Written & Reviewed by Akash Biswas, MSW | Former Medicaid Caseworker Trainer | Verified against Medicaid.gov, KFF, and CMS official guidelines | Last Updated: June 2026
Most Medicaid members pay little or nothing out of pocket. But in 2026, some states do charge small copays for certain services — usually between $4 and $8 per visit.
This guide explains exactly what those amounts are, which states charge them, and who qualifies for a $0 copay.
Quick Summary:
- Medicaid copays are small fees charged for certain covered services
- Federal law sets the maximum — states decide whether to charge at all
- Children, pregnant women, and nursing home residents pay $0
- Only 19 out of 41 expansion states charge any copays in 2026
- Your total out-of-pocket costs cannot exceed 5% of your household income
What Is a Medicaid Copay?
A Medicaid copay is a small fee you pay when you receive a covered service. It is not a monthly premium, and it is not a deductible — it is simply a per-visit or per-prescription charge.
Copays in Medicaid are much smaller than what you would pay under private insurance.
How Copays Work in Medicaid
The federal government sets maximum limits on what any state can charge. Each state then chooses whether to charge a copay at all — and if so, how much. Not every state uses copays, and not every service within a state has one.
The 5% Household Income Protection
Federal law includes a hard safety net for every Medicaid member. Your total Medicaid out-of-pocket costs — including all copays and premiums combined — cannot go above 5% of your monthly household income.
Once you hit that cap, you owe nothing more for the rest of the month.
Nominal vs. Alternative Cost Sharing
Federal rules use two types of cost sharing. “Nominal” amounts are small fixed fees for people with incomes at or below 100% of the Federal Poverty Level (FPL).
“Alternative” cost sharing applies to higher incomes within Medicaid — usually expressed as a percentage of the state’s cost of the service.
Who Has to Pay Medicaid Copays in 2026?
Whether you owe a copay depends on your income level and which Medicaid group you belong to. Federal law permanently exempts several groups from paying any copays at all.
To understand how your income affects both your eligibility and your cost sharing, see our full guide to Medicaid income limits by state in 2026.
Groups That Never Pay Copays
Federal law says the following groups cannot be charged copays for most services:
- Children — most services are fully exempt
- Pregnant women — all pregnancy-related services are exempt
- People living in nursing homes, ICFs, or other care institutions
- Terminally ill individuals receiving hospice care
Groups That May Pay Copays
Adults enrolled through ACA Medicaid expansion may owe small copays in some states.
Your exact income level within Medicaid also matters — members with incomes above 100% FPL may face slightly higher cost sharing than those below it.
If you are not sure whether you qualify for Medicaid at all, read our guide to Medicaid eligibility in 2026 for a full breakdown by category.
Can a Provider Refuse Care If You Can’t Pay?
No. Federal law protects you here. If your income is at or below 100% FPL, your provider cannot deny you care for failing to pay a nominal copay. The copay is still technically owed, but access to care cannot be blocked.
Federal Maximum Copay Limits for 2026
Federal law caps how much states can charge for each type of service. These caps are called “nominal” amounts, and they are updated each year based on the medical care component of the Consumer Price Index (CPI). The table below shows the federal maximum copay limits currently in effect for 2026, sourced from Medicaid.gov and the KFF 2026 Annual Survey.
| Service Type | Max Copay (≤100% FPL) | 101–150% FPL | Above 150% FPL |
|---|---|---|---|
| Doctor visits / outpatient services | ~$4 per visit | 10% of state’s cost | 20% of state’s cost |
| Preferred prescription drugs | ~$4 per fill | ~$4 per fill | ~$4 per fill |
| Non-preferred prescription drugs | ~$8 per fill | ~$8 per fill | Up to 20% of cost |
| Non-emergency ER visit | ~$8 per visit | ~$8 per visit | No upper limit* |
| Inpatient hospital stay | ~$75 per stay | 10% of state’s cost | 20% of state’s cost |
| Managed care visit | ~$4 | — | — |
*Subject to the 5% household income aggregate cap.
Source: Medicaid.gov Cost Sharing Framework; KFF 2026 Annual Survey (May 21, 2026)
Note: CMS has not published a standalone updated FY2026 nominal copay table as of June 2026. The $4/$8/$75 tiers remain the operative federal reference framework per Medicaid.gov.
What “Nominal” Means for You
“Nominal” means intentionally small — the federal government designed these amounts to be affordable for low-income households. They are updated for inflation each year, but changes are usually just a few cents at a time. To understand how these amounts relate to what Medicaid reimburses providers, see the Medicaid Fee Schedule 2026.
Income Level Changes What You Owe
Your income relative to the Federal Poverty Level (FPL) is the key factor. Members at or below 100% FPL pay the lowest fixed nominal amounts. Members with incomes above 100% FPL may owe a percentage of the service cost instead of a flat fee.
Which States Charge Copays in 2026?
Not all states charge Medicaid copays — and that is important to know. According to a May 2026 KFF survey of all 41 Medicaid expansion states, only 19 states charge cost sharing on any services for ACA expansion adults as of January 2026. The majority of expansion states charge no copays at all.
How States Differ in Charging Copays
Among the 19 states that do charge copays, here is how they break down:
- 14 states charge cost sharing at all income levels for expansion adults
- 3 states charge cost sharing only for adults with incomes between 100% and 138% FPL
- 2 states charge cost sharing even for adults with incomes below 100% FPL
Services Most Commonly Charged (January 2026)
| Service | Expansion States Charging Copays |
|---|---|
| Preferred brand-name drugs | 16 states |
| Generic drugs | 15 states |
| Non-preferred brand-name drugs | 15 states |
| Non-emergency ER / outpatient hospital | 12 states |
| Inpatient hospital stays | 10 states |
Source: KFF 2026 Medicaid Eligibility, Enrollment, and Renewal Policies Annual Survey (May 21, 2026)
States That Charge Prescription Drug Copays Only
Four states keep cost sharing limited to prescription drugs only — with no copays for visits or hospital stays. Those states are Delaware, Louisiana, Maryland, and New Hampshire.
Colorado: Non-Emergency ER Copay Only
Colorado is the only state that charges a copay exclusively for non-emergency ER visits. It does not charge any other cost sharing for ACA expansion adults in 2026.
State-by-State Medicaid Copay Highlights
Most states keep copays at or below $10 per service — especially for doctor visits and prescriptions. However, a small number of states charge significantly higher amounts for inpatient hospital stays. Here is what the data shows for the highest-copay states in 2026.
States with Higher Inpatient Hospital Copays
According to KFF’s 2026 Annual Survey, four states charge more than $35 per inpatient hospital stay for Medicaid expansion adults. These amounts will require adjustment when new federal rules take effect in 2028.
| State | Inpatient Hospital Copay | Notes |
|---|---|---|
| Alaska | $50/day, up to $200 per discharge | Exceeds future $35 federal limit |
| Michigan | $50 per stay | Exceeds future $35 federal limit |
| Utah | $75 per stay | Exceeds future $35 federal limit |
| West Virginia | $75 per stay (incomes above 100% FPL) | Exceeds future $35 federal limit |
Source: KFF 2026 Annual Survey
What Most States Charge
The vast majority of states limit all cost sharing to under $10 per service. Prescription drug copays are the most common charge, typically $4 for generics and $8 for non-preferred brand-name drugs.
North Carolina: Copay Increase Coming in 2027
North Carolina has passed a law to set all Medicaid copays at the maximum amount allowed under federal law, effective July 1, 2027. This means copays for non-preferred drugs, non-emergency ER visits, and hospital stays will increase to federal maximums for currently covered populations. This change does not affect 2026 costs.
Medicaid Copays for Dual-Eligible Beneficiaries
Dual-eligible beneficiaries are people enrolled in both Medicare and Medicaid at the same time. This group has a separate cost-sharing structure through the Medicare Low-Income Subsidy (LIS) program. CMS published updated 2026 LIS copay limits specifically for dual-eligible members.
2026 LIS Drug Copay Amounts for Dual Eligibles
| Group | Generic Drug Copay | Brand-Name Drug Copay |
|---|---|---|
| Living in a nursing home or receiving HCBS | $0 | $0 |
| Income at or below 100% FPL (~$15,960/year) | $1.60 | $4.90 |
| Income between 100%–150% FPL (~up to $23,940/year) | $5.10 | $12.65 |
| QMB-only / SLMB-only / SSI (not full Medicaid) | $5.10 | $12.65 |
Source: CMS 2026 LIS Resource and Cost-Sharing Limits Memo
Why Dual Eligibles Usually Pay Less
When you have both Medicare and Medicaid, Medicaid typically acts as secondary coverage. It covers costs that Medicare does not pay, including many drug copays. Full-benefit dual eligibles — especially those living in nursing homes — often owe $0 on covered prescriptions.
How to Know If You Are Dual Eligible
You are dual eligible if you are enrolled in Medicare Part A or Part B and you also qualify for your state’s Medicaid program. Your state Medicaid agency can confirm this status. Contact them directly or log into your state’s Medicaid portal to check.
How the “One Big Beautiful Bill Act” Changes Copays in 2028
Congress passed the One Big Beautiful Bill Act (OBBBA) in 2025. This law makes several changes to Medicaid — including a new cost-sharing requirement. But those changes do not take effect until October 1, 2028. Your copay amounts in 2026 are not affected by this law.
What the New Law Will Require Starting October 2028
Beginning October 1, 2028, states will be required — not just permitted — to charge ACA Medicaid expansion adults with incomes between 100% and 138% FPL a copay of up to $35 per service. This is a major shift from current rules, which leave copay decisions entirely up to each state.
Key Details of the New $35 Rule
- States may allow providers to condition care on payment of the required copay
- Providers may reduce or waive copays for individual patients on a case-by-case basis
- The existing 5% household income aggregate cap is unchanged
- The rule applies only to ACA expansion adults in the 100%–138% FPL range
Services Exempt from the New $35 Requirement
Even after 2028, many services will remain completely free of copays for expansion adults:
- Primary care, mental health, and substance use disorder services
- Services at FQHCs, rural health clinics, and certified community behavioral health clinics
- Indian Health Program services
- Pregnancy-related services and tobacco cessation for pregnant women
- Inpatient hospital, nursing facility, and ICF/IID stays
- Emergency services and family planning services
- Hospice services
- CDC-recommended vaccines and COVID-19 testing
Source: AMA summary of OBBBA Medicaid changes; ACC Implementation Guide (July 2025)
Frequently Asked Questions (FAQ)
Q: What are the Medicaid copay amounts in 2026?
A: Federal maximums are approximately $4 for doctor visits and generic drugs, $8 for non-preferred drugs and non-emergency ER visits, and up to $75 for an inpatient hospital stay. These are ceilings — your state may charge less or nothing at all. Check your state’s Medicaid agency for exact current amounts.
Q: Do all states charge Medicaid copays in 2026?
A: No. Only 19 out of 41 Medicaid expansion states charge copays on any service for ACA expansion adults as of January 2026. More than half of expansion states charge no copays at all. Prescription drug copays are the most common charge when states do impose cost sharing.
Q: Who is completely exempt from Medicaid copays?
A: Federal law permanently exempts children for most services, pregnant women for pregnancy-related care, people living in nursing homes or institutions, and terminally ill individuals in hospice. If you belong to any of these groups, you should owe $0 in copays for covered services under current federal rules.
Q: Can a provider refuse to see me if I can’t pay my Medicaid copay?
A: Generally no. If your income is at or below 100% of the Federal Poverty Level (FPL), your provider cannot legally deny you care for failing to pay a nominal Medicaid copay. The amount is still technically owed, but access to your covered services cannot be withheld based on inability to pay.
Q: Does the “One Big Beautiful Bill Act” raise my Medicaid copays right now?
A: No — not in 2026. The new mandatory $35 copay requirement for ACA expansion adults does not take effect until October 1, 2028. Your current copay amounts are still governed by existing federal rules and your state’s own policies. Nothing changes until 2028 at the earliest.
Q: How much do dual-eligible members (Medicare + Medicaid) pay for drugs in 2026?
A: CMS updated the 2026 LIS drug copay limits. Members with income at or below 100% FPL pay $1.60 for generics and $4.90 for brand-name drugs. Those in nursing homes pay $0. Members between 100%–150% FPL pay $5.10 for generics and $12.65 for brand-name drugs.
Sources & Disclaimer
Last Updated: June 2026
Official Sources:
- Medicaid.gov — Cost Sharing / Out-of-Pocket Costs: medicaid.gov/medicaid/cost-sharing/cost-sharing-out-pocket-costs
- KFF — “Understanding Medicaid Cost Sharing and Policy Changes from the 2025 Reconciliation Law” (May 21, 2026): kff.org/medicaid/understanding-medicaid-cost-sharing-and-policy-changes-from-the-2025-reconciliation-law
- CMS — 2026 LIS Resource and Cost-Sharing Limits Memo: cms.gov/files/document/cy2026-lis-resource-limits-memo.pdf
- AMA — Changes to Medicaid and CHIP Cost Sharing (July 2025): ama-assn.org
Disclaimer: CheckMedicaid.com is not affiliated with any government agency. This content is for educational purposes only. For official eligibility and copay information, contact your state Medicaid office or visit Medicaid.gov.
Written & Reviewed by Akash Biswas, MSW | Former Medicaid Caseworker Trainer | 10+ years in Medicaid policy and caseworker training | Verified against Medicaid.gov, KFF, and CMS official guidelines | Last Updated: June 2026
