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MassHealth Copay Information – For Providers

A copay is the dollar amount charged by a provider to a member for the use of a covered service or item. Drugs dispensed by a pharmacy are the only MassHealth covered service that may have copays. There are no copays for other MassHealth covered services.

For copay information related to COVID-19 treatment and services, please see the Frequently Asked Questions for Members and Applicants.

MassHealth Copays

If a member is enrolled in a health plan through MassHealth, the copay rules depend on the type of plan. MassHealth Accountable Care Organizations (ACOs) and Managed Care Organizations (MCOs) use MassHealth’s copay rules. Copays are not applied for enrollees in One Care, Program of All-Inclusive Care for the Elderly (PACE), or Senior Care Options (SCO).

MassHealth copays for pharmacy services covered under MassHealth are subject to member and service exclusions. The copays are as follows:

  • $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
  • $3.65 for each prescription and refill for all other generic and over-the-counter drugs, and all brand-name drugs covered by MassHealth.

Member and Provider Rights

If a member cannot afford their current or previously unpaid copays when you provide the service, you cannot refuse services to the member. You do have the right, however, to bill the member for the copay.

Copay Cap

MassHealth members are assigned a member-specific monthly copay cap that won’t be more than 2% of the member’s monthly household income. Members will be subject to the new copay policy starting July 1, 2021. During the federal COVID-19 public health emergency, however, MassHealth will also ensure that members will not be charged more than $250 in total copays annually.

How MassHealth Determines the Copay Cap

MassHealth calculates a monthly copay cap for each member based on the lowest income in their household and their household size, as applicable. MassHealth rounds the member’s monthly copay cap down to the nearest $10 increment up to $60 and determines their final monthly copay cap as shown in the table below.

 

If the member’s monthly copay cap is calculated to be:

The member’s final monthly copay cap will be:

$0 to $9.99

No Copays

$10 to $19.99

$10

$20 to $29.99

$20

$30 to $39.99

$30

$40 to $49.99

$40

$50 to $59.99

$50

$60 or More

$60

For example, if a member’s monthly copay cap is $12.50 in July, the member is not charged more than $10 of copays in July. If the member’s household income or family size changes in August, their monthly copay cap may change for August.

This copay policy does not apply to Children’s Medical Security Plan (CMSP) members. Any drugs that are charged through Health Safety Net (HSN) are subject to the $250 annual pharmacy copay cap.

MassHealth premiums are not more than 3% of the member’s monthly household income, as applicable. This limit does not apply to CommonHealth members.

Each family member has their own cap. Once the member has been charged the maximum in copays during a given month, the member will no longer have to pay copays until the next month.

The pharmacy claims processing system should not indicate a copay amount if one isn’t required. MassHealth sends a letter to the member when the member has reached their copay cap. When a member presents that letter, the provider should not charge the member a copay. If the pharmacy claims processing system incorrectly shows that there is a copay due, the pharmacist should call the appropriate Pharmacy Benefit Manager (PBM).

If you need help identifying the appropriate PBM, please call the MassHealth Customer Service Center at (800) 841-2900.

If members have questions about the copay policy, they can reach the MassHealth Customer Service Center (CSC) at (800) 841-2900, Monday through Friday between 8:00 a.m. and 5:00 p.m. For TTY, they can call (800) 497-4648 during the same hours.

Copay Cap Notifications

If members want to know their copay cap amount, instruct them to call (800) 841-2900, select 1 for “member”, select their desired language, and then follow the prompts.

MassHealth sends a notice to members whenever they meet their current monthly copay cap. If the pharmacy tries to charge the member any more copays for that month, the member should show the pharmacy the letter and the pharmacy should not charge the copay. Members who do not receive a letter, or who have any questions, should call the MassHealth Customer Service Center at (800) 841-2900, or TTY at (800) 497-4648.

Member Exclusions

MassHealth members are responsible for MassHealth copays, unless they meet one of the exclusions specified in the regulations at 130 CMR 450.130(D).

The following members are excluded from copays:

  • Members with income at or below 50% of the federal poverty level (FPL)
  • Members who are eligible for MassHealth because they are receiving certain public assistance benefits such as Supplemental Security Income (SSI), Transitional Aid to Families with Dependent Children (TAFDC), or services through the Emergency Aid to the Elderly, Disabled and Children (EAEDC) Program. See regulations at 130 CMR 450.130(D)(1)(i)
  • Members who are under 21 years old
  • Members who are pregnant or have recently given birth (are in their postpartum period)
  • Members who are receiving benefits under MassHealth Limited (Emergency Medicaid)
  • Members with MassHealth Senior Buy-In or MassHealth Standard, and who are receiving a drug that is covered under Medicare Parts A and B only, when provided by a Medicare-certified provider
  • Members in a long-term care facility such as:
    • A nursing facility
    • Chronic-disease or rehabilitation hospital, or
    • Intermediate-care facility for individuals with intellectual disabilities
      or
    • Members admitted to a hospital from such a facility or hospital
  • Members receiving hospice services
  • Members who were a foster care child and are eligible for MassHealth Standard, until age 21 or 26. See regulations at 130 CMR 450.130(D)(1)(h)
  • Members who are American Indian or an Alaska Native currently receiving or have ever received services at the Indian Health Service, an Indian tribe, a tribal organization, or an urban Indian organization, or
  • Members who are in another exempt category specified in regulations at 130 CMR 450.130(D)

 

Members who have accumulated copayment charges totaling their member-specific monthly copay cap on pharmacy services do not have to pay further MassHealth copays during the month in which the member reached the copay maximum.

Service Exclusions

In addition, there is no copay for the following services:

  • Detoxification and maintenance treatment of an individual for substance use disorders (SUD) using FDA approved medications, including methadone, buprenorphine, buprenorphine/naloxone, and naltrexone
  • Preventive services assigned a grade of ‘A’ or ‘B’ by the United States Preventive Services Task Force (USPSTF), or such broader exclusion as specified by MassHealth
  • All approved vaccines and their administration, recommended by the Advisory Committee on Immunization Practices (ACIP)
  • Family-planning services and supplies such as oral contraceptives, contraceptive devices such as diaphragms and condoms, and contraceptive jellies, creams, foams, and suppositories
  • Smoking cessation products and drugs
  • Emergency services, or
  • Provider-preventable services as defined in 42 CFR 447.26(b).

Copay Processing for Pharmacy Providers

All claims processing will remain the same. If you are a pharmacy provider and you dispense drugs that require a copay to a member who is not excluded from the copay requirement, the amount of the copay will be subtracted from your MassHealth payment.

Pharmacy claim responses will show the copay amount deducted from the payment amount to the pharmacy.

Pharmacy providers will be able to see the new service and population exclusions as part of the claim response in their pharmacy claims processing system.

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