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Medicaid Cost Sharing

Cost sharing is a small portion of a medical bill. A cost share may be charged when you receive a medical service. This is often called a co-insurance or co-pay. Cost sharing is paid directly to your health care provider at the time you receive medical care. You may still receive services even if you are unable to pay the cost share at the time of the service. If you do not pay your cost share, the provider may report you to collections for the amount of the cost share and may decline to schedule future appointments with you until you pay your cost share.

Individuals Exempt from Cost Sharing

Some individuals do not have a cost share for medical services. Individuals exempt from cost sharing include:

  • Children under age 21;
  • Individuals receiving hospice care;
  • Individuals residing in a long-term care facility or receiving home and community-based services;
  • American Indians who have ever received an item or service furnished by an Indian Health Services (IHS) provider or through referral under contract health services; and
  • Individuals eligible for Medicaid through the Breast and Cervical Cancer program.

Services Exempt from Cost Sharing

Some medical services do not have a cost share. Services exempt from cost sharing include:

  • True emergency services
  • Family planning services and supplies
  • Services relating to a pregnancy, postpartum condition, a condition caused by the pregnancy, or a condition that may complicate the pregnancy;
  • Provider-preventable services
  • Laboratory services
  • Psychiatric inpatient and rehabilitation services;
  • Radiological services; and
  • Substance use disorder treatment.

If you are enrolled in the Primary Care Provider Program or the Health Home Program and you see your PCP or another provider selected to cover for your PCP in the same clinic, you will not be charged a cost share. If you see a specialist in the same clinic as your PCP, you will be required to pay the cost share.

Cost Sharing Amounts

The table below contains the cost sharing amounts for covered Medicaid services. The cost sharing amounts are also listed in the Medicaid Recipient Handbook.

Service

Cost Sharing Amount

Ambulatory Surgical Centers

5% up to $50.00

Chiropractic Services

$1.00 for each procedure

Dental Services

$3.00 per procedure

Dentures $3.00 for each denture or reline of dentures

Diabetes Education

$3.00 per unit of service

Dieticians and Nutritionist Services $3.00 per visit

Durable Medical Equipment, Supplies, and Prosthetic Devices

5% of allowable reimbursement

Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC)

$3.00 per encounter

Independent Mental Health Practitioners

$3.00 per procedure

Inpatient Hospital Services

$50.00 for each admission

Mental Health Clinics

5% of allowable reimbursement

Nutrition Services

$2.00 per day for Enteral
$5.00 per day for Parenteral

Optometric Services

$2.00 per visit

Optical Supply $2.00 per procedure

Outpatient Hospital Services

5% of allowable reimbursement up to maximum $50.00

Physician Services

$3.00 per visit

Podiatry Services

$2.00 per visit

Prescription Drugs

$3.30 for each brand name prescription
$1.00 for each generic prescription