Massachusetts residents enrolled in Primary Care Clinician (PCC) Plans and Primary Care Accountable Care Organization (ACO) plans will once again need referrals for certain services, as MassHealth ends a temporary suspension put in place during the height of the COVID-19 pandemic. The change, announced recently, impacts access to care and marks a return to pre-pandemic protocols for these plans. This shift affects how members obtain access to specialists and other healthcare services.
The suspension of referral requirements was one of several flexibilities implemented by MassHealth to address challenges posed by the public health emergency. These changes, detailed in previous All Provider Bulletins 367, 371, and 384, aimed to ensure continued access to care during a period of significant disruption. Now, MassHealth is reverting to standard procedures, requiring referrals to ensure coordinated care within the PCC and ACO frameworks.
The reinstatement of referral requirements primarily affects members enrolled in PCC Plans or Primary Care ACOs. These plans emphasize a strong relationship with a primary care provider who coordinates a patient’s overall healthcare. Referrals are now required for members seeking services outside of their primary care network, ensuring that their primary care physician is informed and involved in their care plan. The specific requirements for urgent care services are similarly being updated as part of this change.
Impact on Patients and Providers
The return to referral requirements means patients will need to obtain approval from their primary care physician before seeing specialists or accessing certain services. This may involve scheduling an appointment with their PCP, discussing their needs, and receiving a formal referral. Providers will need to ensure they are adhering to the updated referral processes to avoid claim denials. The goal of the referral process is to promote coordinated care and prevent fragmented treatment.
MassHealth’s decision to end these flexibilities reflects a broader shift towards pre-pandemic healthcare operations. Even as the temporary suspension of referral requirements eased access to care during a crisis, the reinstatement aims to restore established care coordination protocols. The agency has not specified a timeline for further adjustments to these policies.
Understanding the 403(b) Plan
Separately, the Massachusetts 403(b) Supplemental Retirement Plan offers state employees a way to supplement their core retirement benefits. Available to employees of the Executive Office of Education, the Department of Higher Education, and other state entities, the plan allows contributions before or after state and federal income taxes, offering tax advantages and potential inflation protection. More information about the 403(b) plan, including contribution limits for 2025 and new rules for hardship withdrawals, is available online.
The 403(b) plan is a voluntary benefit designed to assist employees build a more secure financial future. Participants can access their savings in a variety of ways, including as an emergency fund during retirement. Recent updates to the plan include the introduction of a Roth “after-tax” feature in October 2018 and a name change for the plan itself.
Looking Ahead
The reinstatement of referral requirements for PCC and ACO plans represents a significant change for MassHealth members and providers. The agency will likely monitor the impact of this change on access to care and adjust policies as needed. Members are encouraged to contact their primary care providers with any questions about the new requirements. Further updates from MassHealth regarding healthcare policies and procedures are expected as the state continues to navigate the evolving healthcare landscape.
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