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 166 August 2007 TO: MassHealth Staff FROM: Tom Dehner, Medicaid Director RE: Emergency Department Copayment Elimination Effective January 1, 2007, MassHealth is revising the copayment regulations for members who access nonemergency services from an acute care hospital’s emergency department. MassHealth has eliminated the copayment on emergency screening that acute hospitals were previously allowed to collect when they delivered nonemergency services to members in the emergency department. This change is a result of new requirements enacted in the federal Deficit Reduction Act of 2005 which became effective January 1, 2007. MANUAL UPKEEP Insert Remove Trans. By 520.035 520.035 E.L. 162 520.038 520.038 E.L. 119 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 166 Rev. 01/01/07 MASSHEALTH FINANCIAL ELIGIBILITY Chapter Page 520 520.035 520.035: 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 MassHealth agency notifies 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 The MassHealth agency requires its 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 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. 166 Rev. 01/01/07 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. (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; and (2) $3 for each prescription and refill for all other drugs covered by MassHealth. (B) Nonpharmacy Services. The copayment for nonpharmacy services is $3 for an acute inpatient hospital stay.