42 CFR 438.6(c). This alternative payment contract framework will hold MCO-Contracted ACOs financially accountable through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). As with MCO enrollees not attributed to ACOs, these MCO enrollees may experience fixed enrollment to their MCO, and receive services from their MCO’s provider network (except for certain Direct Coverage services provided directly by XxxxXxxxxx, as described above) subject to their MCO’s rules for referral, prior authorization, and primary care provider assignment. See Attachment O for additional detail on pricing for MCO-Contracted ACOs. Accountable Care Partnership Plans (“Partnership Plans”). MassHealth will contract selectively with Partnership Plans that provide comprehensive health coverage, including behavioral health services, to enrollees. Some Direct Coverage services are not provided by the Partnership Plans but are instead covered directly by MassHealth for members enrolled in Partnership Plans. Over the course of the Demonstration, MassHealth anticipates that enrollees will begin to receive certain of these Direct Coverage services from the Partnership Plans. For example, Long Term Services and Supports (LTSS) are anticipated to be phased into Partnership Plan covered services during the Demonstration extension period. Members enrolled in Partnership Plans may receive family planning services from any provider without consulting their PCP or Partnership Plan and are not required to obtain prior approval from MassHealth. For family planning services provided by MassHealth providers not participating in a member’s Partnership Plan network, MassHealth reimburses the provider on a fee-for-service basis and recoups the funds from the Partnership Plan. See Attachment O for additional detail on pricing for Partnership Plans. The state may limit disenrollment for Partnership Plan enrollees. Any such limitation will be consistent with 42 CFR 438.56(c). Partnership Plans may have certain additional requirements such as requirements to partner with an ACO-based provider network to deliver services and coordinate care for enrollees, and to hold such ACO and providers financially accountable for the cost and quality of care under a MassHealth-approved framework that may include minimum levels and/or frequency of risk sharing. Such arrangements will be consistent with 438.6. MassHealth will contract with Partnership Plans selectively. Partnership Plans are MCOs under 42 CFR 438.

ACO Pilot. In state fiscal years 2017 and 2018, MassHealth will contract with ACOs (“Pilot ACOs”) for an ACO Pilot within the PCC Plan; the ACO Pilot is not a separate delivery system or an enrollment option for members. Members in the PCC Plan will not experience fixed enrollment periods for the ACO Pilot, and members will still have access to all PCC Plan benefits and network of providers. Pilot ACOs consist of provider-led entities such as health systems or groups of health care providers that contract with MassHealth to provide care coordination and management and to take financial accountability for cost and quality of care for certain attributed PCC Plan members. Members enrolled in the PCC Plan who are assigned to PCCs that participate with Pilot ACOs will be considered attributed to these Pilot ACOs. MassHealth may establish Referral Circles for Pilot ACOs; Referral Circles are groups of providers within MassHealth’s FFS network, for which MassHealth will eliminate the need for otherwise-required primary care referrals for ACO-attributed members, in order to facilitate increased access and coordinated care. MassHealth will hold Pilot ACOs financially accountable for cost and quality of care through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). MassHealth will contract with Pilot ACOs selectively. Pilot ACOs are not managed care entities under 42 CFR 438. See Attachment L for additional detail on the ACO Pilot. Primary Care ACOs. Primary Care ACOs are managed care options operated by MassHealth using PCCM contractors (“Primary Care ACOs”). MassHealth contracts with Primary Care ACOs to serve as PCCM entities. Primary Care ACOs are not paid directly to provide services. Members enrolled in Primary Care ACOs are also enrolled in MassHealth’s Behavioral Health PIHP for behavioral health coverage and access other services from MassHealth’s FFS network, subject to primary care referral and other utilization management requirements. Each member enrolled in a Primary Care ACO is assigned to a primary care provider from among the Primary Care ACO’s participating primary care providers. Primary Care ACO enrollees may receive family planning services from any provider without consulting their primary care provider or their Primary Care ACO, or obtaining prior approval from MassHealth. The State may limit disenrollment for Primary Care ACO enrollees. Any such limitation will be consistent with 42 CFR 438.56(c). MassHealth may establish Referral Circles for Primary Care ACOs; Referral Circles are groups of providers within MassHealth’s FFS network, for which MassHealth will eliminate the need for otherwise-required primary care referrals for Primary Care ACO enrollees, in order to facilitate increased access and coordinated care. MassHealth will hold Primary Care ACOs financially accountable for cost and quality of care through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). See Attachment O for additional detail on pricing for Primary Care ACOs. Similar to the Center for Medicare and Medicaid Innovation (CMMI) “Next Gen” ACO program and its option for population-based payment, MassHealth may also prospectively pre-pay a Primary Care ACO, at the request of both the Primary Care ACO and the providers. Providers and Primary Care ACOs may choose such arrangements to support greater control of service revenue funds within a coordinated system, to increase accountability for total cost of care, to support up-front investments in infrastructure that supports integrated care delivery, or for other purposes in service of MassHealth’s delivery system goals. Under such a payment mechanism, MassHealth would continue to maintain the FFS network and receive claims from network providers for payments for services, but would reconcile those claims to prepayments for such services. The Commonwealth will submit a proposal for any such payment mechanism to CMS for approval prior to implementation. Primary Care ACOs may be required to implement payment arrangements in their contracts with their participating primary care providers that may include minimum levels and/or frequency of risk sharing. Such arrangements will be consistent with 42 CFR 438.6. MassHealth will contract with Primary Care ACOs selectively. Primary Care ACOs are PCCM entities under 42 CFR 438. Other features of MassHealth’s PCCM delivery systems. MassHealth will maintain responsibility for requirements of the delivery systems not specifically delegated to the PCCMs or PCCM entities (e.g., member communications about the delivery system). MCO-based delivery systems: MassHealth MCOs. MassHealth contracts selectively with Managed Care Organizations (MCOs) that provide comprehensive health coverage, including behavioral health services, to enrollees. Some Direct Coverage services are not provided by the MCOs but are instead covered directly by MassHealth for members enrolled in MCOs. Over the course of the Demonstration, MassHealth anticipates that enrollees will begin to receive certain of these Direct Coverage services from the MCOs. For example, Long Term Services and Supports (LTSS) are anticipated to be phased into MCO covered services during the Demonstration extension period. Members enrolled in MCOs may receive family planning services from any provider without consulting their PCP or MCO and are not required to obtain prior approval from MassHealth. For family planning services provided by MassHealth providers not participating in a member’s MCO network, MassHealth reimburses the provider on a fee-for-service basis and recoups the funds from the MCO. See Attachment O for additional detail on pricing for MassHealth MCOs. MassHealth MCOs are MCOs under 42 CFR 438. The State may limit disenrollment for MCO enrollees. Any such limitation will be consistent with 42 CFR 438.56(c). MCO contracts will include requirements to use alternative payment methodologies and other arrangements described in STC 45 and Attachment Q, to increase accountability for cost and quality of care through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). MCO-Contracted ACOs. MassHealth will select certain qualified ACOs through a competitive selection process, for accountability for services furnished through MassHealth MCOs. These “MCO-Contracting ACOs” will be provider-led entities such as health systems or groups of health care providers that contract with MCOs to provide care coordination and management and to take financial accountability for cost and quality of care for certain attributed MCO enrollees. They are not managed care entities under 42 CFR 438 and there will not be a separate delivery system or enrollment option for MCO enrollees attributed to MCO-contracting ACOs; such individuals will receive services from the MCO service delivery system. MCO enrollees who receive primary care from primary care providers who participate in MCO- contracting ACOs are considered attributed to those ACOs for the purposes of this cost and quality accountability. MassHealth MCO contracts will include requirements for MCOs to contract with MCO-Contracted ACOs using a MassHealth-approved alternative payment contract framework that includes risk tracks and schedules set by the state, which will be broadly consistent with 42 CFR 438.6(c). This alternative payment contract framework will hold MCO-Contracted ACOs financially accountable through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). As with MCO enrollees not attributed to ACOs, these MCO enrollees may experience fixed enrollment to their MCO, and receive services from their MCO’s provider network (except for certain Direct Coverage services provided directly by XxxxXxxxxx, as described above) subject to their MCO’s rules for referral, prior authorization, and primary care provider assignment. See Attachment O for additional detail on pricing for MCO-Contracted ACOs. Accountable Care Partnership Plans (“Partnership Plans”). MassHealth will contract selectively with Partnership Plans that provide comprehensive health coverage, including behavioral health services, to enrollees. Some Direct Coverage services are not provided by the Partnership Plans but are instead covered directly by MassHealth for members enrolled in Partnership Plans. Over the course of the Demonstration, MassHealth anticipates that enrollees will begin to receive certain of these Direct Coverage services from the Partnership Plans. For example, Long Term Services and Supports (LTSS) are anticipated to be phased into Partnership Plan covered services during the Demonstration extension period. Members enrolled in Partnership Plans may receive family planning services from any provider without consulting their PCP or Partnership Plan and are not required to obtain prior approval from MassHealth. For family planning services provided by MassHealth providers not participating in a member’s Partnership Plan network, MassHealth reimburses the provider on a fee-for-service basis and recoups the funds from the Partnership Plan. See Attachment O for additional detail on pricing for Partnership Plans. The state may limit disenrollment for Partnership Plan enrollees. Any such limitation will be consistent with 42 CFR 438.56(c). Partnership Plans may have certain additional requirements such as requirements to partner with an ACO-based provider network to deliver services and coordinate care for enrollees, and to hold such ACO and providers financially accountable for the cost and quality of care under a MassHealth-approved framework that may include minimum levels and/or frequency of risk sharing. Such arrangements will be consistent with 438.6. MassHealth will contract with Partnership Plans selectively. Partnership Plans are MCOs under 42 CFR 438.

ACO Pilot. In state fiscal years 2017 and 2018, MassHealth will contract with ACOs (“Pilot ACOs”) for an ACO Pilot within the PCC Plan; the ACO Pilot is not a separate delivery system or an enrollment option for members. Members in the PCC Plan will not experience fixed enrollment periods for the ACO Pilot, and members will still have access to all PCC Plan benefits and network of providers. Pilot ACOs consist of provider-led entities such as health systems or groups of health care providers that contract with MassHealth to provide care coordination and management and to take financial accountability for cost and quality of care for certain attributed PCC Plan members. Members enrolled in the PCC Plan who are assigned to PCCs that participate with Pilot ACOs will be considered attributed to these Pilot ACOs. MassHealth may establish Referral Circles for Pilot ACOs; Referral Circles are groups of providers within MassHealth’s FFS network, for which MassHealth will eliminate the need for otherwise-required primary care referrals for ACO-attributed members, in order to facilitate increased access and coordinated care. MassHealth will hold Pilot ACOs financially accountable for cost and quality of care through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). MassHealth will contract with Pilot ACOs selectively. Pilot ACOs are not managed care entities under 42 CFR 438. See Attachment L for additional detail on the ACO Pilot. Primary Care ACOs. Primary Care ACOs are managed care options operated by MassHealth using PCCM contractors (“Primary Care ACOs”). MassHealth contracts with Primary Care ACOs to serve as PCCM entities. Primary Care ACOs are not paid directly to provide services. Members enrolled in Primary Care ACOs are also enrolled in MassHealth’s Behavioral Health PIHP for behavioral health coverage and access other services from MassHealth’s FFS network, subject to primary care referral and other utilization management requirements. Each member enrolled in a Primary Care ACO is assigned to a primary care provider from among the Primary Care ACO’s participating primary care providers. Primary Care ACO enrollees may receive family planning services from any provider without consulting their primary care provider or their Primary Care ACO, or obtaining prior approval from MassHealth. The State may limit disenrollment for Primary Care ACO enrollees. Any such limitation will be consistent with 42 CFR 438.56(c). MassHealth may establish Referral Circles for Primary Care ACOs; Referral Circles are groups of providers within MassHealth’s FFS network, for which MassHealth will eliminate the need for otherwise-required primary care referrals for Primary Care ACO enrollees, in order to facilitate increased access and coordinated care. MassHealth will hold Primary Care ACOs financially accountable for cost and quality of care through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). See Attachment O for additional detail on pricing for Primary Care ACOs. Similar to the Center for Medicare and Medicaid Innovation (CMMI) “Next Gen” ACO program and its option for population-based payment, MassHealth may also prospectively pre-pay a Primary Care ACO, at the request of both the Primary Care ACO and the providers. Providers and Primary Care ACOs may choose such arrangements to support greater control of service revenue funds within a coordinated system, to increase accountability for total cost of care, to support up-front investments in infrastructure that supports integrated care delivery, or for other purposes in service of MassHealth’s delivery system goals. Under such a payment mechanism, MassHealth would continue to maintain the FFS network and receive claims from network providers for payments for services, but would reconcile those claims to prepayments for such services. The Commonwealth will submit a proposal for any such payment mechanism to CMS for approval prior to implementation. Primary Care ACOs may be required to implement payment arrangements in their contracts with their participating primary care providers that may include minimum levels and/or frequency of risk sharing. Such arrangements will be consistent with 42 CFR 438.6. MassHealth will contract with Primary Care ACOs selectively. Primary Care ACOs are PCCM entities under 42 CFR 438. Other features of MassHealth’s PCCM delivery systems. MassHealth will maintain responsibility for requirements of the delivery systems not specifically delegated to the PCCMs or PCCM entities (e.g., member communications about the delivery system). MCO-based delivery systems: MassHealth MCOs. MassHealth contracts selectively with Managed Care Organizations (MCOs) that provide comprehensive health coverage, including behavioral health services, to enrollees. Some Direct Coverage services are not provided by the MCOs but are instead covered directly by MassHealth for members enrolled in MCOs. Over the course of the Demonstration, MassHealth anticipates that enrollees will begin to receive certain of these Direct Coverage services from the MCOs. For example, Long Term Services and Supports (LTSS) are anticipated to be phased into MCO covered services during the Demonstration extension period. Members enrolled in MCOs may receive family planning services from any provider without consulting their PCP or MCO and are not required to obtain prior approval from MassHealth. For family planning services provided by MassHealth providers not participating in a member’s MCO network, MassHealth reimburses the provider on a fee-for-service basis and recoups the funds from the MCO. See Attachment O for additional detail on pricing for MassHealth MCOs. MassHealth MCOs are MCOs under 42 CFR 438. The State may limit disenrollment for MCO enrollees. Any such limitation will be consistent with 42 CFR 438.56(c). MCO contracts will include requirements to use alternative payment methodologies and other arrangements described in STC 45 43 and Attachment Q, to increase accountability for cost and quality of care through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). MCO-Contracted ACOs. MassHealth will select certain qualified ACOs through a competitive selection process, for accountability for services furnished through MassHealth MCOsACOs. These “MCO-Contracting ACOs” will be provider-led entities such as health systems or groups of health care providers that contract with MCOs to provide care coordination and management and to take financial accountability for cost and quality of care for certain attributed MCO enrollees. They are not managed care entities under 42 CFR 438 and there will not be a separate delivery system or enrollment option for MCO enrollees attributed to MCO-contracting ACOs; such individuals will receive services from the MCO service delivery system. MCO enrollees who receive primary care from primary care providers who participate in MCO- contracting ACOs are considered attributed to those ACOs for the purposes of this cost and quality accountability. MassHealth MCO contracts will include requirements for MCOs to contract with MCO-Contracted ACOs using a MassHealth-approved alternative payment contract framework that includes risk tracks and schedules set by the state, which will be broadly consistent with 42 CFR 438.6(c). This alternative payment contract framework will hold MCO-Contracted ACOs financially accountable through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). As with MCO enrollees not attributed to ACOs, these MCO enrollees may experience fixed enrollment to their MCO, and receive services from their MCO’s provider network (except for certain Direct Coverage services provided directly by XxxxXxxxxx, as described above) subject to their MCO’s rules for referral, prior authorization, and primary care provider assignment. See Attachment O for additional detail on pricing for MCO-Contracted ACOs. Accountable Care Partnership Plans (“Partnership Plans”). MassHealth will contract selectively with Partnership Plans that provide comprehensive health coverage, including behavioral health services, to enrollees. Some Direct Coverage services are not provided by the Partnership Plans but are instead covered directly by MassHealth for members enrolled in Partnership Plans. Over the course of the Demonstration, MassHealth anticipates that enrollees will begin to receive certain of these Direct Coverage services from the Partnership Plans. For example, Long Term Services and Supports (LTSS) are anticipated to be phased into Partnership Plan covered services during the Demonstration extension period. Members enrolled in Partnership Plans may receive family planning services from any provider without consulting their PCP or Partnership Plan and are not required to obtain prior approval from MassHealth. For family planning services provided by MassHealth providers not participating in a member’s Partnership Plan network, MassHealth reimburses the provider on a fee-for-service basis and recoups the funds from the Partnership Plan. See Attachment O for additional detail on pricing for Partnership Plans. The state may limit disenrollment for Partnership Plan enrollees. Any such limitation will be consistent with 42 CFR 438.56(c). Partnership Plans may have certain additional requirements such as requirements to partner with an ACO-based provider network to deliver services and coordinate care for enrollees, and to hold such ACO and providers financially accountable for the cost and quality of care under a MassHealth-approved framework that may include minimum levels and/or frequency of risk sharing. Such arrangements will be consistent with 438.6. MassHealth will contract with Partnership Plans selectively. Partnership Plans are MCOs under 42 CFR 438.

ACO Pilot. In state fiscal years 2017 and 2018, MassHealth will contract with ACOs (“Pilot ACOs”) for an ACO Pilot within the PCC Plan; the ACO Pilot is not a separate delivery system or an enrollment option for members. Members in the PCC Plan will not experience fixed enrollment periods for the ACO Pilot, and members will still have access to all PCC Plan benefits and network of providers. Pilot ACOs consist of provider-led entities such as health systems or groups of health care providers that contract with MassHealth to provide care coordination and management and to take financial accountability for cost and quality of care for certain attributed PCC Plan members. Members enrolled in the PCC Plan who are assigned to PCCs that participate with Pilot ACOs will be considered attributed to these Pilot ACOs. MassHealth may establish Referral Circles for Pilot ACOs; Referral Circles are groups of providers within MassHealth’s FFS network, for which MassHealth will eliminate the need for otherwise-required primary care referrals for ACO-attributed members, in order to facilitate increased access and coordinated care. MassHealth will hold Pilot ACOs financially accountable for cost and quality of care through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). MassHealth will contract with Pilot ACOs selectively. Pilot ACOs are not managed care entities under 42 CFR 438. See Attachment L for additional detail on the ACO Pilot. Primary Care ACOs. Primary Care ACOs are managed care options operated by MassHealth using PCCM contractors (“Primary Care ACOs”). MassHealth contracts with Primary Care ACOs to serve as PCCM entities. Primary Care ACOs are not paid directly to provide services. Members enrolled in Primary Care ACOs are also enrolled in MassHealth’s Behavioral Health PIHP for behavioral health coverage and access other services from MassHealth’s FFS network, subject to primary care referral and other utilization management requirements. Each member enrolled in a Primary Care ACO is assigned to a primary care provider from among the Primary Care ACO’s participating primary care providers. Primary Care ACO enrollees may receive family planning services from any provider without consulting their primary care provider or their Primary Care ACO, or obtaining prior approval from MassHealth. The State may limit disenrollment for Primary Care ACO enrollees. Any such limitation will be consistent with 42 CFR 438.56(c). MassHealth may establish Referral Circles for Primary Care ACOs; Referral Circles are groups of providers within MassHealth’s FFS network, for which MassHealth will eliminate the need for otherwise-required primary care referrals for Primary Care ACO enrollees, in order to facilitate increased access and coordinated care. MassHealth will hold Primary Care ACOs financially accountable for cost and quality of care through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). See Attachment O for additional detail on pricing for Primary Care ACOs. Similar to the Center for Medicare and Medicaid Innovation (CMMI) “Next Gen” ACO program and its option for population-based payment, MassHealth may also prospectively pre-pay a Primary Care ACO, at the request of both the Primary Care ACO and the providers. Providers and Primary Care ACOs may choose such arrangements to support greater control of service revenue funds within a coordinated system, to increase accountability for total cost of care, to support up-front investments in infrastructure that supports integrated care delivery, or for other purposes in service of MassHealth’s delivery system goals. Under such a payment mechanism, MassHealth would continue to maintain the FFS network and receive claims from network providers for payments for services, but would reconcile those claims to prepayments for such services. The Commonwealth will submit a proposal for any such payment mechanism to CMS for approval prior to implementation. Primary Care ACOs may be required to implement payment arrangements in their contracts with their participating primary care providers that may include minimum levels and/or frequency of risk sharing. Such arrangements will be consistent with 42 CFR 438.6. MassHealth will contract with Primary Care ACOs selectively. Primary Care ACOs are PCCM entities under 42 CFR 438. Other features of MassHealth’s PCCM delivery systems. MassHealth will maintain responsibility for requirements of the delivery systems not specifically delegated to the PCCMs or PCCM entities (e.g., member communications about the delivery system). MCO-based delivery systems: MassHealth MCOs. MassHealth contracts selectively with Managed Care Organizations (MCOs) that provide comprehensive health coverage, including behavioral health services, to enrollees. Some Direct Coverage services are not provided by the MCOs but are instead covered directly by MassHealth for members enrolled in MCOs. Over the course of the Demonstration, MassHealth anticipates that enrollees will begin to receive certain of these Direct Coverage services from the MCOs. For example, Long Term Services and Supports (LTSS) are anticipated to be phased into MCO covered services during the Demonstration extension period. Members enrolled in MCOs may receive family planning services from any provider without consulting their PCP or MCO and are not required to obtain prior approval from MassHealth. For family planning services provided by MassHealth providers not participating in a member’s MCO network, MassHealth reimburses the provider on a fee-for-service basis and recoups the funds from the MCO. See Attachment O for additional detail on pricing for MassHealth MCOs. MassHealth MCOs are MCOs under 42 CFR 438. The State may limit disenrollment for MCO enrollees. Any such limitation will be consistent with 42 CFR 438.56(c). MCO contracts will include requirements to use alternative payment methodologies and other arrangements described in STC 45 55 and Attachment Q, to increase accountability for cost and quality of care through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). MCO-Contracted ACOs. MassHealth will select certain qualified ACOs through a competitive selection process, for accountability for services furnished through MassHealth MCOs. These “MCO-Contracting ACOs” will be provider-led entities such as health systems or groups of health care providers that contract with MCOs to provide care coordination and management and to take financial accountability for cost and quality of care for certain attributed MCO enrollees. They are not managed care entities under 42 CFR 438 and there will not be a separate delivery system or enrollment option for MCO enrollees attributed to MCO-contracting ACOs; such individuals will receive services from the MCO service delivery system. MCO enrollees who receive primary care from primary care providers who participate in MCO- contracting ACOs are considered attributed to those ACOs for the purposes of this cost and quality accountability. MassHealth MCO contracts will include requirements for MCOs to contract with MCO-Contracted ACOs using a MassHealth-approved alternative payment contract framework that includes risk tracks and schedules set by the state, which will be broadly consistent with 42 CFR 438.6(c). This alternative payment contract framework will hold MCO-Contracted ACOs financially accountable through shared savings and shared losses (i.e., downside risk), including potentially asymmetric risk (i.e., potential shared savings exceed potential shared losses). As with MCO enrollees not attributed to ACOs, these MCO enrollees may experience fixed enrollment to their MCO, and receive services from their MCO’s provider network (except for certain Direct Coverage services provided directly by XxxxXxxxxx, as described above) subject to their MCO’s rules for referral, prior authorization, and primary care provider assignment. See Attachment O for additional detail on pricing for MCO-Contracted ACOs. Accountable Care Partnership Plans (“Partnership Plans”). MassHealth will contract selectively with Partnership Plans that provide comprehensive health coverage, including behavioral health services, to enrollees. Some Direct Coverage services are not provided by the Partnership Plans but are instead covered directly by MassHealth for members enrolled in Partnership Plans. Over the course of the Demonstration, MassHealth anticipates that enrollees will begin to receive certain of these Direct Coverage services from the Partnership Plans. For example, Long Term Services and Supports (LTSS) are anticipated to be phased into Partnership Plan covered services during the Demonstration extension period. Members enrolled in Partnership Plans may receive family planning services from any provider without consulting their PCP or Partnership Plan and are not required to obtain prior approval from MassHealth. For family planning services provided by MassHealth providers not participating in a member’s Partnership Plan network, MassHealth reimburses the provider on a fee-for-service basis and recoups the funds from the Partnership Plan. See Attachment O for additional detail on pricing for Partnership Plans. The state may limit disenrollment for Partnership Plan enrollees. Any such limitation will be consistent with 42 CFR 438.56(c). Partnership Plans may have certain additional requirements such as requirements to partner with an ACO-based provider network to deliver services and coordinate care for enrollees, and to hold such ACO and providers financially accountable for the cost and quality of care under a MassHealth-approved framework that may include minimum levels and/or frequency of risk sharing. Such arrangements will be consistent with 438.6. MassHealth will contract with Partnership Plans selectively. Partnership Plans are MCOs under 42 CFR 438.