What is Copay - Insurance copayment - Meanign and Definitiono

what is copay?

Copayments are fixed dollar amounts (for example, $15) you pay for covered health service to the provider, usually when you receive the service.

Definition of terms: Copayment (copay): A predetermined fee for physician office visits, prescriptions or hospital services that the member pays at the time of service.

Medicare Definition

• A copayment amount for each service you get in an outpatient visit. For each service, this amount generally can’t be more than the Part A inpatient hospital deductible. If you get hospital outpatient services in a critical access hospital, your copayment may be higher and may exceed the Part A hospital stay deductible.

• All charges for items or services that Medicare doesn’t cover.

Example: Mr. Davis needs to have his cast removed. He goes to his local hospital outpatient department. The hospital charges $150 for this procedure. His copayment amount for this procedure, under the outpatient prospective payment system, is $20. Mr. Davis has paid $85 of his $155 Part B deductible. To have his cast removed, Mr. Davis must pay $90 ($70 remaining deductible amount + $20 copayment amount). The amount you pay may change each year. The amount you pay may also be different for different hospitals. Note: If you have a Medigap (Medicare Supplement Insurance) policy, other supplemental coverage, or employer or union coverage, it may pay the Part B deductible and copayment amounts

Medicaid Co-payments guidelines

Co-payment and co-insurance apply to clients covered by the Non-Traditional Medicaid Plan. Clients are  required  to  make  a  co-payment  for  the  types  of  services  listed  below.  The  provider  is  responsible  to  collect the co-pay at the time of service or bill the client. The co-payment shall be collected even if the  client has other third party coverage. An exception to this policy is that co-payments are not taken out  for Medicare Crossover claims.

Medicaid will automatically reduce the payments for each of these services by the indicated co-payment  or  coinsurance  amounts  at  the  time  of  reimbursement.  The  amount  of  the  co-pay  is  described  on  the  attached Benefit Chart for Non-Traditional Medicaid Plan.

•  Hospital inpatient and non-emergency use of Emergency Department
•  Outpatient hospital services, including free standing surgical center services
•  Office visits for physician services, except preventive services and immunizations
•  Vision care over $30 a year
•  Pharmacy Services
•  Physical Therapy
•  Occupational Therapy

Co-pay Maximum Per Client

The out-of-pocket maximum is $15.00 per month for pharmacy co-pays.  For inpatient procedures, the  maximum is $220 per year.  For physician and outpatient procedures, the combined maximum out-of-pocket is $100 per year
Which Providers can charge a Co-pay?

• Chiropractors

• Podiatrists

• Optometrists

• Physical, Occupational & Speech Therapists

• Hospitals (outpatient services except ER)

• Physicians & mid-levels (NP or PA)

• FQHCs & RHCs

How do I know to collect a Co-pay?

• First check eligibility on the participant to see if they are Medicaid eligible and co-pay exempt or not


• Then determine whether or not the services you are about to render are subject to Co-pay by using this guide.

Who is exempt from Co-pay?

• A child with family income less than 133% FPG

• An adult with family income less than 100% FPG

• A pregnant or post-partum woman

• Children in foster care

• Those women who are eligible due to breast or cervical cancer

• Those on Hospice

• Those in Long Term care facilities

• Those on A&D or DD waiver

• Those who have primary insurance other than Medicaid

• Native Americans/Alaskan Natives

• Members who have reached a 5% CAP (a member who has paid out 5% or more of their monthly income is exempt for the remainder of the month)

• Workers with Disabilities Providers do not need to remember all these exemptions – the eligibility information provided by the system will reflect them.

What services can a provider charge a Co-pay for?

• Chiropractic services-services performed by a chiropractor.

• Podiatrist services-services performed by a podiatrist.

• Optometrist services- General Ophthalmological services billed by an Optometrist

• Physical, Occupational & Speech Therapy Services rendered in the therapist’s office or as an Outpatient hospital service

What services are subject to Co-pay? 

• Outpatient Hospital –any of the services on this list performed in an outpatient hospital setting, except the emergency department

• Physician office visit-services provided at a doctor’s office unless preventive, family planning, or pregnancy-related.

• FQHC & RHC medical encounters, unless preventive, family planning, pregnancy-related or mental health.

Which Services are Co-pay exempt?

• Services performed in an Emergency room

• Services performed by an Urgent care clinic billing as an Urgent Care Facility

• Preventive services

• Family Planning

• Pregnancy related services

• Mental Health Services

• Services rendered that are $36.49 or less for the total claim.

What can I do if a participant doesn’t make their Co-pay?

• You can refuse to render services

• You can waive the Co-pay but you must have a written policy documenting under what circumstances you will waive it

• You can bill the patient

• Whether or not you choose to charge a Co-pay, when both the participant and the visit is subject to Co-pay provisions, the Co-pay amount will be deducted from your reimbursement.

What about the 5% cost-sharing cap?

• The copay will be tracked against the CAP. It is possible the exempt status may not be triggered due to the timing of providers submitting claims. DHW will handle reimbursements to participants should this happen.

• How long will reimbursement to the participant take?

– The length of reimbursement time will vary depending on the situation. I.e. provider billing, number of visits.

How do I know if I have met my 5% 

CAP for Co-pay?

• You must calculate your CAP using the income information you provided Medicaid to determine your eligibility.

• EXAMPLE ONLY: If your family income is $1,635.00 a month you would need to go to 22 qualifying appointments in a month to reach your CAP. (Use this guide to determine “qualifying” appointments)

(Calculation for example: $1635 x 5% = $81.75 (Max out-of-pocket (CAP)) $81.75 divided by $3.65 = 22 visits)

Copayment for commercial insurance

Its differ patient to patient and plan to plan. For example see the different type of plan or treatment and the copayment.

Copayment for different plan


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