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 96 January 1, 2003

TO:	Division Staff
FROM:     Wendy E. Warring, Commissioner
RE:	Changes to Pharmacy Copayments

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, including the original prescription and all refills. MassHealth members who are enrolled in MassHealth managed-care organizations (MCOs) must follow the Division-approved copayment rules of the MCO, which cannot exceed the Division’s copayment levels.
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
■	
MassHealth Eligibility Letter 96 January 1, 2003 Page 2
■    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.
Providers may not refuse services to a MassHealth member who is unable to pay the copayment at the time the service is provided.
These regulations are effective January 1, 2003.
MANUAL UPKEEP

Insert
508.000 508.016 508.018
520.000 520.035 520.038

Remove
Trans. By
508.000	E.L. 51	
508.016	E.L. 81	
508.018	E.L. 51	
520.000	E.L. 63	
520.035	E.L. 63	
520.039	E.L. 63	

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 96
MASSHEALTH
MANAGED CARE REQUIREMENTS	Chapter    508
Rev. 01/01/03	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 through 508.015 Reserved)
508.016:	Copayments Required by the Division
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. 96
MASSHEALTH
MANAGED CARE REQUIREMENTS	Chapter    508
Rev. 01/01/03	Page	508.016
508.016: 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 508.018, except as excluded in 130 CMR 508.017. 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 508.017, and may not exceed the MassHealth copayment amounts set forth in 130 CMR 508.018. (See also 130 CMR 450.130.)
(B)	Certain MassHealth Family Assistance members and MassHealth Buy-In members whose employer-sponsored health insurance premiums are paid in part by the Division are exempt from the copayment requirement described in 130 CMR 508.018, but must pay any copayments required of them under their health insurance, except as provided in 130 CMR 505.005(B)(6).
(C)	The Division will pay certain copayments required by employer-sponsored health insurance for certain MassHealth Family Assistance members. See 130 CMR 505.005(B)(6).
508.017: Copayment Requirement Exclusions
The following are excluded from the copayment requirement described in 130 CMR 508.018:
(A)	MassHealth members who have not reached their 19th birthday;
(B)	MassHealth members who are pregnant;
(C)	MassHealth members who are in the postpartum period described in 130 CMR 505.002(E)(2);
(D)	MassHealth Limited members;
(E)	MassHealth members who are inpatients in hospitals, nursing facilities, chronic-disease or
rehabilitation hospitals, and intermediate-care facilities for the mentally retarded;
(F)	family-planning services and supplies such as oral contraceptives, contraceptive devices such
as condoms and diaphragms, and contraceptive jellies, creams, foams, and suppositories;
(G)	emergency services;
(H) hospice-care services; and
(I) 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.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 96
MASSHEALTH
MANAGED CARE REQUIREMENTS	Chapter    508
Rev. 01/01/03	Page	508.018
508.018: Services Subject to Copayment
(A)	Drugs. All MassHealth members, except those excluded in 130 CMR 508.016(B) and 508.017, must pay $2 for each prescription for drugs covered by MassHealth, including the original prescription and all refills.
(B)	Emergency Department Services. All MassHealth members, except those excluded in 130 CMR 508.016(B) and 508.017, must pay the provider $3 for nonemergency services covered by MassHealth provided in a hospital emergency department.
508.019: Members Unable to Pay Copayment
Providers may not refuse services to a member who is unable to pay at the time the service is furnished. However, the member remains liable to the provider for the copayment amount.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 96
MASSHEALTH
FINANCIAL ELIGIBILITY	Chapter    520
Rev. 01/01/03	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 the Division
520.037:	Copayment Requirement Exclusions
520.038:	Services Subject to Copayment
520.039:	Members Unable to Pay Copayment

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 96
MASSHEALTH
FINANCIAL ELIGIBILITY	Chapter     520
Rev. 01/01/03	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, the Division 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 the Division
The Division requires MassHealth members to make the copayments described in 130 CMR 520.038, except as excluded in 130 CMR 520.037.
520.037:  Copayment Requirement Exclusions
The following are excluded from the copayment requirement described in 130 CMR 520.038:
(A)	MassHealth members who have not reached their 19th birthday;
(B)	MassHealth members who are pregnant;
(C)	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;
(D)	MassHealth Limited members;
(E)	MassHealth Senior Buy-In members or MassHealth Standard members for Medicare-covered
drugs only, when furnished by a Medicare-certified provider;
(F)	MassHealth members who are inpatients in hospitals, nursing facilities, chronic-disease or
rehabilitation hospitals, and intermediate-care facilities for the mentally retarded;
(G)	family-planning services and supplies such as oral contraceptives, contraceptive devices such
as condoms and diaphragms, and contraceptive jellies, creams, foams, and suppositories;
(H) emergency services;
(I) hospice-care services; and
(J) 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.

130 CMR: DIVISION OF MEDICAL ASSISTANCE
Trans. by E.L. 96
MASSHEALTH
FINANCIAL ELIGIBILITY	Chapter     520
Rev. 01/01/03	Page	520.038
520.038: Services Subject to Copayment
(A)	Drugs. All MassHealth members, except those excluded in 130 CMR 520.037, must pay $2 for each prescription for drugs covered by MassHealth, including the original prescription and all refills.
(B)	Emergency Department Services. All MassHealth members, except those excluded in 130 CMR 520.037, must pay the provider $3 for nonemergency services covered by MassHealth provided in a hospital emergency department.
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 furnished. However, the member remains liable to the provider for the copayment amount.