Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER ALL-146 February 2007 TO: All Providers Participating in MassHealth FROM: Tom Dehner, Acting Medicaid Director RE: All Provider Manuals (Revisions to Regulations about Copayments) This letter transmits clarifications to the regulations about copayments that are required by MassHealth and the circumstances under which certain members are excluded from those requirements. MassHealth Senior Buy-In and Standard members are excluded from paying copayments for drugs covered by Medicare Parts A and B only, when they are provided by a Medicare-certified provider. These regulations are being issued as emergency regulations and are effective January 1, 2006. Please note that, for services delivered on or after January 1, 2007, MassHealth has eliminated the copayment for non-emergency services provided in a hospital emergency department. Given this change, acute hospitals are instructed not to charge MassHealth members copayments for such services on or after January 1, 2007. Revised regulations will follow in a subsequent transmittal letter. If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) All Provider Manuals Pages 1-23 and 1-24 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manuals Pages 1-23 and 1-24 — transmitted by Transmittal Letter ALL-125 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-23 All Provider Manuals Transmittal Letter ALL-146 Date 01/01/06 450.124: Behavioral Health Services (A) Behavioral Health Contractor. Except as provided in 130 CMR 450.124(B) and (C), all behavioral health (mental health and substance abuse) services will be authorized, provided, and paid solely by the MassHealth agency's behavioral health contractor (the Contractor). Payment for such services will be subject to the terms of the Contractor's provider contracts including, but not limited to, provisions governing service authorization and billing requirements. Any provider seeking a contract with the Contractor should contact the Contractor directly. (B) Emergency Services. Emergency services may be provided by any provider regardless of whether that provider has entered into an agreement with the Contractor. However, all providers of emergency services (except those provided to exempt members pursuant to 130 CMR 450.124(C)) may claim payment for such services solely from the Contractor and such payment will be subject to the Contractor's billing requirements. (C) Services to Exempt Members. Services provided to the following MassHealth members are not subject to 130 CMR 450.124: (1) members who are enrolled in a MassHealth-contracted MCO; and (2) members who are excluded from participating in managed care under 130 CMR 508.004. (130 CMR 450.125 through 450.129 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-24 All Provider Manuals Transmittal Letter ALL-146 Date 01/01/06 450.130: Copayments Required by the MassHealth Agency (A) Copayment Requirement. The MassHealth agency requires its members to make the copayments described in 130 CMR 450.130(B) up to the calendar-year maximum described in 130 CMR 450.130(C), except as excluded in 130 CMR 450.130(D) and (E). Providers may collect copayments only in the amounts and for the services listed in 130 CMR 450.130(B). If the usual-and-customary fee 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 the MassHealth agency; (2) exclude the persons and services listed in 130 CMR 450.130(D) and (E); (3) not exceed the MassHealth copayment amounts set forth in 130 CMR 450.130(B); and (4) not exceed the calendar-year maximum set forth in 130 CMR 450.130(C). (See also 130 CMR 508.016 through 508.019 and 520.035 through 520.039.) (B) Services Subject to Copayments. MassHealth members are responsible for making the following copayments unless excluded in 130 CMR 450.130(D) or (E). (1) Pharmacy Services. The copayment for pharmacy services is (a) $1 for each prescription and refill for each generic drug and nonlegend drug covered by MassHealth; and (b) $3 for each prescription and refill for all other drugs covered by MassHealth; (2) Nonpharmacy Services. The copayment for nonpharmacy services is (a) $3 for nonemergency services covered by MassHealth provided in a hospital emergency department. (See 130 CMR 450.118 for regulations governing payment for hospital emergency department services for members who are enrolled with a MassHealth managed-care provider.); and (b) $3 for an acute inpatient hospital stay. (C) Calendar-Year Maximum. Members are responsible for the MassHealth copayments described in 130 CMR 450.130(B), up to the following calendar-year maximums: (1) $200 for pharmacy services; and (2) $36 for nonpharmacy services. (D) Excluded Individuals. (1) The following individuals do not have to pay the copayments described in 130 CMR 450.130(B): (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 (see 130 CMR 519.010) 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