Cost Sharing Out of Pocket Costs

Out of Pocket Costs

States can impose copayments, coinsurance, deductibles, and other similar charges on most Medicaid-covered benefits, both inpatient and outpatient services, and the amounts that can be charged vary with income. All out of pocket charges are based on the individual state’s payment for that service.

Out of pocket costs cannot be imposed for emergency services, family planning services, pregnancy-related services, or preventive services for children. Generally, out of pocket costs apply to all Medicaid enrollees except those specifically exempted by law and most are limited to nominal amounts. Exempted groups include children, terminally ill individuals, and individuals residing in an institution. Because Medicaid covers particularly low-income and often very sick patients, services cannot be withheld for failure to pay, but enrollees may be held liable for unpaid copayments.

States have the option to establish alternative out of pocket costs. These charges may be targeted to certain groups of Medicaid enrollees with income above 100 percent of the federal poverty level. Alternative out of pocket costs may be higher than nominal charges depending on the type of service, and they are subject to a cap not exceeding 5 percent of family income. In addition, Medicaid enrollees may be denied services for nonpayment of alternative copayments.

Maximum Nominal Out of Pocket Costs

Cost sharing for most services is limited to nominal or minimal amounts. The maximum copayment that Medicaid may charge is based on what the state pays for that service, as described in the following table. These amounts are updated annually to account for increasing medical care costs.

FY 2013 Maximum Nominal Deductible and Managed Care Copayment Amounts 

 Deductible  $2.65
 Managed Care Copayment  $4.00

MAXIMUM ALLOWABLE COPAYMENTS FOR FY 2013 

Services and Supplies Eligible Populations by Family Income
<100% FPL                 101-150% FPL                   >150% FPL
Institutional Care (inpatient hospital care, rehab care, etc.) $75 10% of the cost the agency pays for the entire state 20% of cost the agency pays for the entire state
Non-Institutional Care (physician visits, physical therapy, etc.)

 

$4.00

 

10% of costs the agency pays 20% of costs the agency pays
Non-emergency use of the ER $8.00 $8.00

No limit

*within 5% aggregate limit

Drugs
Preferred drugs
Non-preferred drugs

 

$4.00
$8.00

 

$4.00
$8.00

 

$4.00
20% of cost the agency pays