Collection of Medicare Copayments
- Physicians (does not apply to Cal MediConnect)
- Participating Physician Groups (PPG)
A member copayment is a set dollar amount based on the service provided, unlike coinsurance that is a percentage of the total cost of a service. Member copayments are determined by the plan. Providers may collect member copayments when a member is treated by a physician, physician assistant, nurse practitioner, or any qualified professional provider for basic medical care. The provider type does not dictate the copayment amount.
Member copayments should be collected at the time the service is provided. If immediate collection of a copayment is not possible, the provider may bill the member for the copayment amount only. Providers may not impose a surcharge on a member for covered services provided or collect copayments or any other fees for missed appointments. Providers have the option of having the member transferred after three missed appointments.
Most plans require a member copayment for covered services or supplies. Member copayment amounts vary by plan, county and type of service. A service rendered by any provider type other than the member's assigned PCP may be subject to a separate and different copayment amount. For example, the copayment amount for a primary care physician (PCP) office visit may vary from the copayment amount of a specialist office visit. Copayment amounts can be collected for most services including PCP office visits, specialist office visits (with exception to preventive care services under some plans), emergency room services, urgent care center visits, inpatient hospitalization, outpatient surgery, and prescription medications.
Some member identification (ID) cards list only the PCP office visit copayment. For example, a member may incur a $15 copayment for a PCP office visit and a $25 copayment for a specialist office visit (or consultation) depending on the plan.
Members are not subject to copayments if they have full dual-eligibility with Medicare Advantage and Medi-Cal, Medi-Cal managed care, or Cal MediConnect.
To ensure accurate collection of copayments, providers should refer to the member's Evidence of Coverage (EOC) or the plan's Schedule of Benefits for specific services and applicable copayment amounts. The Schedule of Benefits is available on the provider website.