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Changes to MassHealth’s Cost Sharing Policy

April 26, 2021

MassHealth’s copay policy will change on July 1, 2021. The revised cost sharing policies will limit members’ copay and premium obligations to 5% of the member’s household income. These changes are not expected to increase members’ copay and premium obligations and are being implemented in two phases: the first phase became effective on July 1, 2020, and the second phase will become effective on July 1, 2021. The copay exclusions that became effective July 1, 2020, will remain the same.

Overview of the Phase 1 Changes

On July 1, 2020, MassHealth newly excluded the following list of services and populations from copays (see list below). Please note that copays for acute inpatient hospital stays were also eliminated on March 18th, 2020.

Services

The following services were newly excluded from copays as of July 1, 2020:

  • FDA-approved medications for detoxification and maintenance treatment of substance use disorders (SUD);
  • preventive services rated Grade A and B by the US Preventive Services Task Force (USPSTF) or broader exclusions specified by MassHealth (e.g., low-dose aspirin; colonoscopy preparation); and 
  • vaccines and their administration recommended by the Advisory Committee on Immunization Practices (ACIP).

 Populations

The following populations were newly excluded from copays as of July 1, 2020:

  • members with incomes at or under 50% federal poverty level (FPL); and
  • members automatically eligible for MassHealth because they are receiving other public assistance 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.
 
For the complete list of copay exclusions, go to https://www.mass.gov/service-details/masshealth-copayments-frequently-asked-questions or refer to 130 CMR 506.015 and 130 CMR 520.037.

Overview of the Phase 2 Changes

  • Starting July 1, 2021, a member’s cost sharing obligation for copays and premiums combined will not exceed 5% of the member’s monthly household income

Starting July 1, 2021, MassHealth will replace the current $250 annual pharmacy copay cap with a member-specific monthly pharmacy copay cap not to exceed 2% of the member’s monthly household income. Please note that members will be subject to the new copay policy starting July 1, 2021. However, for the duration of the COVID-19 federal Public Health Emergency, MassHealth will also ensure that members will not be charged more than $250 in total copays annually.

  • A copay cap is the highest dollar amount that a member can be charged in copays in a month.

MassHealth will calculate a monthly copay cap for each member based on the lowest income in their household and their household size, as applicable. MassHealth will round the member’s monthly copay cap down to the nearest ten dollar increment up to $60 and determine their final monthly copay cap as shown in the table below.

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

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

Member Notifications of These Changes

  • Beginning in late May 2021, MassHealth will send members an initial notice explaining these changes and notifying them of their initial monthly copay cap.
  • Starting July 1, 2021, MassHealth will send a notice to members whenever their monthly copay cap changes or whenever they meet their current monthly copay cap. 

Learn More and Upcoming Webinar

To learn more about these changes, go to the MassHealth Eligibility Operations Memo #21-07 at https://www.mass.gov/lists/eligibility-operations-memos-by-year.

Attend an Upcoming Webinar and learn more about the changes.

Spring 2021 MTF Session: MassHealth Updates

Description:

Join the MassHealth webinar during the Spring 2021 MTF session to hear about the upcoming changes to MassHealth’s copay policy, in addition to other MassHealth program and operations update.

MassHealth Updates 

Online Training via Zoom Platform

Webinar: Understanding MassHealth Cost Sharing Policy Updates: Phase 2

Coming June 2021! Be on the look-out for registration details.

Description:

MassHealth’s copay policy will change on July 1, 2021. Join the webinar to understand how these changes will impact MassHealth members. Additionally, learn how MassHealth will calculate copays and premiums, the new terms members should be familiar with, view new sample copay notices members may receive, and learn of the new premium hardship waivers.