Effective July 1, 2020, MassHealth changed its member copay rules to exclude additional categories of members and services from copays. Since MassHealth eliminated acute inpatient hospital copays on March 18, 2020, MassHealth copays apply only to certain covered outpatient drugs dispensed at pharmacies. These changes were presented to the provider community as part of the Massachusetts Health Care Training Forum (MTF) meetings in June 2020. The presentation used during this forums can be found here.
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, PACE, and SCO.
MassHealth copays for pharmacy services covered under MassHealth are as follows, subject to member and service exclusions:
- $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.
There is a $250 calendar year copay cap for pharmacy services.
Each family member has their own cap. Once the member has been charged the maximum in copays during a calendar year, the member will no longer have to pay copays until the next calendar year.
The pharmacy claims processing system will not indicate a copay amount if none is required. MassHealth also sends a letter to the member when the member has reached their copay cap. When a member presents such a 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.
MassHealth members are responsible for MassHealth copays, unless they meet one of the exclusions specified in 130 CMR 450.130(D). Members excluded from copays include the following:
• Members with income at or below 50% of the federal poverty level
• Members who are eligible for MassHealth because they are getting 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 130 CMR 450.130(D)(1)(i)
• Members who are under 21 years old
• Members who are pregnant or whose pregnancy has recently ended
• Members who are getting benefits under MassHealth Limited (emergency MassHealth)
• Members with MassHealth Senior Buy-In or MassHealth Standard, and who are getting 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
• Members getting hospice services
• Members who were a foster care child and are eligible for MassHealth Standard, until age 21 or 26. See 130 CMR 450.130(D)(1)(h)
• Members who are American Indian or an Alaska Native, or
• Members who are in another exempt category specified in 130 CMR 450.130(D).
Members who have accumulated copayment charges totaling the calendar-year maximum of $250 on pharmacy services do not have to pay further MassHealth copays during the calendar year in which the member reached the copay maximum.
In addition, there is no copay for the following services:
• detoxification and maintenance treatment of an individual for substance use disorders 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
• provider-preventable services as defined in 42 CFR 447.26(b)
• COVID-19 testing and treatment services for the duration of the national emergency, or
• Other services described in MassHealth regulations (see 130 CMR 450.130(E)).
All claims processing will remain the same. If 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.
If a member cannot afford a current or previously unpaid copay 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 copay.