Covered Services

MassHealth pays for many important health-care services including doctor visits, hospital stays, rehabilitation and therapeutic services, and behavioral health and substance use disorder services.

To get more specific information, call the MassHealth Customer Service Center.

Prescription drugs

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 prior authorization (PA) in most cases where there is a generic equivalent. 

*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.

Family Planning Drugs

• MassHealth members may request up to a 12-month supply of birth control.
• If you are interested in receiving a 12-month supply of birth control dispensed all at once, please talk with your health care provider and/or pharmacist.
• This policy is consistent with the requirements of Massachusetts’s Advancing Contraceptive Coverage and Economic Security in our State (ACCESS) law, which ensures that residents have access to affordable birth control.
• Under the law, MassHealth members can get up to a 12-month supply of prescription birth control at once after completing a three-month trial of the prescription.

 

Prior authorization (PA)

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.

 

Transportation services

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.

 

Behavioral health and substance use disorder services

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 use disorder 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 use disorder provider, you can call the MassHealth Customer Service Center.

 

Out-of-state emergency treatment

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.

 

Therapy services

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.

 

Gender Affirming Care

Click here above to learn more about Gender-Affirming Care.

 

Copayments

MassHealth members, including those in managed care plans, do not have to pay copayments for prescription drugs or other MassHealth covered services. 

 

Out-of-pocket expenses

In some cases, MassHealth can pay you back for medical bills that you paid before you got approved for MassHealth. We may do this if your eligibility was denied and later found to be incorrect. In this case, your health-care provider must pay you back for a MassHealth-covered service and bill MassHealth for the service. The provider must accept the MassHealth payment as payment in full.