Does Medicaid Have Copays? Limits, Exemptions and Your Rights

Medicaid can charge copays, but federal rules exempt whole groups of people and services and cap what everyone else pays. If a pharmacy just asked your parent for a few dollars, you may have reason to question it.1,2

In This Guide

• Who Pays No Medicaid Copays
• How Much Can Medicaid Charge for a Copay?
• The 5 Percent Household Cap
• Can a Provider Refuse Care If You Can't Pay?
• If You Also Have Medicare

Who Pays No Medicaid Copays

Under 42 CFR 447.56, states may not charge premiums or cost sharing to:1

• Children under 18 in the eligibility groups listed, children in foster care, and anyone receiving title IV-E foster care or adoption benefits4
• Pregnant women through the postpartum period, except for premiums the rule allows and services the state plan lists as not pregnancy-related
• Anyone whose institutional Medicaid (or, at state option, home and community-based Medicaid) is reduced by income beyond their personal-needs amount
• People receiving hospice care
• American Indians and Alaska Natives ever served by an Indian health care provider or through a contract health services referral5
• People covered through the state's breast and cervical cancer option

Emergency services, family planning, preventive care for children under 18, pregnancy-related services, and provider-preventable services carry no Medicaid cost sharing for anyone.1

The nursing-home exemption from Medicaid cost sharing depends on income going toward care, so confirm it fits your parent. A state can still charge exempt people a Medicaid copay for a non-preferred drug or non-emergency ER use, up to the limit for incomes at or below 150% of the federal poverty level (FPL).2

How Much Can Medicaid Charge for a Copay?

Each state sets its own Medicaid copays, within federal maximums tied to family income. The federal Medicaid dollar maximums in the table are base figures that have risen every year since October 1, 2015 with the medical care component of the Consumer Price Index for All Urban Consumers, so today's dollar limits are higher. The Medicaid percentage limits are not indexed.2

Above 150% FPL, 20% of a hospital stay adds up fast on a fixed income, so ask your state Medicaid agency for current amounts.2

The 5 Percent Household Cap

Medicaid premiums and cost sharing for everyone in the household can't exceed 5% of family income, applied monthly or quarterly as your state chooses. When a household reaches the 5% Medicaid cap, the state must notify the family and its providers, and no one in the family owes cost sharing for the rest of that period.1

You shouldn't need a shoebox of receipts. A state whose charges could push families to the cap must track spending without relying on family records.1

Can a Provider Refuse Care If You Can't Pay?

Usually, no. A state may let a provider, including a pharmacy, require a Medicaid copay before care only when your family income is above 100% of the FPL, you aren't exempt, and, for a non-emergency ER charge, the hospital met the screening and referral conditions. Otherwise, no Medicaid provider may deny services because you can't pay the copay.2

A provider may waive a copay case by case, but medicaid.gov notes, "enrollees may be held liable for unpaid copayments."6

The non-emergency ER copay. To charge a Medicaid copay for non-emergency ER use, the hospital must screen you and find no emergency, tell you the amount, name an available, lower-cost provider who can see you in a timely way, and refer you there. None of this limits the hospital's duty to stabilize an emergency. See our Georgia Medicaid emergency room guide.2,1

If You Also Have Medicare

If you're a Qualified Medicare Beneficiary (QMB), no Medicare provider may bill you for Medicare Part A or Part B deductibles, coinsurance or copays on covered services, even when Medicaid pays nothing. You can't waive this, and you're owed a refund of anything you paid. If bills continue, call 1-800-MEDICARE (1-800-633-4227). More in our QMB billing guide and Medicare Savings Programs by state.3

One State's Schedule: Georgia

In its notice of Pathways copays effective October 1, 2025, the Georgia Department of Community Health (DCH) lists Medicaid copays of $12.50 for an entire inpatient stay, $3 for an outpatient hospital visit or non-emergency ER use, and $0.50 to $3 for prescriptions, by drug cost. DCH adds, "If you cannot pay the copayment, you may still receive services."7

A copay isn't patient liability, a nursing-home resident's income paid toward care; see our personal needs allowance guide.

Learn More

Get help working out your state's Medicaid copays at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.