Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Eligibility Letter 201 July 1, 2010 TO: MassHealth Staff FROM: Terence G. Dougherty, Medicaid Director RE: Change in Pharmacy Copayment Amounts Effective July 1, 2010, MassHealth is revising the copayment amount for certain pharmacy services. The resulting pharmacy copayments are * $1 for each prescription and refill for each generic drug and over-the-counter drug covered by MassHealth in the following drug classes: antihyperglycemics, antihypertensives, and antihyperlipidemics (no change from current amount); and * $3 for each prescription and refill for all other generic, brand-name, and over-the- counter drugs covered by MassHealth. In addition, MassHealth placed copayment language in 130 CMR 506.013 through 506.017 to conform to language already in 130 CMR 520.036 through 520.040. All other copayment policies remain the same. These regulations were promulgated as an emergency, and are effective July 1, 2010. MANUAL UPKEEP Insert Remove Trans. By 506.000 506.000 E.L. 171 506.013 -- -- 506.015 -- -- 508.016 508.016 E.L. 200 520.038 520.038 E.L. 195 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 201 Rev. 07/01/10 MASSHEALTH FINANCIAL REQUIREMENTS Chapter Page 506 506.000 TABLE OF CONTENTS Section 506.001: Introduction 506.002: Financial Responsibility 506.003: Countable Income 506.004: Noncountable Income 506.005: Verification of Income 506.006: Transfer of Income 506.007: Calculation of Financial Eligibility 506.008: Cost-of-Living Adjustment (COLA) Protections 506.009: The One-Time Deductible 506.010: Verification of Medical and Remedial-Care Expenses 506.011: MassHealth Standard, CommonHealth, Family Assistance, and the Children’s Medical Security Plan (CMSP) Premiums 506.012: Family Assistance Premium Assistance Payments 506.013: Copayments Required by MassHealth 506.014: Copayment and Cost Sharing Requirement Exclusions 506.015: Services Subject to Copayments 506.016: Members Unable to Pay Copayment 506.017: Calendar-Year Maximum 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 201 Rev. 07/01/10 MASSHEALTH FINANCIAL REQUIREMENTS Chapter Page 506 506.013 506.013: Copayments Required by MassHealth The MassHealth agency requires its members to make the copayments described in 130 CMR 506.015, up to the calendar-year maximum described in 130 CMR 506.017, except as excluded in 130 CMR 506.014. 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. 506.014: Copayment and Cost Sharing Requirement Exclusions (A) Excluded Individuals. (1) The following individuals do not have to pay the copayments described in 130 CMR 506.015: (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 drugs covered under Medicare Parts A and B 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 who are admitted to a hospital from such a facility or hospital; (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 or MassHealth Essential. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 201 Rev. 07/01/10 MASSHEALTH FINANCIAL REQUIREMENTS Chapter Page 506 506.015 506.015: Services Subject to Copayments MassHealth members are responsible for making the following copayments unless excluded in 130 CMR 506.014. (A) Pharmacy Services. The copayment for pharmacy services is (1) $1 for each prescription and refill for each generic drug and over-the-counter drug covered by MassHealth in the following drug classes: antihyperglycemics, antihypertensives, and antihyperlipidemics; and (2) $3 for each prescription and refill for all other generic, brand-name, and over-the-counter drugs covered by MassHealth. (B) Nonpharmacy Services. The copayment for nonpharmacy services is $3 for an acute inpatient hospital stay. 506.016: 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. 506.017: Calendar-Year Maximum Members are responsible for the MassHealth copayments described in 130 CMR 506.015, up to the following calendar-year maximums: (A) $200 for pharmacy services; and (B) $36 for nonpharmacy services. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 201 Rev. 07/01/10 MASSHEALTH MANAGED CARE REQUIREMENTS Chapter Page 508 508.016 508.016: Copayments Required by MassHealth MassHealth requires MassHealth members who are not enrolled in MCOs to make the copayments described in 130 CMR 506.013 through 506.017 and 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) exclude the persons and services listed in 130 CMR 506.014 and 520.037; (3) not exceed the MassHealth copayment amounts set forth in 130 CMR 506.015 and 520.038; and (4) include the calendar-year maximum set forth in 130 CMR 506.017 and 520.040. (See also 130 CMR 450.130.) 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 201 Rev. 07/01/10 MASSHEALTH FINANCIAL ELIGIBILITY Chapter Page 520 520.038 (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. (6) American Indians or Alaska Natives who are furnished an item or service directly by the Indian Health Services, an Indian tribe, a tribal organization, or an urban Indian organization are exempt from cost sharing. (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 Copayments MassHealth members are responsible for making the following copayments unless excluded in 130 CMR 520.037. (A) Pharmacy Services. The copayment for pharmacy services is (1) $1 for each prescription and refill for each generic drug and over-the-counter drug covered by MassHealth in the following drug classes: antihyperglycemics, antihypertensives, and antihyperlipidemics; and (2) $3 for each prescription and refill for all other generic, brand-name, and over-the-counter drugs covered by MassHealth. (B) Nonpharmacy Services. The copayment for nonpharmacy services is $3 for an acute inpatient hospital stay.