Most Medicaid enrollees pay nothing out of pocket, and federal law makes sure that whatever a state does charge stays small. Copays, when they exist, are capped at nominal amounts of about $4 to $8 for most outpatient visits and preferred drugs and up to $75 for an inpatient hospital stay for people at or below the poverty line. Every premium, copay, deductible, and coinsurance charge combined cannot exceed 5% of a household's income in a given month or quarter. Children, pregnant women, and emergency or family planning services are exempt from cost sharing entirely. As of January 2026, about half of the 41 states that expanded Medicaid charge no cost sharing at all to the adults covered under expansion, and four states (Delaware, Louisiana, Maryland, and New Hampshire) charge only for prescription drugs.
This guide explains the federal framework that controls Medicaid costs nationwide, who is exempt, what happens if you cannot pay a copay, and what is actually known about state-by-state charges, without guessing at numbers nobody has published.
The Federal Rules That Cap Every State's Medicaid Cost Sharing
Medicaid cost sharing is governed by federal regulation at 42 CFR Part 447, Subpart A, and it works the same way in every state. States are not free to charge whatever they want. Federal rules set the maximum any state can charge, based on where a household's income falls relative to the Federal Poverty Level (FPL).
| Household Income | Outpatient Visit / Preferred Drug | Non-Preferred Drug / Non-Emergency ER | Inpatient Hospital Stay |
|---|
| At or below 100% FPL | Nominal amount, roughly $4 | Nominal amount, roughly $8 | Nominal amount, roughly $75 per stay |
| 101% to 150% FPL | Up to 10% of the state's cost for the service | Up to 10% of the state's cost for the service | Up to 10% of the state's total payment |
| Above 150% FPL | Up to 20% of the state's cost for the service | Up to 20% of the state's cost for the service | Up to 20% of the state's total payment |
The "nominal" dollar figures in the top row are set in federal regulation and adjusted upward each year by the medical care component of the Consumer Price Index, so the exact cents-level figure creeps up annually. Treat $4, $8, and $75 as the baseline a state cannot exceed for the lowest income band, not as a fixed price that never moves. For context, the 2026 Federal Poverty Level is $15,960 a year for one person and $33,000 for a family of four, so 100% FPL for an individual works out to about $1,330 a month.
States are allowed to charge less than these maximums, and many do. A large share of states charge nothing at all for most services. No state may charge more than these federal ceilings.
Who Is Completely Exempt From Medicaid Cost Sharing
Federal law exempts certain groups and certain services from cost sharing entirely, regardless of which state you live in or how the state structures its copay schedule. A provider cannot charge these populations or for these services under any circumstances.
Exempt populations:
- Children under 18 (some states extend this exemption through age 21)
- Pregnant women, during pregnancy and through the end of the month containing the 60th day postpartum
- Beneficiaries receiving hospice care
- People in institutions, such as nursing facilities, who are required to contribute nearly all their income to their cost of care
- American Indians and Alaska Natives with any history of eligibility through the Indian Health Service
- Women enrolled through the Breast and Cervical Cancer Treatment Program pathway
Exempt services, for everyone, regardless of income:
- Emergency services
- Family planning services and supplies, including contraception
- Pregnancy-related care, including tobacco cessation counseling
- Preventive services for children
If you fall into one of these groups, or the service you need is on this list, a Medicaid provider cannot bill you a copay for it. Full stop.
The 5% Rule: No Household Pays More Than 5% of Its Income
On top of the per-service caps, federal law sets an aggregate ceiling. All premiums, copays, deductibles, and coinsurance owed by every Medicaid-enrolled member of a household, combined, cannot exceed 5% of that household's income over a monthly or quarterly period, whichever the state chooses to use.
States are required to track this automatically. You are not supposed to have to keep your own receipts and petition the state once you hit the cap; federal rules require states to build a tracking process that does not rely on the enrollee documenting their own costs. In practice, this means heavy Medicaid users with frequent doctor visits, hospital stays, or multiple prescriptions are protected from runaway bills, even in a state that charges cost sharing on most services.
Can a Provider Deny Care If You Cannot Pay the Copay?
This is one of the most misunderstood parts of Medicaid cost sharing, and the answer genuinely depends on your income band.
At or below 100% FPL: A provider cannot deny or reduce a service because you are unable to pay the copay at the time of the visit. The provider can still bill you for the amount later and attempt to collect it, but they must treat you that visit regardless.
Above 100% FPL: States may permit providers to deny non-emergency services to a beneficiary who does not pay the required cost sharing. Even here, though, providers must retain the option to reduce or waive the charge case by case, and the exempt services and exempt populations listed above still cannot be charged or denied no matter the income level.
So if you are at or under the poverty line, you cannot be turned away for owing a copay. If your income is above the poverty line, a provider may be allowed to require payment as a condition of a non-emergency visit, depending on your state's specific policy.
Which States Charge Medicaid Copays in 2026
This is the part where most articles either invent a complete 51-row table or quietly copy someone else's guesswork. We are not going to do that. Here is what is actually documented by the annual KFF and Georgetown University Center for Children and Families survey of state Medicaid officials, current as of January 2026, and nothing beyond that.
| Category | What's known |
|---|
| States charging no cost sharing to expansion adults | Roughly half of the 41 states that adopted the ACA Medicaid expansion charge nothing at all to adults covered under expansion. |
| States charging cost sharing on multiple services | About 20 of the 41 expansion states charge some cost sharing to expansion adults, most at modest levels under $10 per service. |
| States limiting cost sharing to prescription drugs only | Delaware, Louisiana, Maryland, and New Hampshire charge cost sharing only on prescription drugs, not on visits or hospital stays. |
| States charging above the typical range | Alaska, Michigan, Utah, and West Virginia are reported to charge $50 to $75 for an inpatient hospital admission, above the $35-per-service level that becomes a federal floor for some enrollees starting in 2028. |
Beyond these documented examples, exact per-state copay schedules change by plan, by managed care organization, and sometimes mid-year, and most states do not publish a single, stable statewide number the way they publish income limits. The reliable way to find your exact copay is your state Medicaid agency's member handbook or your managed care plan's member services line, not a secondhand chart. If a page tells you your specific state charges exactly $3.40 for a doctor visit without citing a state Medicaid agency document, treat that number with suspicion.
Non-expansion states (Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming) set their own cost-sharing rules for the eligibility categories they do cover, such as children, pregnant women, and people with disabilities, under the same federal nominal caps described above. See our guide to Medicaid income limits by state for which categories each state actually covers.
Medicaid Premiums: Less Common Than Copays, But They Exist
Straight Medicaid rarely charges a monthly premium the way CHIP sometimes does for children above the Medicaid income threshold. (See our CHIP premium by state guide for that separate program's cost chart.) But a handful of states use a federal Section 1115 waiver to build a premium-like contribution into their expansion coverage.
The clearest example is Indiana's Healthy Indiana Plan (HIP). Members who choose the HIP Plus tier contribute 2% of household income each month into a POWER account, which can be as little as $1 a month for someone near the bottom of the income range and scales up from there. Paying into the account gets you dental and vision coverage with no separate copays. Members who do not pay fall to HIP Basic, which has no monthly contribution but does charge copays and does not include dental or vision.
If your state runs its Medicaid expansion through a waiver program with its own name (Indiana's HIP, for example), check that specific program's rules rather than generic Medicaid cost-sharing guidance, since waiver programs can structure costs differently than the standard copay bands described above.
A Change Coming in 2028 for Expansion Adults
A provision in the 2025 federal reconciliation law requires states, for the first time, to impose mandatory cost sharing on certain Medicaid expansion adults. Starting October 1, 2028, states must charge up to $35 per service to expansion adults with income between 100% and 138% of the FPL. Primary care, mental health and substance use disorder services, emergency care, pregnancy-related care, family planning, and services at federally qualified health centers remain exempt even under this new requirement, and prescription drug cost sharing for this group must stay at nominal levels. This does not take effect until fiscal year 2029 and does not apply to anyone below 100% FPL or outside the expansion group.
How to Find Your Exact Medicaid Copay Amount
- Check your state Medicaid member handbook. Every state publishes a benefits and cost-sharing handbook for its program, often under its own state-specific name (MassHealth, TennCare, Medi-Cal, and similar).
- Call your managed care plan, not just the state agency. Most Medicaid enrollees are in a managed care organization, and the plan's member services line can confirm the exact copay for a specific service.
- Ask your provider's billing office before the visit. Front desk staff at Medicaid-accepting clinics deal with this daily and can usually quote the copay for your specific visit type.
- Track your spending if you're a heavy user of care. If you believe you're approaching the 5% household income cap, ask your state agency how it verifies that threshold and what to do if you think you've hit it.
- Compare your plan choice if you have options. In states with managed care, choosing the right Medicaid health plan can affect which copays and extra benefits you get, even though the underlying state cost-sharing rules stay the same.
Frequently Asked Questions
Does Medicaid cost anything per month?
For most enrollees, no. The majority of Medicaid beneficiaries, including nearly all children, pregnant women, and people below the poverty line, pay no monthly premium. Some states charge small per-service copays, and a few states run waiver programs like Indiana's Healthy Indiana Plan that include a modest monthly contribution tied to income.
What is the maximum copay Medicaid can charge?
For people at or below 100% of the Federal Poverty Level, federal rules cap nominal copays at roughly $4 for outpatient visits and preferred drugs, $8 for non-preferred drugs and non-emergency ER use, and $75 for an inpatient hospital stay. These figures adjust slightly each year with medical inflation. Above 100% FPL, states can charge up to 10% or 20% of the service cost, depending on the income band, subject to the overall 5% of household income cap.
Can my state charge more than the federal copay limits?
No. The federal maximums in 42 CFR Part 447 are ceilings, not suggestions. States can charge less, and many charge nothing, but no state can legally exceed the nominal amount caps for the lowest income band or the 10%/20% caps for higher income bands.
Who is exempt from Medicaid copays?
Children, pregnant women, people in hospice care, residents of nursing facilities who contribute most of their income to care, American Indians and Alaska Natives with Indian Health Service eligibility history, and women covered through the Breast and Cervical Cancer Treatment Program are exempt from cost sharing. Emergency services, family planning, pregnancy-related care, and preventive services for children are exempt for everyone, regardless of income or state.
Can a doctor refuse to see me if I can't pay my Medicaid copay?
If your household income is at or below 100% of the FPL, no. The provider must still treat you and can only bill you for the copay afterward. If your income is above 100% FPL, your state may allow providers to deny non-emergency services for unpaid cost sharing, though exempt services and exempt groups are protected regardless of income.
Which states charge no Medicaid copays at all?
Roughly half of the 41 states that expanded Medicaid under the ACA charge no cost sharing to expansion adults, according to the January 2026 KFF and Georgetown University survey of state Medicaid officials. Because exact rules vary by eligibility category and can change, confirm your own state's current policy through its Medicaid member handbook rather than a general list.
Will Medicaid copays go up in the future?
The federal nominal copay caps rise slightly each year with medical inflation. Separately, a 2025 federal law requires states to begin charging up to $35 per service to expansion adults with income between 100% and 138% of the FPL starting October 1, 2028, with exemptions for primary care, mental health and substance use services, emergency care, pregnancy-related care, family planning, and community health center visits.
