Federal law permits the Medical Assistance program to require copayments from beneficiaries for medical services. The department requires copayments to help contain the costs of the Medical Assistance program so that you can continue to receive most of the medical care you need at little cost to you.
The following questions and answers will help explain copayments:
No. Copayments are not required for:
- Persons younger than 18 years old. This is any person who has not reached his or her 18th birthday.
- Pregnant women (including the postpartum period)
- Residents of a long term care facility or other medical institution.
- Individuals receiving hospice care.
- Women in the Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program.
- Individuals in the Title IV-B Foster Care and IV-E Foster Care and Adoption Assistance Programs, regardless of age.
No. You will not be asked to pay a copayment for the following services:
- Any services during an emergency situation. An emergency exists when immediate medical care is necessary to prevent death or serious damage to health. If the doctor, hospital or other medical provider does not agree that the situation is a true emergency, you will be responsible to pay the copayment for the service.
- Laboratory services
- If you get an x-ray or certain other medical diagnostic tests or have treatment through nuclear medicine or radiation therapy, there will be no copayment on the physician's part of that service. (A special physician has to "read" the x-ray or test.) However, there is a copayment on the "technical" part of the service which is the actual x-ray or test.
- Family planning services and supplies
- Home health agency services
- Services provided to individuals receiving hospice care.
- Psychiatric partial hospitalization program services
- Funeral Director services
- Renal dialysis services
- Blood and blood products
- Oxygen
- Ostomy supplies
- Rental of durable medical equipment
- Targeted case management service.
- Tobacco cessation counseling services
- Services for which the Medical Assistance fee is less than $2
- Medical examinations are requested by the Department of Human Services to determine public assistance eligibility, employability, mental competency or need for skilled nursing or intermediate care facility services.
- Medical examinations for persons under age 21 provided through the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT).
- More than one of a series of specific allergy tests provided in a 24-hour period.
Adult Medical Assistance beneficiaries: Medical Assistance beneficiaries will not be asked to pay a copayment for specific drugs generally used for the treatment of high blood pressure, cancer, diabetes, epilepsy, heart disease, HIV/AIDS, and psychosis. The Department of Human Services will determine which drugs do not require a copayment and will give that list of drugs to your pharmacy. You may see a copy of this list at your County Assistance Office or at your pharmacy. Additionally, Medical Assistance beneficiaries will not be required to pay a copayment for drugs and vaccines given to you directly by a physician.
The following is a list of copayments you will be asked to pay:
- $3 for each day you are in a hospital, up to $21 for one hospital stay. This includes general hospitals, rehabilitation hospitals or private psychiatric hospitals.
- $1 for each prescription and prescription refill of a generic drug.
- $3 for each prescription and prescription refill of a brand name drug.
- $1 for each x-ray or other medical diagnostic tests or for treatment by nuclear medicine or radiation therapy.
- For outpatient psychotherapy services, the copayment is $.50 per unit of service.
For all other services, where copayments are required, the amount of the copayment is based on the Medical Assistance fee for the service, as shown in the following table:
Medical Assistance, Other Than General Assistance
| MA Fee for the Service | Copayment effective May 15, 2012 |
|---|---|
| $2 - $10 | $0.65 |
| $10.01 - $25 | $1.30 |
| $25.01 - $50 | $2.55 |
| $50.01 or more | $3.80 |
General Assistance (GA) beneficiaries: The amount of the copayments you will be asked to pay is:
- $6 for each day you are in a hospital, up to $42 for one hospital stay. This includes general hospitals, rehabilitation hospitals, and private psychiatric hospitals.
- $1 for each prescription and prescription refill of a generic drug
- $3 for each prescription and prescription refill of a brand name drug
- $2 for each x-ray or other medical diagnostic tests or for treatment by nuclear medicine or radiation therapy.
- For outpatient psychotherapy services, the copayment is $1.00 per unit of service.
For all other services where copayments are required, the amount of the copayment is based on the Medical Assistance fee for the service, as shown in the following table:
General Assistance
| MA Fee for the Service | Copayment effective May 15, 2012 |
|---|---|
| $2 - $10 | $1.30 |
| $10.01 - $25 | $2.60 |
| $25.01 - $50 | $5.10 |
| $50.01 or more | $7.60 |
The copayment will never be more than the amount that the provider would bill to Medical Assistance. For example, if the Medical Assistance fee for a service is $52, and you have other medical insurance that pays the provider $50, your copayment would be the remaining $2 owed to the provider, not $3.
The doctor or other providers of service will tell you what the copayment amount is and will ask you to pay him or her. Each time you pay a copayment, you should ask for a receipt.
If you need a medical service and truly cannot pay the copayment amount at the time you receive the service, the provider will give you the service and bill you for the copayment. You will still owe the provider the copayment for that service and the provider will require you to pay the copayment.
If you think that the provider has made a mistake in charging you a copayment or has charged you too much, talk to the provider. If the provider disagrees with you, and you or your representative still believe that the provider is wrong, contact your County Assistance Office and explain why you think the provider made a mistake. Those complaints that the County Assistance office cannot resolve will be referred to the Office of Medical Assistance Programs in Harrisburg. The Office of Medical Assistance Programs will review your complaint and, if appropriate, take action against the provider which can include requiring the provider to repay to you the amount of the incorrect copayment charge. If you decide to continue to use that provider even though you disagree with the provider's copayment charge, unless and until the County Assistance Office or the Office of Medical Assistance Programs determines that the provider has made a mistake, you still have to make the copayment to that provider for that service.
NOTE: IF YOU HAVE QUESTIONS CONCERNING COPAYMENTS, CONTACT YOUR COUNTY ASSISTANCE OFFICE.
The regulations relating to copayments on Medical Assistance services are found at 55 Pa Code, Chapter 1101 (relating to general provisions), §1101.63(b). These regulations are adopted under the authority of the Public Welfare Code, as amended by Act 42 of 2005, at 62 P.S. § 403 (b) and § 403.1 (a), Section 1916 of Title XIX for the Social Security Act, and federal Medicaid regulations at 42 CFR, Parts 435, 440 and 447.