What are the Copayments?

New Information about copayments proposed for members in the new adult group beginning         January 1, 2015, subject to approval by the Centers for Medicare and Medicaid         Services can be found at the following link: Proposed Copay Changes 1/1/15

Some people who get AHCCCS Medicaid benefits are asked to pay copayments for some of the AHCCCS medical services that they receive.

Some changes to copayments became effective January 1, 2014. These changes to copayments can be found in the new AHCCCS rule AAC R9-22-711 which started January 2014. For a limited time persons who are eligible in the AHCCCS Care Program and persons who are determined AHCCCS eligible on and after January 1, 2014 in the new Adult Group will not have any co-payments starting January 1, 2014. Co-payments for persons in AHCCCS Care and the new adult group are planned for the future. Members will be told about any changes in copayments before they happen.

Copayments are never charged to the following persons:

  • Children under age 19
  • People determined to be Seriously Mentally Ill (SMI) by the Arizona Department of Health Services
  • Individuals up through age 20 eligible to receive services from the Children's Rehabilitative Services program
  • People who are acute care members and who are residing in nursing homes, or residential facilities such as an Assisted Living Home and only when the acute care member’s medical condition would otherwise require hospitalization. The exemption from copayments for acute care members is limited to 90 days in a contract year
  • People who are enrolled in the Arizona Long Term Care System
  • People who are eligible for Medicare Savings Programs only*
  • People who receive hospice care
  • American Indian members who are active or previous users of the Indian Health Service, tribal health programs operated under P.L. 93-638, or urban Indian health programs
  • Women in the Breast & Cervical Cancer Treatment Program
  • Receiving child welfare services under Title IV-B on the basis of being a child in foster care or receiving adoption or foster care assistance under Title IV-E

  • * NOTE: Copayments referenced in this section means copayments charged under Medicaid (AHCCCS). It does not mean a person is exempt from Medicare copayments.

In addition, copayments are never charged for the following services for anyone:

  • Hospitalizations
  • Emergency services
  • Family Planning services and supplies
  • Pregnancy related health care and health care for any other medical condition that may complicate the pregnancy, including tobacco cessation treatment for pregnant women
  • Well visits and preventive services
  • Services paid on a fee-for-service bases

Nominal (Low) Copays for Some AHCCCS Programs

Individuals eligible for AHCCCS through any of the following programs are subject to nominal copayments. The copays apply unless a copay is not charged for the above reasons:

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 or by going to myahcccs.com. You can also check your health plan's website for more information.

Most people who get AHCCCS benefits are asked to pay the following nominal copayments for medical services:

Nominal Copay Amounts for Some Medical Services
Service Copayment
Prescriptions $2.30
Out-patient services for physical, occupational and speech therapy $2.30
Doctor or other provider outpatient office visits for evaluation and management of your care $3.40

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.

People with Required Copayments

Families with Children that are no Longer Eligible Due to Earnings - Transitional Medical Assistance (TMA)

If a family is no longer eligible for any AHCCCS program due to higher income that they get from working, they may still get AHCCCS benefits through the Transitional Medical Assistance (TMA) program. Adults on TMA have to pay higher copays for some medical services and will need to pay the copays in order to get the 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.

Copayment Amounts for Persons Receiving TMA Benefits
Service Copayment
Prescriptions $2.30
Doctor or other provider outpatient office visits for evaluation and management of your care $4.00
Physical, Occupational and Speech Therapies $3.00
Outpatient Non-emergency or voluntary surgical procedures $3.00

Pharmacists and Medical Providers can refuse services if the copayments are not made.

A family receiving TMA will not be required to make the copays if the total amount of the copays made is more than 5% of the gross family income (before taxes and deductions) during a calendar quarter (January through March, April through June, July through September, and October through December.)

When a family receiving TMA benefits thinks that they have paid copays that equal 5% of the family's total quarterly income and AHCCCS has not already told them this has happened, they should send copies of receipts or other proof of how much they have paid to AHCCCS, 801 E. Jefferson, Mail Drop 4600, Phoenix, Arizona 85034.

If you think that your income or circumstances have changed, contact your eligibility office right away.