130 Mass. Reg. 506.015

Current through Register 1523, June 7, 2024

Section 506.015 - Copayment and Cost Sharing Requirement Exclusions

(A)Excluded Individuals.

(1) The following individuals do not have to pay the copayments described in 130 CMR 506.016:

(a) members younger than 21 years old;

(b) members who are pregnant or in the postpartum period that extends through the last day of the 12^th calendar month following the month in which their pregnancy ends (for example, if the woman gave birth May 15^th, she is exempt from the copayment requirement until June 1^st the following year);

(c) MassHealth Limited members;

(d) MassHealth Medicare Saving Programs members or MassHealth Standard members for drugs covered under Medicare Parts A and B only, when provided by a Medicare-certified provider;

(e) members who are inpatients in nursing facilities, chronic-disease or rehabilitation hospitals, or intermediate care facilities for individuals with intellectual disabilities or who are admitted to a hospital from such a facility or hospital;

(f) members receiving hospice services;

(g) persons receiving medical services through the Emergency Aid to the Elderly, Disabled and Children Program pursuant to 130 CMR 450.106: Emergency Aid to the Elderly, Disabled and Children Program, if they do not receive MassHealth Standard, MassHealth CarePlus, or MassHealth Family Assistance;

(h) members who are former foster care individuals and who are eligible for MassHealth Standard until they reach 21 years old or 26 years old, as specified in 130 CMR 505.002(H): Eligibility Requirements for Former Foster-Care Individuals;

(i) members who are American Indians or Alaska Natives who are currently receiving or have 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;

(j) "referred eligible" members, who are

1. persons who receive Supplemental Security Income (SSI) benefits from the Social Security Administration (SSA) and who receive MassHealth Standard under 130 CMR 505.002(A)(2) or 130 CMR 519.002(B);

2. persons who receive Transitional Aid to Families with Dependent Children (TAFDC) cash assistance from the Department of Transitional Assistance (DTA) and who receive MassHealth Standard under 130 CMR 505.002(A)(3);

3. children, young adults, and parents and caretaker relatives who receive Emergency Aid to the Elderly, Disabled and Children (EAEDC) cash assistance and who receive MassHealth Standard under 130 CMR 505.002(K) or 130 CMR 519.002(D), MassHealth Family Assistance under 130 CMR 505.005(G) or 130 CMR 519.013(C), or MassHealth CarePlus under 130 CMR 505.008(B);

4. children receiving medical assistance under 130 CMR 522.003: Adoption Assistance and Foster Care Maintenance, because they are receiving Title IV-E or state-subsidized adoption or foster-care assistance;

5. persons who receive extended eligibility for MassHealth Standard under 130 CMR 505.002(L)(1) and (2) or 130 CMR 519.002(C); and

6. persons who receive MassHealth Standard or CarePlus because they are eligible for Refugee Medical Assistance (RMA) under 130 CMR 522.002: Refugee Resettlement Program; and

(k) members whose applicable income for the purposes of calculating copayments is at or below 50% of the FPL.

(2) Members who are inpatients in a hospital do not have to pay a copayment for pharmacy services provided as part of the hospital stay.

(3) Members who are inpatients in a hospital do not have to pay a copayment for pharmacy services provided as part of the hospital stay.

(B)Excluded Services. The following services are excluded from the copayment requirement described in 130 CMR 506.016:

(1) family planning services and supplies such as oral contraceptives, contraceptive devices, such as diaphragms and condoms, and contraceptive jellies, creams, foams, and suppositories;

(2) detoxification and maintenance treatment of an individual for substance use disorders using FDA approved medications (including methadone, buprenorphine, buprenorphine/naloxone, and naltrexone);

(3) 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;

(4) all approved vaccines and their administration, recommended by the Advisory Committee on Immunization Practices (ACIP);