If you are part of Pennsylvania’s Medical Assistance Program, which is the state’s name for Medicaid, you may be wondering if you are required to pay for any of your medical care at all.


We’ve put together a guide on Medicaid copays in Pennsylvania.


What is Medicaid?

Medicaid is a federal health insurance program, but it is administered on a state-by-state basis. That means there are different rules about the program across the United States, including who is eligible. It is different from the Medicare program.


The purpose of Medicaid is to enable people with low income and few resources access to healthcare. Each state program pays for Medicaid recipients’ medical assistance. In Pennsylvania, a copay is often required to help contain the costs of the Medicaid program so more people can benefit from it.


Medicaid provides a wide range of benefits and helps pay for doctor visits, hospital stays, and even home health care. But coverage varies by state.


Does Medicaid cover prescriptions?

According to federal Medicaid law, prescription medication coverage is optional and individual states get to decide whether or not to cover the cost of prescriptions. However, all states currently provide coverage for outpatient prescription drugs to any individual eligible for Medicaid.


In fact, there are laws that require pharmaceutical companies participating in the Medicaid program to provide prescriptions at a large discount in order to make them more affordable. That allows Medicaid money to be spread around to more people.


Just because Medicaid covers prescriptions doesn’t mean any and all prescriptions written by your doctor will be free. You may have to pay a small fee, and doctors can be somewhat limited in the kinds of medications they prescribe. Some drugs even require prior authorization from Medicaid before doctors can prescribe them to Medicaid patients.


Residents of Pennsylvania can find a list of covered drugs on the Department of Human Services Preferred Drug List.


What is a copay?

A copay is a small amount of the total cost of your care that you will be required to pay to a provider, even if you are covered by Medicaid. Not all health services will require you to pay a fee out of pocket, but you should ask your health provider if they charge a co-pay when you make your appointment.


Because Medicaid is administered differently by each state, there are different rules for how much a copay can cost. It will often vary according to your income.


States can impose copayments, coinsurance, deductibles, and other similar charges on most Medicaid-covered benefits. This is the case for both inpatient and outpatient services, and the amounts that they can charge vary with income. All out-of-pocket charges are based on what the state pays for that service.


What happens if you cannot pay?

Because Medicaid is a program for low-income patients who also tend to suffer from chronic disease, medical providers cannot refuse to serve you just because you failed to make a copayment. However, they can hold you liable for any unpaid copayments.


Inform your doctor at the time of service if you cannot pay the copayment at that time and they will likely send you a bill to pay later.


If your state has established an alternative out-of-pocket cost (which is different from a copay) and your income is more than 100% over the federal poverty line, then some states can deny you further treatment if you have unpaid bills.


However, out-of-pocket costs for Medicaid recipients are limited as much as possible. There are no out-of-pocket costs for:

–          Emergency services

–          Family planning services

–          Pregnancy-related services

–          Preventive services for children


Will Medicaid cover copays?

It is unlikely that Medicaid will cover the cost of a copay since that money is collected to keep the program running. For standard medical services (not including long-term care or hospitalization), the copay may only be a few dollars.


Medicaid is designed so that the copays are as small as possible. They are even lower for people with very low incomes and few assets.


If you are concerned about making your copayment, it may be helpful to contact your provider in advance to ask about the exact copay they charge for the services you need.


Who decides on a copay?

Each individual state decides on the copay structure for Medicaid patients.


Adult Medical Assistance (aka Medicaid) patients in the state of Pennsylvania do not have to pay a copayment for drugs that treat the following conditions:

–          High blood pressure

–          Cancer

–          Diabetes

–          Epilepsy

–          Heart disease

–          HIV/AIDS

–          Psychosis


You can ask your pharmacy for a list of specific drugs that do not require a copayment. This list is compiled by the Department of Human Services, so individual pharmacies cannot make their own decisions about what is eligible for the Medicaid program.


When you receive your medical care, your provider will ask you to pay the copayment at the time of service.


What services require a copay?

In Pennsylvania, you can expect to pay the following copays:

–          $3 for each day you are in a hospital (up to $21 for one hospital stay)

 According to the Pennsylvania Department of Human Services, this includes general hospitals, rehabilitation hospitals, or private psychiatric hospitals.

–          $1 for each generic prescription drug (including approved refills)

–          $3 for each brand name drug (including approved refills)

–          $1 for each x-ray, diagnostic test, or treatment by nuclear medicine or radiation therapy

–          $.50 per unit of service for outpatient psychotherapy services


All other medical services will have copayments based on a Medical Assistance fee scale, but they will not exceed $3.80.


What if I think my copay is wrong?

If you feel your copay is too high in light of the income information you’ve provided to the Medicaid program, you may appeal the decision. However, it is most useful to contact the doctor’s office first to explain your situation see if charges can be modified.


If there is no resolution after this first step, Medicaid recipients who live in Pennsylvania can contact the County Assistance Office and explain their situation. If the County Assistance Office cannot resolve the issue, then they will refer it to the state’s Office of Medical Assistance Programs in Harrisburg.


If the Office of Medical Assistance Programs reviews your complaint and finds you were correct, they will contact the provider and ask them to reimburse you for any payment already made.


Who does not need to pay a copay?

Some Medicaid recipients are not required to submit a copay to medical providers.


Copayments are not required for:


–          Persons younger than 18 years old

–          Pregnant women (including the postpartum period)

–          Residents of long term care facilities or other medical institutions

–          Individuals receiving hospice care

–          Women in the Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program

–          Individuals in the Title IV-B Foster Care and IV-E Foster Care and Adoption Assistance Programs


Medicaid in Pennsylvania

Medicaid covers around 20% of the Pennsylvania population. To qualify for Medicaid in Pennsylvania, the state will first assess your financial need based on your income, including wages, Social Security Disability Insurance, veteran benefits, pension, and your spouse’s income. They will also consider other resources you have, such as the money in your checking or savings account, any stocks and bonds you own, and the value of your non-residential property.


However, child support or foster care payments, Supplemental Security Income (SSI), other government subsidies, and the value of your primary home and car are not considered in the decision to grant Medicaid coverage.


What does Pennsylvania Medicaid cover?

The Affordable Care Act (ACA) extended Medicaid eligibility to non-elderly adults with incomes at or below 138 percent of the federal poverty limit (FPL). Pennsylvania expanded its Medicaid program in 2015.


Because Medicaid can look different in each state, it’s important to know that Pennsylvania also provides benefits beyond the federally mandated coverage, such as dental benefits. For children, this includes regular cleanings, x-rays, fillings, crowns, and other medically necessary work. Adults receive coverage for medically necessary surgeries and emergency procedures.


Medicaid allows states to choose whether or not to cover 30 additional benefits in addition to the 15 mandated care services. Pennsylvania covers 24 of those optional benefits. In addition to dental, this includes including prescription drugs, vision, physical therapy, home health, and hospice care.


According to the Hospital Health System Association of Pennsylvania, roughly 11,700 Pennsylvanians were saved from “catastrophic out-of-pocket medical costs because of Medicaid expansion” under the ADA. In addition, an estimated 37,100 Pennsylvanians “did not have to borrow to pay bills or skip payments thanks to Medicaid expansion.”


To apply for Medicaid in Pennsylvania, gather your income information and proof of identification, and then visit the COMPASS website or download the myCompass mobile app to start your application. You can also apply by phone by calling the Consumer Service Center for Health Care Coverage at 1-866-550-4355. If you would like to apply by mail, fax, or in person, you can download an application and submit it to your local county assistance office (CAO).