A Mandatory and Optional Co-Payment Groups

Revised 03/03/2014

Policy

Customers who receive AHCCCS Medical Assistance under the following programs are responsible for either optional or mandatory co-payments, unless they meet any one of the exemption criteria in MA1205:

 

Optional	Mandatory
SSI Cash SSI MAO Caretaker relative Child FTW YATI	Transitional Medical Assistance (TMA)

 

1) Exemptions

A customer who meets any of the following is exempt from co-payments:

• Under age 19;

• Children eligible to receive services from the Children's Rehabilitative Services (CRS) program;

• Diagnosed as Seriously Mentally Ill (SMI) by the Arizona Department of Health Services (ADHS);

• Receiving acute care benefits and temporarily living in a nursing home or residential facility, but only when the customer's medical condition would otherwise require hospitalization. This exemption is limited to 90 days in a contract year;

• Receiving hospice care;

• Enrolled with American Indian Health Program (AIHP);

• Eligible for AHCCCS Medical Assistance on a fee-for-service (FFS) basis; or

• Pregnant.

 

2) Exempt Coverage Groups

Customers who qualify for AHCCCS Medical Assistance under any of the following coverage groups are exempt from co-payment requirements:

• ALTCS, including Freedom to Work-ALTCS;

• Medicare Savings Programs (QMB, SLMB or QI-1);

• KidsCare.

• Adult Group (temporarily)

• Breast & Cervical Cancer Treatment Program

 

 

3) Co-Payment Amounts for the Optional Group

Co-payments apply only to specific services and to people who are not exempt.

Co-payments for the optional group described in MA1205 are as follows:

Service	Amount
Prescriptions	$2.30
Doctor or other Provider outpatient office visits for evaluation and management of care (Well Person) or non-emergency surgical procedures	$3.40
Physical, Occupational or Speech Therapies	$2.30

 

NOTE     Providers are required to provide these services even if the member is unable to afford the co-payment.

 

4) Co-Payment Amounts for TMA Customers

Co-payments for TMA customers who are not exempt (MA1205 and MA1205) are as follows:

Service	Amount
Prescriptions	$2.30
Doctor or other Provider outpatient office visits for evaluation and management of care (Well Person)	$4.00
Physical, Occupational or Speech Therapies	$3.00
Non-emergency surgical procedures in an outpatient setting.	$3.00

 

NOTE     These co-payments are mandatory and the pharmacist or medical service provider can deny a TMA customer services if the customer does not make the co-pays.

A family receiving TMA will not be required to make the co-pays if the total amount of the co-pays the family made is more than 5% of the family's gross income (before taxes and deductions) during a calendar quarter.

AHCCCS will inform customers when family co-pays exceed 5%. However, if a customer thinks that he or she has paid co-pays that equal 5% of the customer’s family total quarterly income and AHCCCS has not told the customer that this has happened, the customer should send copies of receipts or other proof of how much the customer has paid to AHCCCS, 801 East Jefferson, Mail Drop 3600, Phoenix, Arizona 85034.

 

Definitions

Term	Definition
Co-Payment	A co-payment is the amount that the customer pays to a medical provider when a medical service is received. Customers who are eligible in some AHCCCS coverage groups have optional co-payments, while others have mandatory co-payments.
Optional co-payments	When a customer has optional co-payments, the provider must provide the service even when the customer does not pay the co-payment.
Mandatory co-payments	When a customer has mandatory co-payments, the provider may refuse to provide the service when the customer does not pay the co-payment.

 

Legal Authority

Program	Legal Authorities
All Programs	42 USC 1302 42 CFR 435.Part 447 ARS 36-2903.01(D)(4) AAC R9-22-711