If you're among the 70-million plus Americans that are enrolled in Medicaid, you might have some questions about Medicaid copay.

A copay (or copayment) is a flat fee that you pay on the spot each time you go to your doctor or fill a prescription. For example, if you hurt your back and go see your doctor, or you need a refill of your child's asthma medicine, the amount you pay for that visit or medicine is your copay. Your copay amount is printed right on your health plan. Medication copayments are required for each prescription, including each 30-day (or less) supply of maintenance medications prescribed on an outpatient basis for nonservice-connected conditions. This copayment may change annually. Patient Advocate Foundation's Co-Pay Relief program exists to help reduce the financial distress patients, and their families face when paying for treatment. We believe that no patient should go without life changing medications because they cannot afford them. We are here to help.

Copay For Prescription For Each Prescription

You may have heard about a copay before, but you're confused about what it means and how it affects your benefits when it comes to medical expenses.

In this article, we'll cover everything you need to know about Medicaid copay. We'll discuss what it is, how it may affect your medical costs, who is exempt from it, and more.

What is a Medicaid copay?

Copay Coupons For Prescriptions

You've enrolled in Medicaid because you know that it provides access to healthcare, improves your health, and reduces your anxiety and stress when it comes to medical expenses.

But having Medicaid doesn't always mean that your expenses will be zero. For some health services, you might be required to pay a fee, which is known as a Medicaid copay.

You can check with your healthcare provider about if your required service involves a copay. If it does, you will pay them directly.

A Medicaid copay is also known as an out-of-pocket cost. These costs are decided at the state level administration of the Medicaid program.

A state can decide that there are going to be copays associated with various medical services that are covered by Medicaid. The service can be either inpatient (when you're formally admitted to the hospital) or outpatient (not admitted to a hospital, like tests or consultations) services.

The copay in each state will vary. It is usually a percentage based on the total cost to the state for your medical service.

The copay or out-of-pocket expense will also typically vary based on your income. Medicaid, as a program is designed to provide care to low-income individuals. So, the lower your income bracket, the more likely that your copay will be minimal, or in some cases non-existent.

Some services, and specific types of people, are generally exempt from Medicaid copay, regardless of the state.

Who is exempt from Medicaid copay?

The detailed exemption from Medicaid copay may vary depending on the state, but in general the following groups are exempt from Medicaid copay.

Children
Pregnant women
People who have reached their quarterly limit of Medicaid copay (more details below)
People who are terminally ill, including those in hospice
Medicaid recipients who are living in an institution
Alaska Natives and American Indians who have ever received a treatment from the Indian Health Service, tribal health programs, or under contract health services referral
Women in the Breast and Cervical Cancer Treatment Medicaid Program are exempt from alternative out of pocket costs (copays if your income is above FPL)

One critical factor to keep in mind is that you’ll most likely still have access to medical care even if you don’t fall in the exempt group and can’t pay your out-of-pocket expense, especially if you’re severely ill. But if you aren’t exempt, you might be billed for the unpaid copay later on.

What services may require a Medicaid copay?

There are a variety of services that might require a copay, including the following.

In patient services, where you are officially admitted to the hospital
Outpatient services, like tests, consultations, clinic appointments, etc.
If you have to go the emergency room for non-emergency care
Prescription drugs

What services are exempt from Medicaid copay?

Services that are exempt from a Medicaid copay include the following.

Emergency services
Family planning services like contraceptives, sterilizations, birth control methods, etc.
Pregnancy-related medical services
Preventative services, like immunizations, screenings, clinical and behavioral interventions, counseling, etc.

How do I know what my Medicaid copay will be?

Before you calculate your copay, you need to figure out if there is an out-of-pocket expense associated with your medical service in the first place.

To find out if there is a copay, you can simply ask your provider.

For example, if you need to fill a prescription, you can ask the pharmacy about a copay. Or, if you need to see your doctor, check with him or her to see if it qualifies as a preventative visit (no copay) or as an outpatient service (may require copay).

If you do find out that there is an expense associated with your visit, then the amount you will owe depends on something known as the FPL, or Federal Poverty Level, and how your income relates to it.

The copay will depend on what state you’re in, and how much the state pays for your medical service, but more on that later.

First, let’s discuss what FPL is, so you can better estimate what your copay expenses might be, based on the type of services you need.

What is the Federal Poverty Level (FPL)?

The Federal Poverty Level (FPL) is a measure of income issued yearly by the Department of Health and Human Services (HHS).

The HHS uses FPL to decide whether you might qualify for medical programs and benefits, including Medicaid, based on your income.

For 2020, here are the numbers to determine Federal Poverty Level.

For one individual - An annual income of $12,760.
For a family of 2 people - An annual household income of $17,240.
For a family of 3 people - An annual household income of $21,720.
For a family of 4 people - An annual household income of $26,200.
For a family of 5 people - An annual household income of $30,680.
For a family of 6 people - An annual household income of $35,160.
For a family of 7 people - An annual household income of $39,640.
For a family of 8 people - An annual household income of $44,120.

A note about income, AGI, and MAGI

We listed the incomes based on the number of people in your household that determine whether you fall over or under the Federal Poverty Level (FPL).

But we have to go one step further and briefly describe how the Health and Human Services (HHS) defines income, when it comes to your eligibility for benefits.

This is where AGI and MAGI come in (we promise this is related to Medicaid copay).

AGI - AGI is your adjusted gross income. It is your income that is deemed taxable after you deduct any eligible expenses, etc.

MAGI - When HHS looks at your income, and whether it falls above or below FPL, they do it based on MAGI, which stands for modified adjusted gross income. It is your AGI, plus any of the following:

Untaxed foreign income
Social Security benefits that are non-taxable, if any
Any tax exempt interest you’ve earned in the previous fiscal year

Another few things to note about MAGI.

For most Medicaid recipients, MAGI and AGI are very close
If you earn Supplemental Security Income (SSI), it is not included in MAGI
Your tax return will not have a MAGI line, because it is only calculated by HHS for health benefit purposes

Ok, now that you’ve got an idea of what FPL is, and how it is calculated by HHS, using MAGI, let’s tie it all back into your Medicaid copay.

Copay For Prescriptions