AHCCCS Copayments

 

AHCCCS Copayments (Copays):

Copays are amounts members pay directly to a provider for each item or service they receive at the time of a service. Copays can be mandatory (also known as required) or optional (also known as nominal) as explained below. Certain services and populations are exempt from any copays which means that no mandatory or optional copays will be charged.


Below is a description of current AHCCCS copays, and the new copays AHCCCS proposes to charge certain members beginning January 1, 2015, subject to approval by the Centers for Medicare and Medicaid Services. These new copays include the mandatory copays that AHCCCS plans to charge members in the Adult Group with income above 106% FPL. 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. Members will be notified of any changes in copays before they happen.

Mandatory Copays (also known as "required"):

If a member has a mandatory copay, providers CAN deny services if the member does not pay the mandatory copay. There are certain services and populations which are exempt from any copays as described below, which means that no copay can be charged. Members who can be charged mandatory copays are persons in the:

  1. Adult Group who have income above 106% FPL effective 1/1/2015; and
  2. Transitional Medical Assistance (TMA) program- individuals who were receiving AHCCCS in the Caretaker Relative category who become ineligible due to the increased earnings.

Optional Copays (also known as "nominal"):

If a member has an optional copay, a provider CANNOT deny the service if the member is unable to pay the optional copay. There are certain services and populations that are exempt from any copays as described below, which means that no copay can be charged. Members who can be charged nominal copays are persons in the:

Copays are not charged for the following services:

  • Family planning services and supplies
  • Pregnancy related health care including tobacco cessation treatment for pregnant women
  • Emergency services
  • Services paid on a fee-for-service basis
  • Preventive services, such as well visits, immunizations, pap smears, colonoscopies, and mammograms
  • Provider preventable services

Copays are not charged to the following persons:

  • Children under age 19
  • People determined to be Seriously Mentally Ill (SMI) by the Arizona Department of Health Services
  • People enrolled in the Arizona Long Term Care System
  • People enrolled in the Children’s Rehabilitative Services program
  • People eligible as Qualified Medicare Beneficiaries
  • People who are acute care members residing in nursing homes, or residential facilities 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 receive hospice care
  • People enrolled in the Breast and Cervical Cancer program
  • People who are pregnant and throughout the postpartum period following the pregnancy
  • 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 receiving Title IV-E Adoption Subsidy or Foster Care Assistance
  • People receiving Title IV-B Child Welfare Services
  • 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. Members will be told about any changes in copays before they happen.



AHCCCS Copayments
Service Population and Copay Amounts
  MANDATORY COPAYS OPTIONAL COPAYS
  Adult Group over 106% FPL New Icon
(proposed for 1/1/15)
TMA
(current and for 1/1/15)
Other
(current and for 1/1/15)
Prescription Drugs $4.00 per drug $2.30 $2.30
*Office Visits $5.00 or $10.001per visit $4.00 $3.40
*Outpatient professional therapies $2.00, $4.00 or $5.002 per visit $3.00 $2.30
*Non-emergency surgery3 $30.00 or $50.004 per surgery $3.00 N/A
Inpatient Hospital Stay $75 per stay N/A N/A
Non-emergency use of the Emergency Room $8.00 per visit N/A N/A
Taxis for Non-emergency Medical Transportation in Pima and Maricopa Counties $2.00 per trip N/A N/A
* = Applies to primary care physician, specialist, or other health care provider visits not in a hospital Emergency Room setting.

5% Limit on All Copays

The amount of total copays cannot 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.


Non-Emergency Use of the Emergency Room

All hospitals in Arizona will have their payments reduced by the copay amounts for Non-emergency use of the Emergency Room as described above. As such, it is expected that all hospitals will charge members in the Adult Group for Non-emergency use of the Emergency Room, beginning 1/1/15

State Plan Amendment and Public Comment Period

AHCCCS is accepting public comments on the DRAFT State Plan Amendment to implement the proposed copays found on the link below.

DRAFT SPA re Copays

Comments are being accepted through September 8, 2014, and can be submitted as follows:
Email: AHCCCSCoPays@azahcccs.gov

Mail: AHCCCS
Attn: Office of Intergovernmental Relations
801 E. Jefferson St., MD 4200
Phoenix, AZ 85034

Proposed and Final Copay Rules for an effective date of 1/1/2015
1$5.00 when AHCCCS pays $50.00-$99.99; $10.00 when AHCCCS pays $100.00 or more.
2$2.00 when AHCCCS pays $20.00-$39.99; $4.00 when AHCCCS pays $40.00-$49.99; $5.00 when AHCCCS pays $50.00 or more.
3Applies to non-emergent surgeries performed in office, outpatient non-emergency room settings, and ambulatory surgical centers.
4$30.00 when AHCCCS pays $300.00-$499.99; $50.00 when AHCCCS pays $500.00 or more.