MassHealth pays for many important health-care services including doctor visits, hospital stays, rehabilitation and therapeutic services, and behavioral health and substance abuse services. To get more specific information, call the MassHealth Customer Service Center.
MassHealth pays for prescription drugs*. Massachusetts law says that when a generic drug is available, the pharmacy must fill the prescription with the generic unless the doctor who prescribed the medicine indicated that the prescription must be filled with the brand-name drug. In order to prescribe a brand-name drug, MassHealth also requires your doctor to request a prior authorization (PA) in most cases where there is a generic equivalent. MassHealth requires most members to pay a copayment for each prescription.
*Beginning January 1, 2006, if you are eligible for both Medicare and MassHealth, Medicare will provide most of your prescription drug coverage through a Medicare prescription drug plan. Visit www.medicare.gov or call 1-800-MEDICARE for information about whether you need to enroll in a Medicare prescription drug plan, and, if so, how to choose one that is best for you.
For some medical services, your doctor or health-care provider has to get approval from MassHealth first. This is called prior authorization (PA) or prior approval. Medical services that are covered by Medicare do not need prior authorization from MassHealth.
MassHealth provides nonemergency transportation services and emergency ambulance services. The general guidelines for nonemergency services are:
- Your medical provider must authorize your need for transportation by completing a Prescription for Transportation (PT-1) form for community-based services or a Medical Necessity Form (MNF) for institutionally based services.
- Transportation must be to and from a MassHealth provider for a MassHealth-reimbursable service.
- You are not able to access public transportation and/or private means of transportation.
There are exceptions to these guidelines. Please call the MassHealth Customer Service Center for more information.
If you are enrolled in a private health plan through MassHealth, call the health plan's member-services department for the names of behavioral health and substance abuse providers who participate in that health plan. If you are not enrolled in a health plan, you can go to any therapist who takes MassHealth. If you need help finding a behavioral health or substance abuse therapist, you can call the MassHealth Customer Service Center.
MassHealth is a health-care program for people living in Massachusetts who get medical care in Massachusetts. In certain situations, MassHealth may pay for emergency treatment for a medical condition when a MassHealth member is out of state. If an emergency occurs while you are out of state, show your MassHealth card and any other health-insurance cards you have, if possible. Also if possible, tell your primary-care provider or health plan within 24 hours of the emergency treatment. If you are not enrolled in a health plan through MassHealth, but instead get premium assistance, your private health insurance may also pay for emergency care you get out of state.
MassHealth pays for therapy services that are determined medically necessary. After 20 physical therapy visits, 20 occupational therapy visits, or 35 speech/language therapy visits, your therapist must get PA from MassHealth for MassHealth to cover more therapy services of that type within a 12-month period. This rule applies to all MassHealth members, including children. If you are enrolled in a private health plan through MassHealth, you need to follow the rules of your health plan. Please call the MassHealth Customer Service Center for more information.
A MassHealth copayment is the amount that a MassHealth member pays for certain pharmacy and nonpharmacy-related services.
Effective October 1, 2011, MassHealth pharmacy copayments for drugs covered under MassHealth, which include both first-time prescriptions and refills, 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.
You will be charged MassHealth copayments for the following hospital services, unless you are excluded from the following copayment requirement:
- $3 for acute inpatient stays.
You do not have to pay a MassHealth copayment for any service covered by MassHealth if
- you are under 19 years old;
- 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 copayment cap for that service.
You also do not have to pay a MassHealth copayment for
- pharmacy services while you are an inpatient in a hospital or an intermediate-care facility for the mentally retarded (However, you may still have to pay a nonpharmacy copayment.);
- 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; and
- mental health or substance abuse-related services provided by a hospital; or
- emergency services.
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.
There is a calendar year copayment cap of $250 for pharmacy servces.
There is also $36 copayment cap for nonpharmacy services.
- Each family member must meet his or her own cap. Once you have been charged the maximum in copayments during a calendar year, you will no longer have to pay copayments until the next calendar year for that type of service.
In some cases, MassHealth can pay you back for medical bills that you paid before you got your MassHealth approval notice.
We will do this if we denied your eligibility and later decided that the denial was incorrect, or you paid for a MassHealth-covered service before we told you that you could get MassHealth. In this case, your health-care provider must pay you back and bill MassHealth for the service. The provider must accept the MassHealth payment as payment in full.
This information is provided by MassHealth.