Copay Information

Beginning January 1, 2014, some services were assigned copay amounts for Medicaid Members. The following copays apply to claims with a date of service on or after January 1, 2014:​

​ServiceTier 1
Up to 50% FPL		​Tier 2
50.01 to 100% FPL		Tier 3
100.01% of FPL
  • ​Inpatient Hospital (Acute Care 11x)
​$0$35​$75
  • Office Visit (Physicians and Nurse Practitioners)
    (99201-99205, 99212-99215 only for office visits for new and established patients based on level of care)​
​$0​$2​$4
  • Non-Emergency use of Emergency Department - Hospital only
    (Lowest level (99281) of Emergency Room visits in hospitals. The definition of this visit is an emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and straightforward medical decision making.)​
​$8​$8​$8
  • Any outpatient surgical services rendered in a physician’s office, ASC or Outpatient Hospital excluding emergency rooms.​
​$0​$2​$4

Member and Providers can access copay and member eligibility information through AVRS by calling 1-888-483-0793.

Gainwell will return a copay amount for the start date of service if the provider inquires on a date range. No copays will be listed for members on the exemption list. Remittance advices will be modified to include the copay amount that was deducted.

Beginning May 1, 2014, Pharmacy co-payments are the same for all Medicaid members regardless of income, however, out of pocket maximums do apply:

​Total Allowed Charge​Co-payment
$0.00 - $5.00​​$0
​$5.01 - $10.00​$0.50
​$10.01 - $25.00​$1.00
​$25.01 - $50.00​$2.00
​$50.01 and above​$3.00

Maximum Out of Pocket (OOP):
Each calendar year quarter, Members will have a maximum OOP​ payment. The OOP is the most the Member will ever be required to pay in any given quarter regardless of the number of healthcare services received. The following table shows the OOP for each tier level.

​Tier Level​Out of Pocket Maximum
1 (Up to 50% FPL)​​$8
​2 (50.01 - 100% FPL)​$71
​3 (100.01% FPL and above)​$143

Quarters

  • January 1 – March 31
  • April 1 – June 30
  • July 1 – September 30
  • October 1 – December 31

Exemptions:

The following populations and services are exempt from copays:

  • Pregnant Women including pregnancy-related services up to one year post-partum;
  • Children under age 21;
  • Native American and Alaska natives;
  • Intermediate care facility or MR services;
  • Preventive services for children under age 18;Provider-preventable services;
  • Individuals in nursing homes,
  • Receiving Hospice services,
  • Medicaid waiver services, or covered through the Breast and Cervical Cancer Treatment Program;
  • Family planning services and emergency services.

Additional exemptions for Pharmacy include diabetic testing supplies syringes and needles, the BMS-approved Home Infusion supplies and three-day emergency supplies.

All vaccines covered through the Pharmacy Point-of-Sale system.