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
	All Provider Bulletin 130
	December 2003

	TO:	All Providers Participating in MassHealth

	FROM:	Beth Waldman, Acting Commissioner

	RE:	Change in MassHealth Copayment Policy

Introduction	The information in this bulletin is about MassHealth copayments, and primarily affects pharmacies and acute hospitals participating in MassHealth.  All providers, however, should be aware of these copayments, especially when prescribing drugs or referring MassHealth members for services in an acute inpatient hospital setting or a hospital emergency department. 

	The Division will change its policy on the MassHealth copayments effective February 1, 2004.  Members will receive notices about the Division’s change in copayment policy within the next two weeks.  This bulletin provides a summary of the changes in the Division’s policy and an advance copy of the notice that will be sent to members.  We are sending this bulletin before MassHealth members are notified of the change.  The Division will send updated provider regulations about this policy in January 2004.   

Change in 	The Division will change the copayment amount for prescription drugs from $2 for
Copayments	all prescriptions, to $1 for multiple-source drugs and nonlegend (over-the-counter) drugs, and $3 for all other pharmaceuticals.  The Division will also establish a copayment of $3 for nonpsychiatric acute inpatient hospital stays.  This copayment is in addition to the existing MassHealth hospital copayment of $3 for nonemergency use of a hospital emergency department.  The Division collects MassHealth copayments from the provider by deducting the amount of the copayment from the MassHealth payment to the provider.

Copayment Cap	The Division will establish calendar-year copayment caps of $200 for pharmacy services and $36 for non-pharmacy services.  These caps are the maximum amounts that a member can be charged in copayments within a calendar year.  Since this new policy will be effective February 1, 2004, the Division will adjust the caps for calendar year 2004 to $184 for pharmacy services and $33 for non-pharmacy services.

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Individuals 	The following individuals cannot be charged a copayment:
Excluded from		 members under 19 years of age;
the MassHealth	 members who are pregnant or in the postpartum period that extends 
Copayment 		through the last day of the second calendar month following the month 
	Requirement 		in which their pregnancy ends (for example, if the woman gave birth May 15, she is exempt from the copayment requirement until August 1);
						 MassHealth Limited members;
					 MassHealth Senior Buy-In members or MassHealth Standard members for Medicare-covered drugs only, when provided by a Medicare-certified provider;
 members who are inpatients in nursing facilities, chronic-disease or rehabilitation hospitals, or intermediate-care facilities for the mentally retarded, or who are admitted to an acute hospital from such a facility;
 members receiving hospice 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, MassHealth Essential, or MassHealth Standard.

Additional 			There is no MassHealth pharmacy copayment for:
Exclusions for 			 family-planning services and supplies;
Pharmacy Services	 members who have reached their pharmacy copayment cap–meaning those members who pay and/or incur charges for MassHealth pharmacy copayments totaling $184 in calendar year 2004 ($200 in succeeding calendar years);
	 members who are inpatients in hospitals (There is no separate pharmacy copayment for members who are inpatients in hospitals.); and
		 emergency services.

Additional 			There is no MassHealth non-pharmacy copayment for:
Exclusions for 			 family-planning services and supplies;
Non-Pharmacy 			 hospital services provided to members who have other comprehensive 
Services							medical insurance, including Medicare;
						 members who have reached their non-pharmacy copayment cap–meaning those members who pay and/or incur charges for MassHealth non-pharmacy copayments totaling $33 in calendar year 2004 (or $36 in succeeding calendar years);
						 mental health and substance abuse-related services; and
						 emergency services.

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Determining If a	A member may not know if he or she has met an annual cap or does not 
Member Needs to 	otherwise need to pay a MassHealth copayment.  The Recipient Eligibility 
Pay a MassHealth 	Verification System (REVS) will usually indicate if a member is excluded from the
Copayment 	copayment, except if the member is pregnant or in the postpartum period described on page 2 of this bulletin, or receiving emergency services.  POPS identifies if any copayment amount is due on each claim.  REVS will indicate if the member has met the calendar-year maximum for non-pharmacy services and pharmacy services, respectively, based on the information available to MassHealth through claims.  

Collecting 		It is the provider’s responsibility to collect the copayment from the member, if a
Copayments from 	copayment is due.  Providers must give members who pay a copayment a 
the Member	receipt.  If a copayment is due, but the member does not pay it at the time of service, the member remains responsible for the copayment, and the provider may bill the member for the copayment.  However, providers may not refuse to provide a covered service to a MassHealth member who is unable to pay the copayment at the time of service.  

Copayment Cap	When a member reaches either copayment cap for the calendar year, the 
Letter			Division or the member’s MCO sends the member a letter stating that the particular copayment cap has been met.  The member may use this letter as proof of having met the copayment cap.  When a member presents such a letter, the provider should not charge the member a copayment.  If the copayment is for a pharmacy service, and POPS shows that there is a copayment due, the pharmacist should call the ACS Hotline at 1-866-246-8503 and fax the letter to ACS at 1-866-556-9314.  ACS will determine if a copayment will be deducted from the provider’s payment.

Self-Declaration 	Because of the time required for claims processing and data-sharing, it is 
of Exclusion from	possible for a member to have met a copayment maximum or otherwise be 
Copayment 	excluded from the copayment requirement, and not be identified as such on 
Requirement	REVS or POPS.  

	Providers may not charge a copayment at the time of service to a member who states that he or she has met one of the exclusions from the copayment requirement.  If the provider does not charge the member a copayment and later discovers that the member was not excluded from the copayment requirement, the provider may bill the member for the unpaid copayment.

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Claims That Are 	When a service requiring a MassHealth copayment is provided to a member
Reduced by the 	who is subject to the copayment requirement, the Division will reduce the Amount of the 	payment for the service by the amount of the required copayment. The Copayment		following claims will be reduced by the amount of the required copayment:
•	pharmacy claims for covered drugs;
•	acute inpatient hospital claims for nonpsychiatric acute inpatient hospital stays with Value Code X1 (standard payment amount per discharge); and  
•	acute outpatient hospital claims with HCPCS code and modifier T1023-U1 (emergency department screening).

If a copayment is not due because the member is exempt, the service is exempt, or the member has met his or her copayment cap, the Division will not deduct the amount of the copayment from the MassHealth payment to the provider.

Correcting the 	If a pharmacy provider believes that a copayment was incorrectly deducted from 
Deduction of a 	a claim, the provider can void and replace the claim on POPS.  If a hospital
Copayment 	believes that a copayment was incorrectly deducted from a claim, the hospital
Amount from a 	may submit an adjustment claim (for 837I transactions, the provider can 
Claim	void and replace the claim).  

Incorrectly 	A provider must reimburse the copayment to a member who has paid the 
Collected		provider a copayment, but who is exempt, has reached his or her calendar-year 
Copayment	maximum, or has been charged a copayment for an excluded service.  Providers must keep all records necessary to determine if a copayment was collected from a member for a particular service on a specific date. 

Special Rules		MassHealth members enrolled with an MCO must make copayments in
for Members		accordance with the MassHealth copayment policy.  These MassHealth MCO
Enrolled in a 	copayments exclude the same persons and services as the fee-for-service
MassHealth MCO	MassHealth copayment requirements, and cannot exceed the amounts charged to Primary Care Clinician (PCC) and fee-for-service MassHealth members.

Copy of Notice	Attached is a copy of the notice that will be sent to MassHealth members.  If members have questions about the MassHealth copayment policy, they should call the MassHealth Customer Service Center at 1-800-841-2900 
(TTY: 1-800-497-4648 for people with partial or total hearing loss).

Questions	Non-pharmacy MassHealth providers may call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231 with any questions about the information in this bulletin.  Pharmacy providers may call the ACS Provider Hotline at 1-866-246-8503.