1. What is a MassHealth copayment?
  2. Do I have to pay a MassHealth copayment?
  3. What if I cannot afford the copayment?
  4. I am enrolled in a health plan through MassHealth. Do I have to follow my health plan’s rules for nonpharmacy services copayments?
  5. Is there a limit to the amount in copayments that I can be charged in a year?
  6. How will I know when I have reached my yearly cap and no longer have to pay MassHealth copayments?
  7. How will my provider know when I have reached my yearly cap for pharmacy or hospital services and no longer have to pay copayments?
  8. If I owe my provider for past copayments, can my provider refuse services to me if I cannot cover the previously unpaid copayments?
  9. Will the provider know if I am excluded from paying the MassHealth copayment?
  10. What is an emergency service? 
  11. What will happen to my credit if I do not pay the copayments and my provider bills me?

 

  1. What is a MassHealth copayment?

A MassHealth copayment is the amount that a MassHealth member pays for certain services.
You will be charged MassHealth copayments for the following hospital services, unless you are excluded from the following copayment requirement:

  • $3 for acute inpatient hospital stays.

Effective October 1, 2011, the pharmacy copayments are

  • $1 for certain covered generic drugs and over-the-counter drugs mainly used for diabetes, high blood pressure, and high cholesterol. These drugs are called antihyperglycemics (such as metformin), antihypertensives (such as lisinopril), and antihyperlipidemics (such as simvastatin); and
  • $3.65 for each prescription and refill for all other generic, brand-name, and over-the-counter drugs covered by MassHealth.
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  1. Do I have to pay a MassHealth copayment?

  • If you are not excluded from the copayment requirement, you will be charged a MassHealth copayment when you get services that require one. All MassHealth members are responsible for MassHealth copayments, unless they are excluded. You do not have to pay a MassHealth copayment for any service covered by MassHealth if
  • you are under 19 years old;
  • you are pregnant;
  • your pregnancy ended and you are within the postpartum period that extends through the last day of the second calendar month following the month in which you pregnancy ended (for example, if you gave birth May 15, you are exempt from the copayment requirement until August 1);
  • you are getting benefits under MassHealth Limited (emergency MassHealth);
  • you are a MassHealth Senior Buy-In member or a MassHealth Standard member getting a drug that is covered under Medicare Parts A and B only, when provided by a Medicare-certified provider;
  • you are an inpatient in a nursing facility, chronic-disease or rehabilitation hospital, or intermediate-care facility for the mentally retarded, or are admitted to a hospital from such a facility;
  • you are an independent foster care adolescent, are in the custody of the Department of Children and Families, and are between the ages of 18 and 21;
  • you are an American Indian or Alaska Native who is currently receiving or has ever received an item or service furnished by the Indian Health Service, an Indian tribe, a tribal organization, or an urban Indian organization, or through referral, in accordance with federal law;
  • you are an inpatient in a hospital and receive covered drugs as part of your hospital stay;
  • you are getting hospice care;
  • you are getting EAEDC (Emergency Aid to the Elderly, Disabled and Children) Program services, and are not covered under MassHealth Basic, Essential, or Standard; or 
  • you have reached your copay cap for that service.

You also do not have to pay a copayment for

  • hospital services (nonpharmacy copayment) when you have other comprehensive medical insurance, including Medicare (however, you still have to pay a pharmacy copayment if you are not otherwise excluded);
  • family-planning services;
  • mental health or substance abuse-related services provided by a hospital; or
  • emergency services.

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  1. What if I cannot afford the copayment?

If you decide that you cannot afford the copayment at the time you receive the service, tell your provider. You should never go without services that you need because you cannot afford the copayment. The provider must still treat you even if you cannot afford to pay the copayment.

If you do not pay the copayment because you cannot afford to, you will still owe the money to the provider. (MassHealth will not pay the provider for the copayment that you owe.) The provider may use a legal method to collect the money you owe.

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  1. I am enrolled in a health plan through MassHealth. Do I have to follow my health plan’s rules for nonpharmacy services copayments?

MassHealth can pay for many important health care services including doctor visits, hospital stays, prescription drugs, rehabilitation and therapeutic services, and behavioral health and substance abuse services.

To get more specific information, call the MassHealth Customer Service Center. You can request an application package, which includes a booklet that contains important information about MassHealth membership.

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  1. Is there a limit to the amount in copayments I can be charged in a year?

Yes.

The cap on the amount of copays you must pay for covered drugs is $250 for the calendar year.

There is a yearly copayment cap of $36 for nonpharmacy services.

Each family member must meet his or her own cap. Once you have reached the maximum copayments during a calendar year, you will no longer have to pay copayments until the next calendar year for that type of service.

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  1. How will I know when I have reached my yearly cap and no longer have to pay MassHealth copayments?

If you meet either MassHealth copayment cap, we will send you a letter stating that you do not have to pay copayments for that type of service for the rest of the calendar year. You should keep these letters and show them to your providers if they say that you must pay a copayment.
If you think you have met your cap and the provider says you owe a copayment, you can let us know by contacting MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

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  1. How will my provider know when I have reached my yearly cap for pharmacy or hospital services and no longer have to pay copayments?

Your provider should receive a message when checking your MassHealth eligibility. If you have reached your cap for either pharmacy or hospital services, the message will tell your provider that you should no longer be charged copayments for that type of service until the next calendar year. You can always show the provider your letter from MassHealth that states that you have met your cap.

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  1. If I owe my provider for past copayments, can my provider refuse services to me if I cannot cover the previously unpaid copayments?

No. The provider cannot refuse services to you because you are unable to pay.

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  1. Will the provider know if I am excluded from paying the MassHealth copayment?

Not always. Because the provider’s computer system may not show that you are exempt from paying the MassHealth copayment, be sure to tell your provider if you are exempt from the copayment requirement.  

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  1. What is an emergency service?

An emergency service is for a sudden, serious medical problem that needs immediate attention.

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  1. What will happen to my credit if I do not pay the copayments and my provider bills me?

Your credit rating could be affected by the nonpayment of your copayments.

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This information is provided by MassHealth.