Having private health insurance and MassHealth does not mean you need to pay more for coverage than you did when you were just on MassHealth. The same copay amounts still apply. When you have private health insurance and MassHealth, you must see a provider who is in both the private health insurance plan’s network and is a MassHealth provider. The private health insurance should be billed first to cover what they cover, then MassHealth will be billed second. This applies even if your private health insurance does not cover a service. The service must be covered by MassHealth and you must see a provider who is both in the private health insurance plan’s network and is also a MassHealth provider.
When you have MassHealth and private insurance
When you have MassHealth and private insurance, you will still have MassHealth benefits, but the way that you receive them will change.
- For adults age 21 or older, all your benefits from MassHealth will be through providers who are both in the private health insurance plan’s network and are MassHealth providers and may not include some providers who were part of your previous MassHealth MCO or ACO network.
- If you are under age 21, your medical benefits will be through providers who are both in the private health insurance plan’s network and are MassHealth providers and may not include some providers who were part of your previous MassHealth MCO or ACO network. Your MassHealth behavioral health services will be through the Massachusetts Behavioral Health Partnership network of providers.
When you see a health care provider
You must always show BOTH your private health insurance ID card and your MassHealth ID card whenever you see a doctor, clinic, hospital, emergency room, pharmacy, dentist, or any other provider.
If you need a new MassHealth card, you may call the MassHealth Customer Service unit at (800) 841-2900 and follow the voice prompts. If you don't have your MassHealth ID number, you will either need your social security number or your name and date of birth to be identified in the MassHealth system.
Once the recording starts:
- press 1 to confirm you're a MassHealth member then
- press 3 to request a new card then
- press 3 to order a new card
Examples of using COB when you have MassHealth and private health insurance or Premium Assistance
- Bob has private health insurance and is covered by MassHealth Standard. He needs a ride to get to the doctor.
The private health insurance plan does not cover non-emergency transportation. MassHealth Standard does cover it. MassHealth would still cover this and Bob can use any MassHealth transportation provider.
- Sue needs Invitro Fertilization (IVF) in order to become pregnant.
MassHealth does not cover IVF. The private plan does cover IVF. Sue can obtain IVF using her private plan benefits but is responsible for the IVF $100 copay. MassHealth cannot pay the copay or otherwise pay for IVF because it is not a MassHealth covered service.
- Sue is pregnant and needs to deliver her baby. She goes to a hospital that is both a MassHealth provider and a provider in her private health insurance plan’s network.
The private health insurance plan covers all but the member copay of $100. Because the provider is a MassHealth provider, the provider will coordinate benefits by submitting the bill for the $100 member copay to MassHealth. Sue does not need to do any more. Sue’s responsibility will only be $3, the MassHealth inpatient copay amount.
- Sue goes to her doctor for follow up care after her baby is delivered. She sees a provider who is a private insurance in-network provider but NOT a MassHealth provider.
The private plan covers all but her $25 office visit copay. This is a MassHealth-covered service, but it is not a MassHealth provider, so Sue will be responsible for the $25 copay.
- Bob hurts his elbow playing flag football with his kids. He really wants to see the same physical therapist (PT) his neighbor used when he hurt his elbow. The PT is not in his private plan’s network, but the PT is still covered by the private plan’s out-of-network benefit. The PT is a MassHealth provider.
The private health insurance plan pays at the out of network rate of 80%, and Bob’s responsibility is 20%. The provider submits the remaining 20% charge to MassHealth. Bob has to do nothing more and should have no out-of-pocket cost.
- Bob’s elbow still hurts and the PT has not been helping. He now wants to see the same PT that his coworker used when he hurt his shoulder. The PT is in neither the private health insurance plan’s network nor the MassHealth provider network.
The private plan pays at the out of network rate of 80%, and Bob’s responsibility is 20%. Bob must pay for the 20% member responsibility. MassHealth will not reimburse him the 20% because he did not see a MassHealth provider.
- Bob goes to Florida for a few weeks to be with his sick mother while she’s hospice. While there he wants to continue his weekly physical therapy for his elbow. He goes to a Florida provider in his private plan’s PPO network.
The private plan covers the weekly PT visit up to a $25-member copay. MassHealth will not pay the $25 copay because the services were not emergency services and he was out of Massachusetts. MassHealth does not cover non-emergency services out of state. Bob will have to pay the $25 copay out-of-pocket.
Note: Amounts used in examples are not actual co-pay amounts.
Coordination of Benefits (COB) FAQs
Reimbursement for mail order pharmacy copayments
MassHealth may reimburse members for out-of-pocket mail order pharmacy co-payments for MassHealth covered services. This reimbursement may be available when a MassHealth member is required by their health insurer to fill a mail order prescription(s) and has to pay the co-payment (including co-insurance and deductibles) up front in compliance with their insurance policy.
To request reimbursement for out-of-pocket mail order pharmacy co-payments, please complete the Pharmacy Mail Order Co-Pay Reimbursement Form. Instructions explaining the documentation that you’ll need, and how to submit your request, are included on the form.