PM 20-03-04-a: Customer Copays

WAG 20-03-04-a

HFS reduces the payment made to the hospital, doctor, or pharmacy by the amount of the copay. The hospital, doctor, or pharmacy is responsible for collecting the copay from the customer.

Hospitals, doctors, and pharmacies cannot refuse to care for someone who has not paid their copay.

Programs Exempt from Copays

Revised Text.Copays are not required for the following medical programs:

  • FamilyCare;
  • Aid to the Aged, Blind or Disabled (AABD); and
  • Affordable Care Act (ACA) Adults.

Programs Requiring Copays

New TextThe following programs require copays:

  • Health Benefits for Workers with Disabilities (HBWD) see PM 06-24-07; and
  • Veterans Care (VC).

Copays for Medicaid Services

$3.90 for each physician or clinic visit. This includes visits to physicians, chiropractors, podiatrists, optometrists, and Behavioral Health clinical services;

$3.90 for each emergency room visit in a non-emergency;

$3.90 for each brand name prescription, and $2 for generic or prescribed over the counter medication;

$3.90 for each day of inpatient hospital visits (copays are limited to half of the Department's rate for the first day).

Persons Who Are Exempt From Copays

The following is a complete list of persons excluded from copays. Copays do not apply to a person who:

  • is pregnant (including Revised Text.postpartum);
  • is under age 19 on an Assist case;
  • is in a DCFS (category 98) case;
  • receives hospice care;
  • lives in an institution (hospitals, nursing facilities, or intermediate care facilities for persons with an intellectual disability);
  • lives in a supportive living facility;
  • lives in a sheltered care facility;
  • lives in a State certified, licensed, or contracted residential setting who, as a condition of receiving care in that program, is required to pay all of their income, except an authorized protected amount for personal use, for the cost of their residential care program. These settings include a residence provided by an agency licensed for Community Integrated Living Arrangement (CILA) services, a Supportive Living Facility (SLF), or a residential facility licensed by the Department of Children and Family Services (DCFS);
  • is enrolled in the Breast & Cervical Cancer (BCC) treatment program; or
  • is an American Indian or Alaskan Native.

There are no copays for the following, even if they are provided to an adult:

  • family planning services and contraceptive supplies;
  • emergency services (does not include non-emergency services provided in a hospital emergency room);
  • services paid by Medicare; and
  • certain medications, including insulin, AIDS drugs, chemotherapy drugs, hemophilia drugs, certain cardiovascular drugs, and over-the-counter drugs.