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A MassHealth copayment is the amount that a MassHealth member pays for certain services. Effective January 1, 2014, MassHealth has changed its member copayment rules for pharmacy and non-pharmacy-related services.
MassHealth pharmacy copayments for pharmacy services covered under MassHealth, which include both first-time prescriptions and refills, are:
The MassHealth copayments for the following hospital services apply, unless the member is excluded from the copayment requirement:
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. MassHealth health plans (managed care organizations) will implement only pharmacy copayments in calendar year 2004.
One charge for the stay.
All MassHealth members are responsible for MassHealth copayments, unless they meet one of the exclusions. MassHealth members are excluded if they:
MassHealth members also do not have to pay a MassHealth copayment for
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.
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.
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.
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.
You should follow the copayment rules of the MassHealth health plan. If the member is enrolled in Boston Medical Center HealthNet Plan, CeltiCare Health Plan, Fallon Community Health Plan, Health New England, Neighborhood Health Plan, or Network Health, there is no copayment for nonpharmacy (hospital) services. The only copayment that applies to MassHealth members enrolled in one of the above MassHealth health plans is for pharmacy services:
Yes. There is a yearly copayment cap of $250 for pharmacy services and $36 for nonpharmacy services. Each family member must meet his or her own cap. Once the member has been charged the maximum in copayments during a calendar year, the member will no longer have to pay copayments until the next calendar year for that type of service.
For hospital 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 1-866-246-8503.
Since there is a lag between the service and the billing, 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 1-866-246-8503.
It is the responsibility of the provider to return the copayment to the member.
No. Providers may not refuse services to a member because of an inability to pay.