Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, 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.
• 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.
Which Providers can charge a Co-pay?
How do I know to collect a Co-pay?
• 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?
• 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.
What services are subject to Co-pay?
• 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 rendered that are $36.49 or less for the total claim.
What can I do if a participant doesn’t make their Co-pay?
• 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.
• You must calculate your CAP using the income information you provided Medicaid to determine your eligibility.
Its differ patient to patient and plan to plan. For example see the different type of plan or treatment and the copayment.