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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;
  • Services provided by an individual’s Primary Care Provider (PCP) or Health Home Provider (HHP) or another provider selected to cover for an individual’s PCP or HHP in the same clinic (referrals to specialists are not exempt);
  • Substance use disorder treatment; and
  • Vaccines and vaccine administration.

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