Copay Guidelines

Copays

You may bill a member for a copay before or after you receive notification of the copay amount on the remittance advice (RA) from PrimeWest Health. 

Copays: If a copay applies to services, a deduction will be made from the payment to the provider. Providers may bill the copay amounts to the member.

Services cannot be withheld from or refused to members enrolled in the Medical Assistance program because of the member’s inability to pay the copay pursuant to Title 42 Code of Federal Regulations (CFR) Part 447.53, MN Stat. sec. 256B.04, and MN Rules part 9505.0225.

PrimeWest Health Copay Guidelines

1. Adult MinnesotaCare members are responsible to pay copays for medical services to providers. Adult MinnesotaCare, Prime Health Complete, and PrimeWest Senior Health Complete members are responsible to pay copays for prescriptions.
2. Providers are responsible to collect copays from PrimeWest Health members.
3. Payment to providers will be reduced by the amount of the copay, except that payment for prescription drugs will not be reduced after a member has reached the monthly maximum listed on the 2026 Member Group Copay Benefits Provider Reference Chart.
4. Providers serving PrimeWest Health members should contact PrimeWest Health regarding the providers’ contractual requirements.

Also refer to PrimeWest Health’s 2026 Member Group Copay Benefits Provider Reference Chart.

Copays for medical services apply to adult MinnesotaCare members as outlined in the following table.

2026 Medical Service Copays

Copays for prescriptions apply to adult MinnesotaCare, Prime Health Complete, and PrimeWest Senior Health Complete members are outlined in the following table.

2026 Prescription Copays

Copays are not required for the following services:

1. Preventive care visits, such as physicals
2. Some preventive screenings and counseling, such as cervical cancer screenings and nutritional counseling
3. Immunizations
4. Ambulatory surgery
5. Outpatient hospital
6. Preventive and diagnostic dental care
7. Non-routine dental services
8. Family planning services and supplies
9. Home care
10. Interpreter services
11. Medical equipment and supplies
12. Mental health services
13. Some mental health drugs (antipsychotics)
14. Substance use disorder treatment
15. Rehabilitation therapies
16. Repair of eyeglasses
17. Tests such as blood work
18. Tobacco use counseling and interventions
19. 100 percent Federally funded services at Indian Health Service clinics

Additional Copay Information for MinnesotaCare Members

Inpatient hospital admission copays include both mental health and substance use admissions. The copay limit includes one copay per admission, per recipient, per treating provider.

All emergency room (ER) visits will be assessed a copay unless the admission results in an inpatient stay. In this case, only the inpatient admission copay will be assessed. 

Copay limits for all services follow the same general rule of one copay per day, per recipient, per treating provider. For example, if a recipient had an X-ray performed at a non-preventive office visit within the same day, the $45 (radiology) copay and the $28 (non-preventive visit) copay would be assessed.

Member Inability to Pay PrimeWest Health Copays

Members who are covered by Federally funded Medical Assistance are protected from denial of service based on inability to pay as long as they inform the provider that they are unable to pay the copay.

Providers cannot deny services to members who are unable to pay copays. A provider must accept a member’s assertion that they are unable to pay a copay and cannot require additional documentation of inability to pay.

Providers must allow members time to pay their copays.

When a member has a copay obligation, PrimeWest Health will pay only the allowable minus the copay.

Member Inability to Pay Copay and Deductible

If a MinnesotaCare member cannot pay the copay at the time of the visit, follow the steps below:

1. Inform the member of their copay obligation for the service
2. Provide services for the current visit
3. Inform the member of their debt and give them the opportunity to pay using standard office policies and procedures
4. Inform the member of your office policy on serving members with outstanding debts or unpaid copays

If it is your standard office policy to refuse services to patients who have debt, you may refuse to provide ongoing services because of the member’s inability to pay their copay.

In accordance with MN Stat. sec. 62Q.751, overpayments by members to providers must be returned to the member by the provider by check or electronic payment within 30 days of the date on which the claim adjudication is received by the provider.

Third Party Liability (TPL) and Copays

Members with private health insurance primary to PrimeWest Health are responsible to pay only the PrimeWest Health copay for covered services. Providers must bill in the usual manner, reporting the insurance payment on the claim with the balance due. If the PrimeWest Health allowable covers all or part of the balance billed, PrimeWest Health will pay up to the maximum PrimeWest Health allowable, minus any applicable PrimeWest Health copay. The PrimeWest Health copay will be deducted from the PrimeWest Health payment amount and reported as the copay amount. Bill the member copay amount to the member.

American Indian copays: For information regarding charging Minnesota Health Care Programs (MHCP) copays to American Indian members, refer to Tribal and Federal Indian Health Services.

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Updated_01/06/2026