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
- Adult Group who have income above 106% FPL effective 1/1/2015; and
- 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.
* = Applies to primary care physician, specialist, or other health care provider visits not in a hospital Emergency Room setting.
||Population and Copay Amounts
||Adult Group over 106% FPL
(proposed for 1/1/15)
(current and for 1/1/15)
(current and for 1/1/15)
||$4.00 per drug
||$5.00 or $10.001per visit
|*Outpatient professional therapies
||$2.00, $4.00 or $5.002 per visit
||$30.00 or $50.004 per surgery
|Inpatient Hospital Stay
||$75 per stay
|Non-emergency use of the Emergency Room
||$8.00 per visit
|Taxis for Non-emergency Medical Transportation in Pima and Maricopa Counties
||$2.00 per trip
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:
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 adding more information to the initial DRAFT State Plan Amendment (SPA)
that was posted. The revised DRAFT SPA contains a description of the Cost Sharing Limitations
in Federal Regulation 42 CFR 447.56, including the 5% copay aggregate limit and the populations
and services which are exempt from copays. 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 rev. 10/10/14
Comments are being accepted through November 7, 2014, and can be submitted as follows:
Proposed and Final Copay Rules for an effective date of 1/1/2015
Attn: Office of Intergovernmental Relations
801 E. Jefferson St., MD 4200
Phoenix, AZ 85034
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.