Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MASSHEALTH
TRANSMITTAL LETTER ALL-110
December 2002
TO:      All Providers Participating in MassHealth FROM:      Wendy E. Warring, Commissioner
RE:      All Provider Manuals (Changes to Pharmacy Copayments)
The Division has revised its administrative and billing regulations at 130 CMR 450.000.
The Massachusetts Legislature increased pharmacy copayments for MassHealth members from 50 cents per prescription to $2 per prescription. This copayment increase applies to drugs covered by MassHealth (whether legend or non legend), including the original prescription and all refills.
The following continue to be excluded from the copayment requirement:
 ■	MassHealth members who have not reached their 19th birthday;
 ■	MassHealth members who are pregnant;
 ■	MassHealth members who are in the postpartum period that extends through the last day of the second calendar month following the month in which their pregnancy ends;
 ■	MassHealth Limited members;
 ■	MassHealth Senior Buy-In members or MassHealth Standard members for Medicare-covered drugs only, when furnished by a Medicare-certified provider;
 ■	MassHealth members who are inpatients in hospitals, nursing facilities, chronic-disease or rehabilitation hospitals, and intermediate-care facilities for the mentally retarded;
 ■	family-planning services and supplies such as oral contraceptives, contraceptive devices such as diaphragms and condoms, and contraceptive jellies, creams, foams, and suppositories;
 ■	emergency services;
 ■	hospice-care services; and
 ■	persons receiving medical services through the Emergency Aid to the Elderly, Disabled and Children Program pursuant to 130 CMR 450.106, if they do not receive MassHealth Basic or MassHealth Standard.
MassHealth members who are enrolled in MassHealth managed-care organizations (MCOs) must follow the MassHealth copayment policy of their MCO. Those MCO copayment policies must be approved by the Division, must exclude the persons and services listed above, and may not exceed MassHealth copayment amounts.
These regulations apply to claims processed for dates of service on or after January 1, 2003.
These regulations are effective January 1, 2003.

MASSHEALTH
TRANSMITTAL LETTER ALL-110 December 2002 Page 2
NEW MATERIAL
(The pages listed here contain new or revised language.)
All Provider Manuals
Pages i, 1-27, and 1-28
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
All Provider Manuals
Page i — transmitted by Transmittal Letter ALL-99
Pages 1-27 and 1-28 — transmitted by Transmittal Letter ALL-98

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
i	

	TRANSMITTAL LETTER
ALL-110	DATE
01/01/03	
1. INTRODUCTION
450.101:    Definitions 	 1-1
450.102:    Purpose of 130 CMR Chapters 400 through 499 	 1-6
450.103:    Promulgation of Regulations 	 1-6
(130 CMR 450.104 Reserved)
450.105:    Coverage Types 	 1-7
450.106:    Emergency Aid to the Elderly, Disabled and Children Program 	 1-15
450.107:    Eligible Members 	 1-15
450.108:    Selective Contracting 	 1-17
450.109:    Out-of-State Services 	 1-18
(130 CMR 450.110 and 450.111 Reserved)
450.112:    Advance Directives 	 1-19
(130 CMR 450.113 through 450.116 Reserved)
450.117:    Managed Care Participation 	 1-20
450.118:    Primary Care Clinician (PCC) Plan 	 1-21
(130 CMR 450.119 through 450.123 Reserved)
450.124:    Behavioral Health Services 	 1-26
(130 CMR 450.125 through 450.128 Reserved)
450.129:    Managed Care Contracts with Chronic Disease and Rehabilitation Inpatient
Hospitals 	 1-26
450.130:    Copayments Required by the Division 	 1-27
(130 CMR 450.131 through 450.139 Reserved)
450.140:    Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services:
Introduction 	 1-29
450.141:    EPSDT Services: Definitions 	 1-29
450.142:    EPSDT Services: Medical Protocol and Periodicity Schedule 	 1-30
450.143:    EPSDT Services: Description of EPSDT Visits 	 1-30
450.144:    EPSDT Services: Diagnosis and Treatment 	 1-31
450.145:    EPSDT Services: Claims for Visits 	 1-31
450.146:    EPSDT Services: Claims for Laboratory Services (Physician, Independent
Nurse Practitioner, and Community Health Center Only) 	 1-32
450.147:    EPSDT Services: Claims for Audiometric Hearing and Titmus Vision Tests
(Physician, Independent Nurse Practitioner, and Community Health
Center Only) 	 1-33
450.148:    EPSDT Services: Reimbursement for Transportation 	 1-33
450.149:    EPSDT Services: Recordkeeping Requirements 	 1-33
450.150:    Preventive Pediatric Health-Care Screening and Diagnosis Services for
MassHealth Basic, MassHealth CommonHealth, MassHealth Prenatal,
and MassHealth Family Assistance Members 	 1-33
(130 CMR 450.151 through 450.199 Reserved)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
1 INTRODUCTION (130 CMR 450.000)	PAGE
1-27	

	TRANSMITTAL LETTER
ALL-110	DATE
01/01/03	
(C) Verifying Member Eligibility for Services. Providers must access the Division's Recipient Eligibility Verification System (REVS) before providing services to verify a member's eligibility for MassHealth (see 130 CMR 450.107). If the member is an inpatient in a chronic-disease or rehabilitation hospital that has a managed-care contract with the Division, REVS will issue a message notifying the provider to contact the chronic-disease or rehabilitation hospital before providing services.
450.130: Copayments Required by the Division
 (A)	The Division requires MassHealth members who are not enrolled in MCOs to make the copayments described in 130 CMR 450.130(B) for drugs obtained from the dispensing pharmacy and for nonemergency services provided in a hospital emergency department, except as excluded in 130 CMR 450.130(C). Providers may collect copayments only in the amounts and for the services listed in 130 CMR 450.130(B). MassHealth members who are enrolled in MassHealth MCOs must make copayments in accordance with the MCO’s MassHealth copayment policy. Those MCO copayment policies must be approved by the Division, must exclude the services and persons listed in 130 CMR 450.130(C), and may not exceed the MassHealth copayment amounts set forth in 130 CMR 450.130(B). (See also 130 CMR 508.016 through 508.019.) If the usual and customary fee is less than the copayment amount, the member must pay the amount of the service.
 (B)	Copayments consist of the following:

 (1)	$2 for each prescription for drugs covered by MassHealth (whether legend or nonlegend), including the original prescription and all refills; and
 (2)	$3 for nonemergency services covered by MassHealth provided in a hospital emergency department. (See 130 CMR 450.118 for a discussion of payment for hospital emergency department services for members who are enrolled with a MassHealth managed-care provider.)
(C)	The following are excluded from the copayment requirement described in 130 CMR
450.130(B):
 (1)	MassHealth members who have not reached their 19th birthday;
 (2)	MassHealth members who are pregnant;
 (3)	MassHealth members who are in the postpartum period that extends through the last day of the second calendar month following the month in which their pregnancy ends (for example, if the woman gave birth May 15, she is exempt from the copayment requirement until August 1);
 (4)	MassHealth Limited members;
 (5)	MassHealth Senior Buy-In members or MassHealth Standard members for Medicare-covered drugs only, when furnished by a Medicare-certified provider;
 (6)	MassHealth members who are inpatients in hospitals, nursing facilities, chronic-disease or rehabilitation hospitals, and intermediate-care facilities for the mentally retarded;
 (7)	family-planning services and supplies such as oral contraceptives, contraceptive devices such as diaphragms and condoms, and contraceptive jellies, creams, foams, and suppositories;
 (8)	emergency services;
 (9)	hospice-care services; and
(10)	persons receiving medical services through the EAEDC Program pursuant to 130 CMR
450.106, if they do not receive MassHealth Basic or MassHealth Standard.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
1 INTRODUCTION (130 CMR 450.000)	PAGE
1-28	

	TRANSMITTAL LETTER
ALL-110	DATE
01/01/03	
(D)	Pharmacies and hospital emergency departments must post a notice in a conspicuous area
that specifies the exclusions from the copayment requirement listed in 130 CMR 450.130(C), and
that instructs members to inform providers if members believe they are excluded from the
copayment requirement.
(E)	A member must pay the copayment described in 130 CMR 450.130(B) at the time service is
provided unless exempted by 130 CMR 450.130(C) or unless the member claims inability to
make the copayment at the time service is provided. The member's inability to make the
copayment at the time service is provided does not alleviate the member's liability for the
copayment, and providers may bill the member for the copayment amount. The Division will
deduct the amount of the copayment from the amount paid to the provider (whether or not the
provider collects the copayment from the member), unless the member or service is exempt
according to 130 CMR 450.130(C). Providers should not deduct the copayment amount from the
amount claimed.  Providers may not refuse services to any members who are unable to pay the
copayment at the time service is provided.
(130 CMR 450.131 through 450.139 Reserved)