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MassHealth Copayments Frequently Asked Questions

FAQ about MassHealth copayments

What is a MassHealth copayment?

A MassHealth copayment is the amount that a MassHealth member pays for certain services. Effective January 1, 2014, MassHealth changed its member copayment rules for pharmacy and nonpharmacy-related services. 

Pharmacy copayments

MassHealth pharmacy copayments for pharmacy services covered under MassHealth, which include both first-time prescriptions and refills are as follows, unless the member is excluded from the copayment requirement:

  • $1 for certain covered generic drugs and over-the-counter drugs mainly used for diabetes, high blood pressure, and high cholesterol. These drugs are called antihyperglycemics (such as metformin), antihypertensives (such as lisinopril), and antihyperlipidemics (such as simvastatin); and
  • $3.65 for each prescription and refill for all other generic, brand-name, and over-the-counter drugs covered by MassHealth.

Nonpharmacy copayments

The MassHealth copayments for the following nonpharmacy services apply, unless the member is excluded from the copayment requirement:

  • $3 for acute inpatient hospital stays.

Is there a limit to the amount in copayments that a member can be charged in a year?

Yes. There is a yearly copayment cap of:

  • $250 for pharmacy services
  • $36 for acute inpatient hospital services

Each family member has his or her own cap. Once the member has been charged the maximum in copayments for a type of service during a calendar year, the member will no longer have to pay copayments until the next calendar year for that type of service.

Will the $3 copayment for acute inpatient hospitals be charged daily or one time for the stay?

One charge for the stay.

Do all MassHealth members have to pay a MassHealth copayment?

All MassHealth members are responsible for MassHealth copayments, unless they meet one of the exclusions. MassHealth members are excluded if they are

  • Younger than 21 years of age
  • Pregnant
  • Within the postpartum period that extends through the last day of the second calendar month following the month in which their pregnancy ended (for example, if a member gave birth May 15, she is exempt from the copayment requirement until August 1)
  • Getting benefits under MassHealth Limited (emergency MassHealth)
  • Getting a Medicare-covered drug at a pharmacy that is a certified provider for Medicare and are getting benefits under MassHealth Senior Buy-In (MassHealth and Medicare) or under MassHealth Standard
  • An inpatient in a hospital and are receiving covered drugs as part of their hospital stay
  • An inpatient in a nursing facility, chronic-disease or rehabilitation hospital, or intermediate-care facility, or are admitted to a hospital from such a facility
  • An American Indian or Alaska Native who is currently receiving or has 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
  • Getting hospice care
  • Getting EAEDC (Emergency Aid to the Elderly, Disabled and Children) Program services, and are not covered under MassHealth Standard, CarePlus, or Family Assistance or
  • At their copayment cap.

MassHealth members also do not have to pay a MassHealth copayment for

  • Pharmacy services while they are inpatients in a hospital or an intermediate care facility (however, they will still have to pay a nonpharmacy copayment if they are not otherwise excluded);
  • Hospital services (nonpharmacy copayment) when they have other comprehensive medical insurance, including Medicare (however, they will still have to pay a pharmacy copayment unless they are otherwise excluded);
  • Family-planning services;
  • Mental health or substance use disorder-related services provided by a hospital. or
  • Emergency services.

Information for Providers: How is my MassHealth payment affected by the copayment policy?

If you provide drugs or services that require a copayment to a member who is not excluded from the copayment requirement, the amount of the copayment will be subtracted from your MassHealth payment.

How will the copayment deduction appear to me?

You will see an edit on your paper remittance advice. This edit will indicate that a deduction has occurred in the amount of the copayment. Pharmacy claim responses will show the copayment amount deducted from the payment amount to the pharmacy.

What happens if a copayment is deducted from my MassHealth payment in error?

If a pharmacy provider believes that a copayment was incorrectly deducted from a claim, the provider can void and replace the claim on the Pharmacy Online Processing System (POPS).

If a hospital believes that a copayment was incorrectly deducted from a claim, the hospital may submit an adjustment claim. For a hospital claim where a copayment was taken for a pregnant member, the hospital can adjust the claim by ensuring that a pregnancy diagnosis code is indicated on the claim and submit an adjusted claim to MassHealth.

If a hospital believes that a copayment was incorrectly deducted from a claim for a reason other than pregnancy, the hospital can submit the adjusted claim to the address below with a written explanation.

How will this affect me if the member does not pay the copayment?

If a member cannot afford the copayment at the time you provide the service, you cannot refuse services to the member. You do have the right, however, to bill the member for the copayment, and enforce the debt through whatever legal means are available.

If a member is enrolled in a health plan through MassHealth, what copayment should I charge?

You should follow the copayment rules of the MassHealth health plan. MassHealth Accountable Care Organizations (ACOs) and Managed Care Organizations (MCOs) use MassHealth’s copayment rules. Copayments are not applied for enrollees in PACE, One Care, and SCO.

The only copayment that applies to MassHealth members enrolled in one of the available MassHealth health plans is for pharmacy services:

  • $1 for certain covered generic drugs and over-the-counter drugs mainly used for diabetes, high blood pressure, and high cholesterol. These drugs are called antihyperglycemics (such as metformin), antihypertensives (such as lisinopril), and antihyperlipidemics (such as simvastatin); and
  • $3.65 for each prescription and refill for all other generic, brand-name, and over-the-counter drugs covered by MassHealth.

How do I know when the member has reached the yearly cap for pharmacy or nonpharmacy services?

For nonpharmacy services, you should receive a message when checking eligibility using the Eligibility Verification System (EVS). The message will state that the member has met the cap. For pharmacy services, POPS will not indicate a copayment amount if none is required. MassHealth also sends a letter to the member when the member has reached either copayment cap. When a member presents such a letter, the provider should not charge the member a copayment if copayments for that type of service have been capped. If the copayment is for a pharmacy service, and POPS shows that there is a copayment due, the pharmacist should call the Conduent Hotline at (866) 246-8503.

If a member is close to the copayment cap, are my claims handled differently?

If a member is close to the nonpharmacy (hospital) cap, the nonpharmacy bills will be suspended to ensure that a copayment is not deducted in error. If a member is close to the pharmacy cap, the provider should call the Conduent Provider Hotline at (866) 246-8503.

What happens if a member pays a copayment after the cap has been met?

It is the responsibility of the provider to return the copayment to the member.

Can I refuse services to a member if a member cannot cover the previously unpaid copayments?

No. Providers may not refuse services to a member because of an inability to pay.

Does the copayment policy affect any other provider types?

Over time, we anticipate that more providers will be required to charge MassHealth members a copayment. For now, only pharmacies and acute inpatient hospitals must charge a copayment for certain services. As additional services become subject to the copayment requirement, other provider types will be notified of any impact a new copayment will have on them.

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