What are the Copayments?

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

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
• 
  * 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
• 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 following are the copays that apply unless a copay is not charged for the above reasons:

• AHCCCS for Families with Children (1931)
• Young Adult Transitional Insurance (YATI) for young adults who were in foster care
• State Adoption Assistance for Special Needs Children who are being adopted
• Receiving Supplemental Security Income (SSI) through the Social Security Administration for people who are age 65 or older, blind or disabled
• SSI Medical Assistance Only (SSI MAO) for individuals who are age 65 or older, blind or disabled
• Freedom to Work (FTW)
• Breast and Cervical Cancer Treatment Program (BCCTP) for Women
• 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

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:

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

1. 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.

2. People with High Medical Expenses Who Are not Eligible for any Other AHCCCS Program Because of Their Income - MED Program

   People with high medical expenses who are not eligible for any other AHCCCS program because of their income may get AHCCCS benefits through the Medical Expense Deduction (MED) program. People on MED have to pay higher copays for some medical services and will need to pay the copays in order to get the services.

   IMPORTANT: The copays for people in the MED program may change because of a lawsuit. If there are changes to these copays in the future, AHCCCS will tell you.

   Copayment Amounts for Persons on MED

   Service	Copayment
   Generic Prescriptions and Brand Name Prescriptions when there is no generic	$4.00
   Brand Name Prescriptions when there is a generic that can be used	$10.00
   Non-emergency use of an emergency room	$30.00
   Doctor office visits	$5.00

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

   If your circumstances have changed and you don't think you belong in the MED program, contact your eligibility office to ask them to review your eligibility.

3. Other Adults - AHCCCS Care Program (Childless Adults)

   An adult may get AHCCCS benefits through the AHCCCS Care Program. An adult is on AHCCCS Care because the adult:

   • Does not have an eligible deprived child living with them (see Arizona Administrative Code R9-22-1427),
   • Is not pregnant,
   • Is not aged 65 or over, or
   • Is not disabled.

   People on AHCCCS Care have to pay higher copays for some medical services and will need to pay the copays in order to get the services.

   IMPORTANT: The copays for people in the AHCCCS Care Program may change because of a lawsuit. If there are changes to these copays in the future, AHCCCS will tell you.

   Copayment Amounts for Persons on AHCCCS Care Program

   Service	Copayment
   Generic Prescriptions and Brand Name Prescriptions when there is no generic	$4.00
   Brand Name Prescriptions when there is a generic that can be used	$10.00
   Non-emergency use of an emergency room	$30.00
   Doctor office visits	$5.00

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

   If your circumstances have changed and you don't think you belong in the AHCCCS Care program, contact your eligibility office to ask them to review your eligibility.