Copayments

Information about copayments proposed for members in the Adult Group with income above 106% FPL 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


What are Copayments (Copays)?

* 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.

Copays are not charged to the following persons:

  • People 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 copays for acute care members is limited to 90 days in a contract year
  • People who are enrolled in the Arizona Long Term Care System (ALTCS)
  • People who are Qualified Medicare Beneficiaries
  • 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
  • People in the Breast & Cervical Cancer Treatment Program
  • People 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 regardless of age.
  • People who are pregnant and throughout the postpartum period following the pregnancy
  • People in the Adult Group (for a limited time*)
  • *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 for 1/1/2015 and can be found on the Proposed Copay Changes tab. Members will be told about any changes in copays before they happen.

 

In addition, copays are not 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 such as pap smears, colonoscopies, and immunizations
  • Services paid on a fee-for-service basis
  • Provider preventable services
  • Services received in the emergency department
 

People with Nominal (Optional) Copays

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:

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

Detailed service codes and category description that comprise each of the above categories are outlined on the attached Document [Excel]

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 (Mandatory) Copays

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.

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

Detailed service codes and category description that comprise each of the above categories are outlined on the attached Document [Excel]

5% Limit on All Copays

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:

AHCCCS
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.