MassHealth Monthly Copay Caps

MassHealth mailed notices to members about a monthly cap on copayments beginning July 1, 2021 that will reduce the amount of copayments people with multiple prescriptions per month will have to pay.  However, the wording of the notice has led to widespread confusion with many people thinking their copayments are being raised to the amount of the monthly cap.  MassHealth says it is aware of the confusion and working on a communication strategy to address it.

Federal law requires an income-based monthly or quarterly cap on Medicaid copayments. MassHealth had been using an annual cap of $250 for all income levels. In phase one of moving to an income-based cap,  MassHealth  exempted people with income of 50% FPL or less and cash welfare receipients from copays on July 1, 2020.  On July 1, 2021 it will be implementing Phase 2 by setting monthly caps that range from $10 per month to $60 per month based on income. For the remainder of 2021 both the annual and monthly caps will be in place, but in 2022 monthly caps will replace annual caps. More people will likely reach the monthly cap than those who reached the annual cap, but those who reached the annual cap may have lower savings with the monthly cap. 

Attached is a copy of the notice, and an insert included with the notice 

Pharmacy Facts #166 explaining the change in the copay cap is posted here: https://www.mass.gov/doc/pharmacy-facts-166-june-15-2021-0/download