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Copayment
A copayment is a charge that the member must pay to the provider of service when the service is covered under Medicaid. No provider participating in the Medicaid program may deny care or services to a member who is eligible for the care or services because of the member's inability to pay a copayment. An assertion that the person is unable to pay establishes inability to pay. However, this does not remove the member's liability for these charges, and it does not preclude the provider from attempting to collect the copayment.
| a. Drugs |
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| The member must pay a copayment for new and refill prescription drugs as follows:
- $1.00 for generic drugs and preferred brand-name drugs.
- $2.00 for non-preferred brand-name drugs for which the cost to the state is $25.01 to $50.00.
- $3.00 for non-preferred brand-name drugs for which the cost to the state is $50.01 or more.
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| b. Other Services |
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The member must pay a $1.00 copayment for the total services rendered on a given date for the following types of services:
- Chiropractor services
- Physical therapists
- Podiatrist services
The member must pay a copayment of $2.00 for the total services rendered on a given date for the following types of service:
- Ambulance services
- Audiologist services
- Hearing aid dealer services
- Medical equipment and appliances
- Optician services
- Optometrist services
- Orthopedic shoes
- Prosthetic devices and sickroom supplies
- Psychologist services
- Rehabilitation agency services
The member must make a copayment of $3.00 for the total covered service rendered on a given date for:
- Dental treatment
- Hearing aids
- Services rendered in a physician (MD/DO) office visit
Dually eligible Medicare and Medicaid members must make a copayment of $1.00 for Medicare Part B (crossover) claims submitted to Medicaid for services in which Medicaid collects a copayment.
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| c. Exemptions |
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Copayment is not applicable to the following services:
- Services provided to members under age 21. The member's age is indicated on the member's Medical Assistance Eligibility Card.
- Family planning services (oral contraceptives, contraceptive devices).
- Services provided to members in nursing facilities, intermediate care facilities for the mentally retarded, or psychiatric institutions.
Exceptions: Copayment is required for:
- Residents in a noncertified facility or noncertified bed,
- Nursing facility residents who have transferred resources, or
- Medically Needy members who reside in a nursing facility.
Medicaid cannot make payment for nursing care for these residents; therefore they are not exempt from copayments.
- Any service provided to pregnant women. Members have been advised that if they wish to be exempt from copayment, they are responsible to inform the providers or their income maintenance worker if they are pregnant.
- Services provided by an HMO.
- Emergency services. Emergency services are those services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain), that the absence of immediate attention could reasonable be expected to result in
- Placing the member's health in serious jeopardy,
- Serious impairment to bodily functions, or
- Serious dysfunction to any bodily organ or part.
Diagnosis codes are used indicate the emergency service exemption from copayment. The diagnosis codes meeting the copayment exemption are provided as follows:
| Click here for Diagnosis Codes |
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