AHCCCS Copayments

Overview

Historical information about copayments can be found on the "Historical" tab

Information about copayments proposed for members in the Adult Group with income above 106% FPL, subject to approval by the Centers for Medicare and Medicaid Services can be found in the Proposed Copay Changes section of this page. More information will be posted here when available.


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 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

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

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.

NOTE: The information posted on this webpage describing proposed copays is being updated. AHCCCS is working with CMS to revise the State Plan Amendment for copays that AHCCCS plans to charge members in the future. This webpage, and the link to the revised State Plan Amendment, will include the updated changes to copays when they become available. AHCCCS will also provide additional public notice of the changes to copays that AHCCCS will be proposing to charge members.

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, subject to approval by the Centers for Medicare and Medicaid Services. Members will be notified of any changes in copays before they happen. These proposed 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.

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 *(PROPOSED; SEE CHART BELOW) 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 proposed, and will be effective after CMS approval. 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
(PROPOSED)
TMA
(current)
Other
(current)
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 None
Inpatient Hospital Stay $75 per stay None None
Non-emergency use of the Emergency Room $8.00 per visit None None
Taxis for Non-emergency Medical Transportation in Pima and Maricopa Counties $2.00 per trip None None
* = 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

As part of the proposed copay request, 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, upon CMS approval

State Plan Amendment and Public Comment Period

SPA Submitted to CMS submitted 12/3/14

Comments were accepted through November 7, 2014.

Summary of Comments as of 11/07/14


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.

AHCCCS CARE Program

Overview

On September 30, 2016, CMS approved Arizona’s 1115 Waiver for the AHCCCS Program. As part of the Waiver, CMS authorized AHCCCS CARE, a new initiative designed to engage members in the New Adult Group with incomes over 100% of the Federal Poverty Level with the goals of improving health literacy and preparing members for transition to private coverage. The following individuals are exempted from participation in the AHCCCS CARE Program:

  • Persons with a serious mental illness
  • American Indian/Alaskan Natives
  • Individuals considered medically frail
  • The AHCCCS CARE Program also allows for hardship exemptions from the Program requirements for members who meet certain criteria such as: unexpected expenses for home repairs, or transportation costs, or death in the household, or expenses for health care that are not covered by insurance.

All other adults in the New Adult Group who are not otherwise mandated into the AHCCCS CARE program may opt in to the AHCCCS CARE program so they can contribute and receive third party contributions into their AHCCCS CARE accounts. Opt in members will not be required to pay monthly premiums, strategic coinsurance, or participate in the Healthy Arizona program.

Members in the AHCCCS CARE Program will be required to make two types of payments: strategic coinsurance and premium payments. Total payments for strategic coinsurance and premiums will not exceed 5% of household income on a quarterly basis. More information is provided below.

CARE Fact Sheet

Premiums

AHCCCS CARE members will make a monthly premium payment that serves as contribution to the their AHCCCS CARE account. The premium payment belongs to the AHCCCS CARE member and is set at the lesser of 2% household income or $25.

The Account is designed like a flexible spending arrangement and is managed by a third party vendor. Members in good standing will be able to withdraw funds in the Account to to pay for services that are not covered by Medicaid such as dental services, vision services, nutrition counseling, and recognized weight loss programs.

Strategic Coinsurance

Members will pay a retrospective strategic coinsurance that will be no more than 3% of the member’s household income. The strategic coinsurance is based on the services the member has received in the past 6 months. A retrospective strategic coinsurance means that the strategic coinsurance is not paid at the time of service so that members are not denied services and providers are not burdened. The purpose of the strategic coinsurance is to offset program costs. Strategic coinsurance is required for the following services:

  • $4.00 for opioid prescriptions or refills, except for members with cancer or in hospice
  • $8.00 for non-emergency use of the emergency room
  • $5 or $10 for specialist services without a PCP referral*
  • $4.00 for brand name drugs when generic available, except when the physician determines the generic drug is not as efficacious as the brand name drug.

*$5.00 when AHCCCS pays $50.00-$99.99; $10.00 when AHCCCS pays $100.00 or more.