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Copayments

Copayments or copays are the money that you pay to get care from your provider. We keep track of the money that you spend on copays each quarter. And we make sure that you’re not overcharged. We’ll refund any extra money if your family reaches their limit for the quarter.

Copay exceptions

You pay $0 in copays for:

 

  • Services for foster children

  • Services for children enrolled in Medicaid

  • Services for pregnant women (includes a 60-day period after pregnancy ends)

  • Services for Kentucky Medicaid beneficiaries who have reached their cost-sharing limit for the quarter (5% of the family’s total income per quarter)

  • Individuals receiving hospice care

  • Emergency services

  • Some family planning services 

  • Preventive services

What are my benefits?

Acute inpatient hospital services: $0 copay

 

  • Per admission

Inpatient physician and surgeon services: $0 copay

 

  • Cosmetic surgery isn’t covered (except postmastectomy reconstructive surgery) 

Transplant: $0 copay

 

  • No limit

Emergency room (ER): $0 copay

 

  • $0 copay for using the ER without an emergency

Emergency ambulance (ground or air): $0 copay

 

  • No limit

Physician office services: $0 copay

 

  • No limit

Outpatient hospital ambulatory surgical center: $0 copay

 

  • Cosmetic surgery isn’t covered (except postmastectomy reconstructive surgery)

Rural Health Clinic (RHC), Federally Qualified Health Center (FQHC) and Primary Care Center (PCC): $0 copay

 

  • Per visit 

Dental services: $0 copay for adults; $0 copay for children

 

  • Per visit

Home health care: $0 copay

 

  • No limit

Vision services: $0 copay for adults; $0 copay for children

 

  • 1 exam per year

Urgent care: $0 copay

 

  • Per visit

Radiation therapy: $0 copay

 

  • No limit

Chemotherapy: $0 copay

 

  • No limit

Family planning: $0 copay

 

  • No limit

Podiatry: $0 copay

 

  • No limit

Prenatal and postnatal care: $0 copay

 

  • No limit

Maternity services: $0 copay

 

  • No limit

Generic medications: $0 copay

 

  • No limit

Brand-name medications: $0 copay

 

  • No limit

Skilled nursing and rehabilitation: $0 copay

 

  • No limit

Chiropractic services: $0 copay

 

  • Per visit (limited to 26 visits per 12-month period)

Durable medical equipment: $0 copay

 

  • Per item

Hearing aids and audiometric services: $0 copay

 

  • Limited to children under 21

Orthotic and prosthetic devices: $0 copay

 

  • Per item

Physical and occupational speech therapy: $0 copay for adults; $0 copay for children

 

  • Per visit (limited to 20 visits for each therapy, per year)

Private duty nursing: $0 copay

 

  • 2,000 hours per year (outpatient only)

Laboratory, diagnostic and radiology services (outpatient): $0 copay

 

  • Per visit and per service

Autism spectrum disorder services: $0 copay

 

  • Up to age 21

Early Periodic Screening Diagnosis and Treatment (EPSDT) special services: $0 copay

 

  • Limited to medically necessary services and must get prior authorization

Commission for Children with Special Healthcare Needs: $0 copay

 

  • Limited to children who meet the eligibility criteria of the Kentucky Commission for Children with Special Healthcare Needs

Specialized children’s services clinics: $0 copay

 

  • Services are limited to children under age 18 and must be performed by specialized clinics

Targeted case management: severe emotional disability (SED) children services: $0 copay

 

  • Limited to children who meet Kentucky’s statutory definition of SED. Services are available to children from birth.

First Steps services: $0 copay

 

  • For children up to 2 years old who have physical or mental developmental delays

Targeted case management: $0 copay

  • No limit

Inpatient mental health and substance use services: $0 copay

 

  • Per admission

Outpatient mental health and substance use services: $0 copay

 

  • Per visit

Psychiatric residential treatment facilities (PRTFs): $0 copay

 

  • Services for residents ages 6 to 21

Smoking and tobacco cessation: $0 copay

 

  • No limit

Allergy services: $0 copay

 

  • No limit

Wellness and preventive health services: $0 copay

 

  • No limit

Nonemergency transportation services: $0 copay

 

  • No limit

Family planning services: $0 copay

 

  • No limit

Hospice services: $0 copay

 

  • No limit

Second opinion: $0 copay

 

  • No limit

Telehealth: $0 copay

 

  • No limit

Renal dialysis and hemodialysis services (outpatient): $0 copay

 

  • No limit

Notes

 

  • All benefits provided must be medically necessary.

  • Copays apply to all members, unless they are exempt.

  • Copays are limited to no more than 5% of your family’s total income every three months.