Medicaid is the cheapest health coverage in the United States, and it is not close. But “free” is not quite right either, and the gap between the two answers is where people get confused when a bill shows up.
The rules live in a short stretch of federal regulation, 42 CFR 447.52 through 447.56, plus whatever your state chose to do inside those limits. This guide walks through the actual dollar figures in that regulation, what states charge in practice as of 2026, and the requirement that changes all of it in October 2028.
The Federal Copay Caps
These are the maximum amounts a state may charge, read directly from 42 CFR 447.52, 447.53, and 447.54 in September 2026. Everything is per service:
| Service | At or below 100% FPL | 101 to 150% FPL | Above 150% FPL |
|---|---|---|---|
| Outpatient visit (physician, physical therapy) | $4 | 10% of cost the state pays | 20% of cost the state pays |
| Inpatient stay (entire stay) | $75 | 10% of total cost the state pays | 20% of total cost the state pays |
| Preferred drug | $4 | $4 | $4 |
| Non-preferred drug | $8 | $8 | 20% of cost the state pays |
| Non-emergency use of the ER | $8 | $8 | No federal limit |
Two structural protections sit on top of that table. Cost sharing can never equal or exceed the amount the state itself pays for the service, so a $4 copay cannot attach to a $3 service. And a state may not impose more than one type of cost sharing for the same service, so you cannot be charged a copay and coinsurance on the same visit.
A note on vintage that matters here. The regulation says these nominal maximums are indexed each year, beginning October 1, 2015, by the increase in the medical care component of the CPI-U, rounded up to the next 5-cent increment. But the table Medicaid.gov publishes on its cost sharing page is still labeled “FY 2013,” listing the same $4, $8, and $75 along with a $2.65 maximum nominal deductible and a $4.00 maximum managed care copayment. KFF’s May 2026 analysis also treats $4, $8, and $75 as the current operative figures. Treat them as the working numbers and expect a state here or there to land a nickel or two above them.
The non-emergency ER charge has real teeth for a different reason: above 150% of FPL there is no federal ceiling on it at all. Before a state can bill it, though, the hospital must screen you, tell you the charge, name an alternative provider that can see you sooner and cheaper, and actually refer you there. If you want the comparison for people without any coverage, see ER visit cost without insurance.
What States Cannot Charge You For, At Any Income
Under 42 CFR 447.56(a)(2), no Medicaid program may impose cost sharing on:
- Emergency services
- Family planning services and supplies, including contraceptives
- Preventive services for children under 18, regardless of family income, covering the well-child visits and immunizations in the Bright Futures guidelines
- Pregnancy-related services, including counseling and drugs for tobacco cessation. All services provided to a pregnant person count as pregnancy-related unless the state plan specifically identifies them otherwise
- Provider-preventable services, meaning care to fix a preventable error
This list is the single most valuable thing on this page. If you are charged a Medicaid copay for an emergency visit, a birth control prescription, or a child’s checkup, that charge is not permitted.
Who Is Exempt From All Cost Sharing
Section 447.56(a)(1) exempts entire groups of people, not just services. The list includes most children under 18 in the mandatory eligibility groups, children in foster care and those receiving Title IV-E benefits regardless of age, pregnant people through the end of the postpartum period, individuals in an institution whose income is already applied toward their cost of care, people receiving hospice care, and enrollees in the breast and cervical cancer coverage group.
American Indians and Alaska Natives get the broadest protection in the regulation: anyone who is currently receiving or has ever received an item or service from an Indian health care provider or through contract health services referral is exempt from all cost sharing.
There is also a rule about what happens when you cannot pay. States generally must specify that no provider may deny services because an enrollee cannot pay the cost sharing. The exception is narrow: a state may permit denial only if your family income is above 100% of FPL and you are not in an exempt group. Inability to pay does not cancel the charge, so an unpaid copay can still be billed to you.
The 5% Cap Is the Real Ceiling
Whatever your state charges, total Medicaid premiums and cost sharing for everyone in your household combined cannot exceed 5% of family income, measured monthly or quarterly at the state’s choice.
Against the 2026 federal poverty guidelines, that is a hard number. A family of three at exactly 100% of FPL has income of $27,320, so their annual ceiling is about $1,366, or roughly $341 per quarter. An individual at $15,960 tops out near $798 a year.
The state has to do the tracking, not you. The rules require a mechanism that does not rely on beneficiary documentation, and the agency must notify you and your providers once your household hits the cap so cost sharing stops for the rest of the period.
What States Actually Charge in 2026
The federal maximums are permissions, not requirements. Most states leave money on the table.
According to KFF’s January 2026 survey with the Georgetown Center for Children and Families, only 19 of the 41 expansion states charged any cost sharing on expansion adults. Prescription drugs are the most common charge: 16 states charge for preferred brand-name drugs and 15 for generics and non-preferred brands. Twelve states charge for non-emergency ER and outpatient hospital visits, and 10 for inpatient stays. Four states (Delaware, Louisiana, Maryland, and New Hampshire) charge only for drugs, and Colorado charges only for non-emergency ER visits.
Most states keep amounts under $10 per service. The outliers are all on the inpatient side: Alaska charges $50 per day up to $200 per discharge, Michigan $50 per inpatient stay, and Utah and West Virginia $75 per stay (West Virginia only above 100% FPL). Pennsylvania runs a sliding scale topping out at $3.80. Two states set their own aggregate caps below the federal one: New York at $200 a year, and Utah at $100 a year or 5% of household income, whichever is lower.
So the honest national range for a Medicaid enrollee is $0 to about $75, with $0 to $8 covering the overwhelming majority of encounters. If drug copays are your pressure point, prescription assistance programs can layer on top of Medicaid coverage.
Medicaid Premiums: Who Charges Them and Under What Authority
Under 42 CFR 447.55, states may not charge premiums to enrollees with income at or below 150% of FPL. Since the Medicaid expansion tops out at 138% of FPL, that rule alone takes premiums off the table for most adult enrollees. The narrow exceptions written into the regulation cover certain pregnant people above 150% FPL (capped at 10% of the amount by which income exceeds 150% FPL), working people with disabilities under the Ticket to Work provisions, and disabled children under the Family Opportunity Act, the last two on a sliding scale.
States that want to charge below that line need a Section 1115 demonstration waiver. Indiana’s Healthy Indiana Plan is the standard example. Its published POWER account contribution schedule:
| Household income (% of FPL) | Monthly contribution, single | With tobacco surcharge |
|---|---|---|
| Under 22% | $1.00 | $1.50 |
| 23 to 50% | $5.00 | $7.50 |
| 51 to 75% | $10.00 | $15.00 |
| 76 to 100% | $15.00 | $22.50 |
| 101 to 138% | $20.00 | $30.00 |
Indiana also charges $8 for non-emergency ER use, matching the federal maximum. Worth flagging a cross-source discrepancy: the state’s page describes these contributions as current, while KFF’s January 2026 survey notes that cost sharing in Indiana’s 1115 waiver population is currently paused. Confirm with the state before assuming either.
What Changes on October 1, 2028
This is the biggest shift in Medicaid cost sharing since the 2013 rules were written, and it flips the default from optional to mandatory.
Section 71120 of Public Law 119-21 adds a new subsection 1916(k) to the Social Security Act. Reading the enacted text at 139 Stat. 315, beginning October 1, 2028, states must impose cost sharing greater than $0 on “specified individuals,” meaning adults enrolled through the ACA expansion whose family income exceeds the poverty line. The charge may not exceed $35 per item or service.
The guardrails that survive are substantial. Premiums are prohibited outright for this group. The 5% family income cap still applies. Prescription drug cost sharing stays at the existing nominal limits. And the statute carves out primary care services, mental health services, substance use disorder services, and anything furnished by a federally qualified health center, certified community behavioral health clinic, or rural health clinic, on top of the existing service exemptions.
KFF estimates that if states charged the full $35 on every non-exempt service, the average expansion enrollee who used such services would pay about $542 a year. Nothing requires states to go that high; the law only requires an amount above zero. Alaska, Michigan, Utah, and West Virginia will likely have to lower their inpatient charges to comply. North Carolina has gone the other direction, enacting legislation to set copays at the federal maximum starting July 1, 2027.
The Bottom Line
For the 73.5 million people enrolled in Medicaid and CHIP as of May 2026, the program costs almost nothing: $0 in most states for most services, $4 to $8 where copays exist, and never more than 5% of household income across an entire family. Emergency care, family planning, pregnancy care, and children’s preventive care are free by federal law.
Before you pay a Medicaid bill, check it against the exempt-services list above, and check whether your household has already hit the 5% cap. If you are still working out whether you qualify at all, start with Medicaid income limits for 2026, then what Medicaid covers and Medicaid vs. Medicare if you are near 65.