Medicaid has no monthly premium for most people, but you may pay small amounts when you use care

Medicaid is a joint federal and state program, which means what you pay — or don't pay — depends on where you live. In most states, there is no monthly premium if you meet the income and other requirements. However, many states do charge small amounts called cost-sharing when you actually use medical services: a copay for a doctor visit, coinsurance for hospital care, or a deductible before coverage starts.

The amounts vary widely by state. A copay for a primary care visit might be $0 to $5 in one state and $3 to $10 in another. Some states charge nothing for preventive care like vaccines and screenings, while others charge for everything. A few states have no cost-sharing at all. You need to know what your specific state's Medicaid program charges, because the rules that apply in one state do not apply in the next.

Key Takeaways

  • Most Medicaid programs have no monthly premium, but many charge small copays or coinsurance when you use services.
  • Cost-sharing amounts are set by your state and can range from $0 to $10 or more per visit, depending on the service and your state's rules.
  • Pregnant people, children under 21, and emergency services are often exempt from cost-sharing in most states.
  • Your state's Medicaid office publishes a document called a "Summary of Benefits and Coverage" or "cost-sharing guide" that lists exactly what you will pay.
  • If you cannot afford even small copays, some states have hardship exemptions that waive the charges.

How states set copays and other out-of-pocket costs

Federal law sets a ceiling on what Medicaid programs can charge. For most adults, copays cannot exceed $5 per visit for primary care or $10 for specialists and emergency room visits. However, states can charge less — and many do. Some states charge $1 or $2 per visit. Others charge nothing at all for certain services.

Coinsurance works differently from copays. Instead of a flat fee, you pay a percentage of the cost. For example, a state might charge 15 percent coinsurance for hospital stays or outpatient surgery. The actual dollar amount you owe depends on what the service costs in your area. States can charge up to 20 percent coinsurance for non-emergency services, but most stay lower.

Deductibles — the amount you must pay before Medicaid starts covering costs — are rare in Medicaid. Federal law generally prohibits them for most services, though a few states have received waivers to charge small deductibles for certain groups.

Who does not have to pay copays or other charges

Certain groups are protected from cost-sharing in all states. Children under 21 enrolled in Medicaid cannot be charged copays, coinsurance, or deductibles for any service. Pregnant people and new parents (usually for the first 60 days after delivery) are also exempt. Emergency services cannot have copays attached — you pay nothing to go to the emergency room, even if you later find out it was not truly an emergency.

Preventive services like vaccines, cancer screenings, and annual wellness visits are free in all Medicaid programs. Family planning services and contraception are also free. Some states extend exemptions further — for example, exempting all copays for people with disabilities or for services related to mental health and substance use treatment.

What happens if you cannot afford the copays

If you are enrolled in Medicaid and a copay would prevent you from getting care you need, you can ask your provider or your state's Medicaid office about a hardship exemption. This is not a formal process in most states — you simply tell the provider or the program that you cannot pay, and they can waive the charge. Providers are required to make a reasonable effort to collect copays, but they cannot deny you emergency care or necessary treatment because you cannot pay.

Some states have formal hardship waiver programs where you can request that copays be waived if your income is very low or if paying would create a genuine hardship. Contact your state's Medicaid office to ask whether this option exists where you live and what documentation you need to provide.

How to find out what your state charges

Your state's Medicaid program publishes a document that lists all copays, coinsurance amounts, and deductibles. This document may be called a "Summary of Benefits and Coverage," a "cost-sharing guide," or a "member handbook." You can find it on your state's Medicaid website, or you can call your state's Medicaid customer service line and ask them to mail or email it to you.

If you are already enrolled, you should have received this document when you joined. If you cannot find it, your Medicaid member ID card usually has a customer service phone number on the back. Call that number and ask for a copy of the cost-sharing information for your plan.

Some states offer different Medicaid plans with different cost-sharing amounts. If you have a choice of plans, compare the copays and coinsurance before you enroll. A plan with slightly higher copays might be worth it if it covers the doctors or hospitals you use most often.

Income limits and premiums in different states

While most Medicaid programs have no monthly premium, a small number of states charge premiums for certain groups — usually people with higher incomes within the Medicaid range. These premiums are typically $10 to $50 per month, depending on your income and your state. As of now, only a handful of states charge premiums, and they are usually optional: if you cannot afford the premium, you can request a waiver.

Income limits for Medicaid vary significantly by state. Federal law sets a minimum (roughly 138 percent of the federal poverty line in states that expanded Medicaid), but states can set their own limits higher or lower. Some states cover people with much lower incomes; others cover people with higher incomes. Your state's Medicaid office can tell you whether your income qualifies you.

Frequently Asked Questions

Do I have to pay a monthly premium for Medicaid?

In most states, no. The vast majority of Medicaid programs have no monthly premium. A small number of states charge premiums for certain groups, usually people with incomes above a certain threshold, but these are often waivable if you cannot afford them. Check your state's Medicaid website or call the customer service number on your member card to confirm whether your program charges a premium.

What is the difference between a copay and coinsurance?

A copay is a flat fee you pay each time you use a service — for example, $3 for a doctor visit. Coinsurance is a percentage of the cost — for example, you pay 15 percent of a hospital bill and Medicaid pays 85 percent. Your state's cost-sharing guide will tell you which services have copays and which have coinsurance.

Can I be denied care if I cannot pay a copay?

No. Providers cannot deny you emergency care or medically necessary treatment because you cannot pay a copay. You can ask for a hardship exemption, and many providers will waive the charge if you explain your situation. If a provider refuses to treat you because of a copay, contact your state's Medicaid office to file a complaint.

Are preventive services free under Medicaid?

Yes. Vaccines, cancer screenings, annual wellness visits, contraception, and other preventive services are free in all Medicaid programs — no copay, coinsurance, or deductible. This applies to all Medicaid members, regardless of age or income level.

How do I find out what my state charges for Medicaid services?

Your state's Medicaid program publishes a cost-sharing guide or member handbook that lists all copays and coinsurance amounts. You can find it on your state's Medicaid website, or call the customer service number on your Medicaid card and ask them to send you a copy. If you are not yet enrolled, contact your state's Medicaid office directly.