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Updates: MassHealth Cost Sharing Policy

July 1, 2021
    •  MassHealth is revising cost sharing policies to limit members’ combined monthly copay and premium obligations to 5% of the members’ monthly household income.
    • MassHealth is not increasing member cost-sharing. The monthly copay cap serves only to further protect members by placing a monthly limit on how much they can be charged in total copays. Changes are not expected to increase members’ copay and premium obligations.

Effective July 1, 2021, a MassHealth member’s cost sharing obligation for copays and premiums combined will not exceed 5% of the member’s monthly household income. These changes 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 – July 1, 2020

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

The complete list of copay exclusions are at MassHealth’s Copayments Frequently Asked Questions, or more information can be found at the MassHealth regulations at 130 CMR 450.130, 130 CMR 506.015, and 130 CMR 520.037.

Overview of the Phase 2 Changes – July 1, 2021

Effective 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

Effective 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. This policy change does not change the set copay amounts, which are usually $1 or $3.65, for prescription drugs but rather limits the total amount of copays that a member can be charged in a month. MassHealth is not increasing member cost-sharing. The monthly copay cap serves only to further protect members by placing a monthly limit on how much they can be charged in total copays.

    • A copay cap is the highest dollar amount that a member can be charged in copays in a month.
    • The Eligibility Systems (MA21 and HIX) 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 $10 increment up to $60 to 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 May 2021, MassHealth sent members an initial notice explaining these changes and notifying them of their initial monthly copay cap. However, as previously communicated, since sending the notices, we have received feedback indicating a need to further clarify the changes. Changes are being made to various public-facing and internal training materials and expected to be released shortly. MassHealth has decided to temporarily hold further noticing related to monthly copay caps to focus on refining the messaging. We will provide more information once this notice is revised and the plan to restart noticing is in place. Members are encouraged to call the MassHealth Customer Service Center select the Self-Service option to learn their current copay cap in the interim.
    • Starting July 1, 2021, MassHealth will still send a notice to members whenever they meet their current monthly copay cap. 

Resources

    • Provider Bulletin: MassHealth issued Provider Bulletin 315 on Wednesday, April 21, 2021. It provides information about member-specific monthly copay cap calculations, Pharmacy Online Processing System (POPS) claim response, updates to the Eligibility Verification System (EVS) on the Provider Online Service Center (POSC), member notification information, and Trading Partner Testing (TPT) information. This bulletin is available on the MassHealth All Provider Bulletins MassHealth page.
 
    • Eligibility Operations Memo: MassHealth issued Eligibility Operations Memo 21-07 on Thursday, April 22, 2021. It provides information about the copay exclusions, the member-specific monthly copay cap calculations, systems changes, and member notification information. This EOM is available on the Eligibility Operations Memos by Year page, under 2021.
 
    • MassHealth Copays and Premiums – For Members: MassHealth members can learn more about MassHealth copays, premiums, the premium schedule, the Health Safety Net (HSN) program, and the Children’s Medical Safety Plan (CMSP) program here.
 
    • Pharmacy Facts and Copay Poster: The Pharmacy Facts provides cost sharing information updates to Pharmacists and the Copay Poster provides this information to members. The copay issue of Pharmacy Facts, 166 is available. The 2021 Copay Poster has also been posted.
 
    • Regulations and Transmittal and Eligibility Letters: 130 CMR 450.130, 130 CMR 506.015, and 130 CMR 520.037 have been updated and both letters will be provided to explain the changes in regulations related to cost sharing. The Transmittal Letter are posted here, and Eligibility Letter posted here