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Information about copayments proposed for members in the
Adult Group with income above 106% FPL,
subject to approval by the Centers for Medicare and Medicaid Services can be found at the following
link: Proposed Copay Changes.
More information will be posted here when available.
* NOTE: Copays under this section
are copays charged under Medicaid (AHCCCS). This section does not describe copay requirements under Medicare.
Some people who get AHCCCS Medicaid benefits are asked to pay copays for some
of the AHCCCS medical services that they receive. Copays can be mandatory (also known as required) or
optional (also known as nominal) as explained below. Some people and certain services are exempt from
copays which means that no mandatory or optional copays will be charged as explained below.
*For a limited time persons who are eligible in the Adult Group will not have any copays.
Members in the Adult Group include persons who were transitioned from the AHCCCS Care
program as well as individuals who are between the ages of 19-64, and who are not entitled to Medicare,
and who are not pregnant, and who have income at or below 133% of the Federal Poverty Level (FPL) and who
are not AHCCCS eligible under any other category. Copays for persons in the Adult Group with income over 106% FPL are planned and can be
found on the Proposed Copay Changes tab. Members will be told about any changes in
copays before they happen.
Individuals eligible for AHCCCS through any of the programs below may be charged
nominal copays, unless they are receiving one of the services above that cannot be charged a copay
or unless they are in one of the groups above that cannot be charged a copay. Nominal copays are also
called optional copays. If a member has a nominal copay,
then a provider cannot deny the service if the member states that s/he is unable to pay the copay.
Members in the following programs may be charged nominal copays unless they are receiving one of the
services above that cannot be charged a copay or unless they are in one of the groups above that cannot
be charged a copay. Members in the following programs may be charged a nominal copay by their provider:
Ask your provider to look up your eligibility to find out what copays you may have. You can also find out
by calling your health plan member services representative. You can also check your health
plan's website for more information.
AHCCCS members with nominal copays may be asked to pay the following nominal copays
for medical services:
Detailed service codes and category description that comprise each of the above categories are
outlined on the attached
Medical providers will ask you to pay these amounts but will NOT refuse you services if you
are unable to pay. If you cannot afford your copay, tell your medical provider you are unable to pay these
amounts so you will not be refused services.
Some AHCCCS members have required (or mandatory) copays unless they are receiving one of the services
above that cannot be charged a copay or unless they are in one of the groups above that cannot be
charged a copay. Members with required copays will need to pay the copays in order to get the services.
Providers can refuse services to these members if they do not pay the mandatory copays. Mandatory copays
are charged to persons in Families with Children that are no Longer Eligible Due to Earnings - also
known as Transitional Medical Assistance (TMA)
Adults on TMA have to pay required (or mandatory) copays for some medical services.
If you are on the TMA Program now or if you become eligible to receive TMA benefits later, the notice
from DES or AHCCCS will tell you so. Copays for TMA members are listed below.
The amount of total copays can not be more than 5% of the family’s total income during a calendar quarter
(January-March, April-June, July-September, and October-December). If this 5% limit is reached, no more
copays will be charged for the rest of that quarter. AHCCCS has a process to track cost sharing.
If a member thinks that the total copays they have paid are more than 5% of the family's total quarterly
income and AHCCCS has not already told them, the member should send copies of
receipts or other proof of how much they have paid to:
801 E. Jefferson
Mail Drop 4600
Phoenix, Arizona 85034
If a member’s income or circumstances have changed, it is important to contact the eligibility office right away.