Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Eligibility Letter 206 January 1, 2012 TO: MassHealth Staff FROM: Julian J. Harris, Medicaid Director RE: Change in Pharmacy Copayment Calendar-Year Maximum Effective January 1, 2012, MassHealth is revising the calendar-year copayment maximum for pharmacy services. Starting in 2012, the pharmacy copayment cap is increasing from $200 per calendar year to $250 per calendar year. These emergency regulations are effective January 1, 2012. MANUAL UPKEEP Insert Remove Trans. By 506.013 506.013 E.L. 205 506.015 506.015 E.L. 205 520.038 520.038 E.L. 205 520.039 520.039 E.L. 202 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 206 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Rev. 01/01/12 Page 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; (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 Basic, MassHealth Standard, or MassHealth Essential; (h) members who are independent foster care adolescents who were in the care and custody of the Department of Children and Families on their 18th birthday and who are eligible for MassHealth Standard until they reach age 21; and (i) members who are American Indians or Alaska Natives who are currently receiving or have ever received an item or service furnished by the Indian Health Service, an Indian tribe, a tribal organization, or an urban Indian organization, or through referral, in accordance with federal law. (2) Members who have accumulated copayment charges totaling the calendar-year maximum of $250 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. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 206 MASSHEALTH FINANCIAL REQUIREMENTS Chapter 506 Rev. 01/01/12 Page 506.015 (B) Excluded Services. The following services are excluded from the copayment requirement described in 130 CMR 506.015: (1) family planning services and supplies such as oral contraceptives, contraceptive devices, such as diaphragms ands condoms, and contraceptive jellies, creams, foams, and suppositories; (2) nonpharmacy behavioral-health services; and (3) emergency services. 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) $3.65 for each prescription and refill for all other generic and over-the- counter drugs, and all brand-name 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) $250 for pharmacy services; and (B) $36 for nonpharmacy services. Trans. by E.L. 206 130 CMR: DIVISION OF MEDICAL ASSISTANCE MASSHEALTH FINANCIAL ELIGIBILITY Chapter 520 Rev. 01/01/12 Page 520.038 (2) Members who have accumulated copayment charges totaling the calendar-year maximum of $250 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 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) $3.65 for each prescription and refill for all other generic and over-the- counter drugs, and all brand-name drugs covered by MassHealth. (B) Nonpharmacy Services. The copayment for nonpharmacy services is $3 for an acute inpatient hospital stay. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 206 Rev. 01/01/12 MASSHEALTH FINANCIAL ELIGIBILITY Chapter 520 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) $250 for pharmacy services; and (B) $36 for nonpharmacy services.