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 Eligibility Letter 119 February 1, 2004

TO:
MassHealth Staff
FROM:     Beth Waldman, Acting Commissioner
RE:	Changes to MassHealth Copayments

Effective February 1, 2004, MassHealth has changed the copayment amount from $2 for all drugs, to $1 for generic drugs and nonlegend (over-the-counter) drugs, and $3 for all other drugs. MassHealth has also established 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.
In addition, MassHealth has established calendar-year copayment caps of $200 for pharmacy services and $36 for nonpharmacy services. These caps are the maximum amounts that a member can be charged in copayments within a calendar year. Since this new policy is effective February 1, 2004, MassHealth has adjusted these caps for calendar year 2004 to $184 for pharmacy services and $33 for nonpharmacy services.
Individuals Excluded from the MassHealth Copayment Requirement
The following individuals are not subject to the copayment requirement:
!    members under 19 years of age;
!    members who are pregnant or 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);
!    MassHealth Limited members;
!    MassHealth Senior Buy-In members or MassHealth Standard members for Medicare-covered drugs only, when provided by a Medicare-certified provider;

MassHealth Eligibility Letter 119 February 1, 2004 Page 2
!    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 a 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 Exclusions for MassHealth Copayment for Pharmacy Services
There is no MassHealth pharmacy copayment for:
!    family-planning services and supplies;
!    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 years); !    members who are inpatients in hospitals (There is no separate pharmacy copayment for
pharmacy services provided as part of the hospital stay.); and !    emergency services.
Additional Exclusions for Non-Pharmacy Services
There is no MassHealth non-pharmacy copayment for:
!    family-planning services and supplies;
!    hospital services provided to members who have other comprehensive 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.
Collecting Copayments from the Member
Providers will give members who pay a copayment a 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.

MassHealth Eligibility Letter 119 February 1, 2004 Page 3
Copayment Cap Letter
When a member reaches either copayment cap for the calendar year, MassHealth sends the member a letter stating that the particular copayment cap has been met. If the member is enrolled with a MassHealth managed care organization (MCO), the MCO sends the letter to the member. The member may use this letter as proof of having met the copayment cap. When a member presents such a letter, the provider will not charge the member a copayment.
Self-Declaration of Exclusion from Copayment Requirement
Because of the time required for claims processing and data-sharing, it is possible for a member to have met a copayment cap or otherwise be excluded from the copayment requirement, and not be identified as such on REVS or POPS.
Providers will 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.
Special Rules for Members Enrolled in a MassHealth MCO
MassHealth members enrolled with an MCO must make copayments in accordance with the MassHealth copayment policy. These MassHealth MCO copayments exclude the same persons and services as the fee-for-service MassHealth copayment requirements, and cannot exceed the amounts charged to Primary Care Clinician (PCC) and fee-for-service MassHealth members.
These regulations are effective February 1, 2004.
MANUAL UPKEEP
Insert	Remove	Trans. By
508.000	508.000	E.L. 116
508.016	508.016	E.L. 109
508.018	E.L. 96
520.000	520.000	E.L. 96
520.035	520.035	E.L. 104
520.38	520.038	E.L. 96
520.39	--	--
520.38	
130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 119
MASSHEALTH
MANAGED CARE REQUIREMENTS	Chapter    508
Rev. 02/01/04	Page	508.000
TABLE OF CONTENTS
Section
508.001:	MassHealth Managed Care Requirement
508.002:	Choosing a MassHealth Managed Care Provider
508.003:	Behavioral Health Contractor
508.004:	Members Excluded from Participation in Managed Care
508.005:	MassHealth Managed Care Providers
508.006:	Right to a Fair Hearing
(130 CMR 508.007 Reserved)
508.008:	Voluntary Enrollment in Senior Care Organizations
(130 CMR 508.009 through 508.015 Reserved)
508.016:	Copayments Required by MassHealth
508.017:	Copayment Requirement Exclusions
508.018:	Services Subject to Copayment
508.019:	Members Unable to Pay Copayment

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 119
MASSHEALTH
MANAGED CARE REQUIREMENTS	Chapter    508
Rev. 02/01/04	Page	508.016
508.016: Copayments Required by MassHealth
MassHealth requires MassHealth members who are not enrolled in MCOs to make the copayments described in 130 CMR 520.036 through 520.040. If the usual and customary fee for the service is less than the copayment amount, the member must pay the amount of the service. Members who are enrolled in MassHealth MCOs must make copayments in accordance with the MCO’s MassHealth copayment policy. Those MCO copayment policies must:
(1)	be approved by MassHealth:
(2)	(2) exclude the persons and services listed in 130 CMR 520.037;
(3)	not exceed the MassHealth copayment amounts set forth in 130 CMR 520.038; and
(4)	include the calendar-year maximum set forth in 130 CMR 520.040. (See also 130 CMR 450.130.)
(1)	
130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 119
MASSHEALTH
FINANCIAL ELIGIBILITY	Chapter    520
Rev. 02/01/04	Page	520.000
TABLE OF CONTENTS
Section
520.001:	Introduction to General Financial Requirements
520.002:	Financial Responsibility
520.003:	Asset Limit
520.004:	Asset Reduction
520.005:	Ownership of Assets
520.006:	Inaccessible Assets
520.007:	Countable Assets
520.008:	Noncountable Assets
520.009:	Countable-Income Amount
520.010:	Business Expenses
520.011:	Standard Income Deductions
520.012:	Community Earned-Income Deductions
520.013:	Community Unearned-Income Deductions
520.014:	Long-Term-Care Earned-Income Deductions
520.015:	Noncountable Income
520.016:	Long-Term Care: Treatment of Assets
520.017:	Right to Appeal the Asset Allowance or Minimum-Monthly-Maintenance-Needs Allowance
520.018:	Transfer of Resources Regardless of Date of Transfer
520.019:	Transfer of Resources Occurring on or after August 11, 1993
520.020:	(Reserved)
520.021:	Treatment of Trusts
520.022:	Trusts or Similar Legal Devices Created before August 11, 1993
520.023:	Trusts or Similar Legal Devices Created on or after August 11, 1993
520.024:	General Trust Rules
520.025:	Long-Term-Care Income Standard
520.026:	Long-Term-Care General Income Deductions
520.027:	Long-Term-Care Deductible
520.028:	Eligibility for a Deductible
520.029:	The Deductible Period
520.030:	Calculating the Deductible
520.031:	Notification of Potential Eligibility
520.032:	Submission of Bills to Meet the Deductible
520.033:	Verification of Medical Expenses
520.034:	Interim Changes
520.035:	Conclusion of the Deductible Process
520.036:	Copayments Required by MassHealth
520.037:	Copayment Requirement Exclusions
520.038:	Services Subject to Copayment
520.039:	Members Unable to Pay Copayment
520.040:	Calendar-Year Maximum

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 119

Rev. 02/01/04

MASSHEALTH FINANCIAL ELIGIBILITY

Chapter     520
Page	520.035

520.035:  Conclusion of the Deductible Process
When the total of submitted bills is equal to or greater than the deductible and all other eligibility requirements continue to be met, MassHealth will notify the applicant that he or she is eligible. The member is eligible for payment of all covered medical expenses incurred during that deductible period, other than those submitted to meet the deductible, as long as the member continues to meet all other eligibility requirements during the balance of the deductible period.
520.036:  Copayments Required by MassHealth
MassHealth requires MassHealth members to make the copayments described in 130 CMR 520.038, up to the calendar-year maximum described in 130 CMR 520.040, except as excluded in 130 CMR 520.037. If the usual and customary fee for the service or product is less than the copayment amount, the member must pay the amount of the service or product.
520.037:  Copayment Requirement Exclusions (A) Excluded Individuals.
(1) The following individuals do not have to pay the copayments described in 130 CMR 520.038:
(a)	members under 19 years of age;
(b)	members who are pregnant or 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);
(c)	MassHealth Limited members;
(d)	MassHealth Senior Buy-In members or MassHealth Standard members for Medicare-covered drugs only, when provided by a Medicare-certified provider;
(e)	members who are inpatients in nursing facilities, chronic-disease or rehabilitation hospitals, or intermediate-care facilities for the mentally retarded or are admitted to hospitals from such facilities;
(f)	members receiving hospice services; and
(g)	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 Standard.
(a)	
130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 119
MASSHEALTH
FINANCIAL ELIGIBILITY	Chapter     520
Rev. 02/01/04	Page	520.038
(2)	Members who have accumulated copayment charges totaling the calendar-year maximum of $200 on pharmacy services do not have to pay further MassHealth copayments on pharmacy services during the calendar year in which the member reached the MassHealth copayment maximum for pharmacy services.
(3)	Members who have accumulated copayment charges totaling the calendar-year maximum of $36 on nonpharmacy services do not have to pay further MassHealth copayments on nonpharmacy services during the calendar year in which the member reached the MassHealth copayment maximum for nonpharmacy services.
(4)	Members who have other comprehensive medical insurance, including Medicare, do not have to pay MassHealth copayments on nonpharmacy services.
(5)	Members who are inpatients in a hospital do not have to pay a separate copayment for pharmacy services provided as part of the hospital stay.
(B) Excluded Services. The following services are excluded from the copayment requirement described in 130 CMR 520.038:
(1)	family-planning services and supplies such as oral contraceptives, contraceptive devices such as diaphragms and condoms, and contraceptive jellies, creams, foams, and suppositories;
(2)	nonpharmacy behavioral health services; and
(3)	emergency services.
520.038:  Services Subject to Copayment
MassHealth members are responsible for making the following copayments unless excluded in 130 CMR 520.037:
(A)	Pharmacy Services.
(1)	$1 for each prescription and refill for each generic drug and over-the-counter drug covered by MassHealth; and
(2)	$3 for each prescription and refill for all other drugs covered by MassHealth.
(B)	Nonpharmacy Services.
(1) $3 for nonemergency services covered by MassHealth provided in a hospital emergency department; and
(2) $3 for an acute inpatient hospital stay.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 119
MASSHEALTH
FINANCIAL ELIGIBILITY	Chapter     520
Rev. 02/01/04	Page	520.039
520.039:  Members Unable to Pay Copayment
Providers may not refuse services to a member who is unable to pay at the time the service is provided. However, the member remains liable to the provider for the copayment amount.
520.040: Calendar-Year Maximum
Members are responsible for the MassHealth copayments described in 130 CMR 520.038, up to the following calendar-year maximums:
(A) $200 for pharmacy services; and
(B) $36 for nonpharmacy services.