Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Eligibility Letter 205 October 1, 2011 TO: MassHealth Staff FROM: Julian J. Harris, Medicaid Director RE: Change in Pharmacy Copayment Amounts Effective October 1, 2011, MassHealth is revising the copayment amount for certain pharmacy services. The resulting pharmacy copayments will be * $1 for each prescription and refill for each generic and over-the-counter drug covered by MassHealth in the following drug classes: antihyperglycemics, antihypertensives, and antihyperlipidemics. This is the same as the current copayment for these drugs; and * $3.65 for each prescription and refill for all other generic and over-the-counter drugs, and all brand-name drugs covered by MassHealth. This is an increase from the current $3 copayment. MassHealth is also updating its regulations to clarify when members or services may be exempt from copayments or premiums. All other copayment and premium policies remain the same. These emergency regulations are effective October 1, 2011. MANUAL UPKEEP Insert Remove Trans. By 506.011 (7 of 7) 506.011 (7 of 7) E.L. 195 506.013 506.013 E.L. 201 506.015 506.015 E.L. 201 520.035 520.035 E.L. 202 520.038 520.038 E.L. 201 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 205 Rev. 10/01/11 MASSHEALTH FINANCIAL REQUIREMENTS (7 of 7) Chapter Page 506 506.011 (J) Monthly Family Assistance Premiums for the Purchase of Medical Benefits for Children. MassHealth Family Assistance members for whom the MassHealth agency purchases medical benefits under 130 CMR 505.005(B)(3) and (E) are assessed a monthly premium in accordance with the following premium schedule. FAMILY ASSISTANCE PREMIUM SCHEDULE % of Federal-Poverty Level (FPL) Premium Cost Above 150% to 200% $12 per child ($36 family group maximum) Above 200% to 250% $20 per child ($60 family group maximum) Above 250% to 300% $28 per child ($84 family group maximum) (K) Children’s Medical Security Plan (CMSP) Premiums. CMSP PREMIUM SCHEDULE % of Federal-Poverty Level (FPL) Premium Cost Greater than or equal to 200%, but less than or equal to 300.9% $7.80 per child per month; family group maximum $23.40 per month Greater than or equal to 301.0%, but less than or equal to 400.0% $33.14 per family group per month Greater than or equal to 400.1% $64.00 per child per month (L) Members Exempted from Premium Payment. The following members are exempt from premium payments: (1) MassHealth members who are American Indians or Alaska Natives who have received or are eligible to receive an item or service furnished by the Indian Health Service, an Indian tribe, a tribal organization, or an urban Indian organization, or by a non-Indian health-care provider through referral, in accordance with federal law; (2) MassHealth members with family group income at or below 150 percent of the federal- poverty level; (3) pregnant women and children under age one receiving MassHealth Standard; and (4) children when a parent or guardian in the family group is paying a premium for and is receiving Commonwealth Care. The premiums for children will be waived after the parent or guardian has enrolled in a Commonwealth Care health plan and is paying a Commonwealth Care health-plan premium, but the premiums for children will not be waived before the parent or guardian has enrolled in a Commonwealth Care health plan. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 205 Rev. 10/01/11 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; (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 $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. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 205 Rev. 10/01/11 MASSHEALTH FINANCIAL REQUIREMENTS Chapter Page 506 506.015 (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) $200 for pharmacy services; and (B) $36 for nonpharmacy services. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 205 Rev. 10/01/11 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 the MassHealth Agency 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 and Cost Sharing 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; (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. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 205 Rev. 10/01/11 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 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. MassHealth Eligibility Letter 205 September 1, 2011 Page 2