Medical Billing Company in Massachusetts | MassHealth ACO Expertise

MassHealth delivers care through Accountable Care Organizations under a structure with three distinct models. The Accountable Care Partnership Plan pairs an ACO exclusively with one MCO. The Primary Care ACO offers only a primary care network, with MassHealth paying other providers directly on a fee-for-service basis and behavioral health delivered through the Massachusetts Behavioral Health Partnership. The MCO-Administered Model allows non-exclusive relationships, so an ACO can contract with more than one MCO. As of 2023, more than 1.3 million members, over half of MassHealth's total enrollment, were in one of 17 ACOs, many branded around specific hospital systems like Mass General Brigham and Mercy Health.

On the commercial side, Blue Cross Blue Shield of Massachusetts is the state's dominant, not-for-profit insurer with 2.8 million policyholders, more than any other carrier in the state. Massachusetts also regulates its individual and small-group markets together as a single "Merged Market" under state law, a structure most states don't use. That regulatory oversight has real teeth: for the 2024-2025 filing cycle, the Division of Insurance rejected BCBSMA's requested 12.9 percent rate increase, along with WellSense Health Plan's 16.2 percent request, as excessive, and directed both carriers to refile at lower rates.