States can impose copayments, coinsurance, deductibles, and other similar charges on most
Medicaid-covered benefits, both inpatient and outpatient services, and the amounts that can be charged vary with income. All out of pocket charges are based on the individual state’s payment for that service. Out of pocket costs cannot be imposed for emergency services, family planning services, pregnancy-related services, or preventive services for children. Generally, out of pocket costs apply to all Medicaid enrollees except those specifically exempted by law and most are limited to
nominal amounts. Exempted groups include children, terminally ill individuals, and individuals residing in an institution. Because Medicaid covers particularly low-income and often very sick patients, services cannot be withheld for failure to pay, but enrollees may be held liable for unpaid copayments. States have the option to establish alternative out of pocket costs. These charges may be targeted to certain groups of Medicaid enrollees with income above 100 percent of the federal
poverty level. Alternative out of pocket costs may be higher than nominal charges depending on the type of service, and they are subject to a cap not exceeding 5 percent of family income. In addition, Medicaid enrollees may be denied services for nonpayment of alternative copayments. Cost sharing for most services is limited to nominal or minimal amounts. The maximum copayment that Medicaid may charge is based on what the state pays for that
service, as described in the following table. These amounts are updated annually to account for increasing medical care costs.Out of Pocket Costs
Maximum Nominal Out of Pocket Costs
FY 2013 Maximum Nominal Deductible and Managed Care Copayment Amounts
Maximum Allowable Copayments for Eligible Populations by Family Income (FY 2013)Services and Supplies100% FPL101-150% FPL>150% FPL Institutional Care (inpatient hospital care, rehab care, etc.)
$75
10% of the cost the agency pays for the entire state
20% of cost the agency pays for the entire state
Non-Institutional Care (physician visits, physical therapy, etc.)
$4.00
10% of costs the agency pays
20% of costs the agency pays
Non-emergency use of the ER
$8.00
$8.00
No limit
*within 5% aggregate limit
Drugs
Preferred drugs
Non-preferred drugs
$4.00
$8.00
$4.00
$8.00
$4.00
20% of cost the agency pays
A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.
Let's say your health insurance plan's
for a doctor's office visit is $100. Your copayment for a doctor visit is $20.
- If you've paid your : You pay $20, usually at the time of the visit.
- If you haven't met your deductible: You pay $100, the full allowable amount for the visit.
Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.
Generally plans with lower monthly
have higher copayments. Plans with higher monthly premiums usually have lower copayments.
Related content
- Learn how deductibles and copayments affect your total costs of care
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