by Emily Widra and Dr. Emily Lupez, May 15, 2025
In most states, people incarcerated in prisons must pay medical “copays,”1 which are essentially fees to access health care including physician visits, medications, dental treatment, and other health services. While these fees may seem reasonable at two or five dollars, research shows they actually act as barriers to health care for incarcerated people who typically earn less than a dollar an hour, if they are paid at all. Prison administrators claim these fees deter the “overuse and abuse” of limited health care resources,2 and have countered critiques by including waivers and exceptions in their copay policies and insisting that no one is denied care because they can’t afford to pay. However, our review of these policies and evidence from a recent study show that these exemptions are so limited, ill-defined, and inconsistent that they fail to make the copay system fairer and less harmful for incarcerated people. Instead, these exemptions lend a veneer of rationality to prison medical fee policies — which are known to limit access to care — ultimately helping to perpetuate them.
We reviewed each state’s prison copay policy, including any waivers or exemptions, to build upon the initial findings of Dr. Lupez and her colleagues, which indicated that copay waivers are likely not working as intended. They found that, despite two-thirds of states that charge copays having chronic condition waivers, people with chronic conditions in states charging copays were substantially more likely to have never seen a doctor since admission compared to those in states without copays.3 If copay waivers were being applied routinely and consistently, we would expect people without a chronic condition (i.e., people ineligible for a chronic condition waiver) to be more likely to have never seen a doctor since incarceration, but this was not the case, implying that these waivers are not promoting healthcare access for some of the most vulnerable people in prison.
In research published in 2024, Dr. Lupez and her colleagues found that among people incarcerated in state prisons for any amount of time, more unaffordable copays were associated with worse access to the necessary healthcare, like obstetrical examinations for pregnant people and seeing a medical provider for people with chronic medical conditions. For more details, see New research links medical copays to reduced healthcare access in prisons.
To better evaluate how copays and copay exemptions function in prison systems, we analyzed policies from all states charging medical copays and the federal Bureau of Prisons. While we cannot estimate the frequency with which care is actually exempt from copays, our analysis of the various policies reveals that copay waivers are inevitably inconsistently4 or retroactively applied,5 unclear to incarcerated people,6 and frequently left up to the discretion of a single healthcare provider, administrator, or other correctional staff.7 This helps explain why incarcerated people may expect to be charged a burdensome fee every time they seek medical care, regardless of potential exemptions, and in turn, how that fee functions as a significant barrier to healthcare access.
Key findings from our study of prison copay policiesAlmost all state prison systems charging copays have policies outlining exemptions for some healthcare services for some incarcerated people. Among the 40 prison systems still charging these fees, the exemptions can be based on any number of factors including how the care was requested,8 the specific health condition,9 the type of medical care required,10 and the circumstances leading to treatment.11 Ultimately, we find that copay waiver policies frequently rely on the discretion of individual healthcare providers or correctional staff and are far too limited and have far too many caveats to meaningfully counteract the harmful deterrent effect of copays on healthcare access.
Below, we highlight the most striking examples from our analysis that illustrate why waivers or exemptions still fail to ensure appropriate and equitable access to the care people need.
Staff-initiated versus patient-requested care. In most states (33), incarcerated people are expected to pay a fee if they request their own medical care, but medical care requested or initiated by healthcare staff, correctional staff, or facility administrators is exempt from fees.12 In some cases, this reflects standardized or systems-based visits like mandatory tuberculosis testing, which is more aligned with the priorities of the carceral system (i.e., infection control) than patient needs. Staff-initiated visits force incarcerated people to rely on the prison medical system to monitor when preventative care or chronic health condition follow-ups are due, a process likely hindered by staffing shortages and the absence of sufficient medical record systems.13 Exemptions for care initiated by correctional staff — such as a request for a mental health evaluation — require incarcerated people to depend on correctional staff to access healthcare services, compromising patient privacy — when medical information has to be shared with non-medical staff — and establishing a system where staff exert control over who gets seen by medical providers, undermining patient autonomy.
Medical emergencies. Only 27 prison systems include an explicit exemption for emergency treatment, and in most of those states, the emergency is defined by either healthcare providers14 or departmental staff,15 not the person actually experiencing the medical emergency.16 In seven states with medical fees, incarcerated people are required to pay the fee for emergency medical care if the injury or illness is determined — by medical staff, correctional staff, or in a disciplinary hearing17 — to be self-inflicted.18 An additional two states specify that care provided for self-inflicted injuries are subject to copays (although do not specifically mention emergency medical care). At least one state (Michigan) requires the incarcerated person to pay all costs associated with the treatment of injuries and illnesses determined to be self-inflicted, which is inevitably above and beyond the initial fee for health services; essentially, such policies use medical fees as additional punishment for accidents, self-harm, and mental illness.19 In our survey of state policies, we only found two states with policies specifying that people with serious mental illness could be exempt from the fees associated with medical care for self-harm20 and only one other state (Texas) that exempts medical treatment for all self-inflicted injuries from medical fees. Policies charging fees for medical care needed for self-inflicted injuries are particularly cruel given the mental health harms caused by incarceration itself. In states that punish self-harm this way, incarcerated people not only have to suffer these injuries — they must also financially pay for them.
Work-related injuries. Almost half of prison systems that charge copays (17) have some exemption for medical care associated with work-related injuries. In some prison systems, only the initial medical treatment for a work-related injury is exempt,21 and in others, the treatment for work-related injuries is exempt from the medical fee only if it is a medical emergency.22 In some prison systems, the treatment for work-related injuries is only exempt if it was reported at the time of the injury and is verified by an incident report (filed by correctional staff).23 Like the exemption for emergency care, this exemption relies entirely on the accuracy and timeliness of staff reporting workplace incidents. It’s also worth noting that incarcerated workers generally do not have the workplace health and safety protections that people do outside of prisons (such as those enforced by the Occupational Safety and Health Administration or similar state programs). They are also often exposed to dangerous work conditions. So it’s remarkable that when incarcerated people are injured under work conditions controlled by the prison system itself, they are often still assessed medical fees and experience lost wages, given the lack of standard labor protections like sick leave.
Chronic health conditions. While most states (26) have exemptions related to care for chronic health conditions like cardiovascular disease, diabetes, HIV, or mental illness, many (17) of these exemptions only apply if the appointment is scheduled by a health care provider or as a part of a recurring “clinic,” not if the individual seeks additional care outside of previously scheduled appointments.24 Someone who meets the exemption criteria may also need to pay copays for the initial two or three nursing sick call visits before clinicians identify them as someone who should be exempt from copays.25 In Alaska, for example, people with chronic conditions are charged a $5.00 fee for their initial provider visit and $5.00 every year “for ongoing treatment of the chronic condition.” At least three states (Georgia, Indiana, and Oklahoma) mention an exemption for fees associated with prescriptions for chronic conditions, but do not exempt chronic condition-related provider visits or other treatments from the fee.26 People in state prisons suffer disproportionately from chronic health conditions when compared to the total U.S. population, and financial barriers to treatment will only exacerbate the poor health outcomes of incarceration.27
Pregnancy-related care. In 18 prison systems, some or all of the care related to pregnancy is exempt from copays. In some states, like Arizona and New Hampshire, they are only exempt from copays for pregnancy-related medical care (i.e., they would not be exempt from copays for treatment for a non-pregnancy-related illness or injury).28 Five states and the federal Bureau of Prisons only exempt prenatal care (care while pregnant) with no mention of delivery-related care or postpartum medical care.29 At least three states explicitly exempt postpartum medical care from copays.30 About 4% of people (or 3,500) in women’s prisons in 2016 — disproportionately women of color — were pregnant at admission, and many of them did not received the basic prenatal care you would expect, like an obstetric exam, medication, special diets, testing, or pregnancy education. Given that many prison systems seem to have limited or no policies exempting pregnant people from medical copays, many may not seek care during their pregnancy. Combined with a lack of robust healthcare resources in prison to identify people in need of care, it’s no wonder many pregnant people are not receiving necessary medical care.
Menstrual health. Only one state’s copay exemption policy makes any mention of menstrual health: in Arizona, people “who require additional feminine hygiene products due to medical issues” can complete a form and submit it to Health Services, and the copay is waived for the subsequent medical appointment. Only half of state prison systems (25) are required by law to provide menstrual products, and only 18 of those systems are obligated to provide those products for free.31 Not only do many women have to pay for their menstrual products, but they also must pay for any healthcare related to problems caused by inadequate access to menstrual products. For the more than 85,000 women in prison in 2023, inadequate access to period products and reproductive healthcare can have serious health consequences, and almost every single prison copay policy fails to even address menstrual health.
Substance use. Only eight states and the federal Bureau of Prisons explicitly exempt substance use related healthcare from medical copays. Even when healthcare providers refer people to substance use treatment, incarcerated patients are frequently charged for their initial request for an appointment with the provider, and many incarcerated people may not know how to access treatment without being charged copays and fees. Any perceived barrier to accessing substance use treatment behind bars has serious consequences for the more than half-million people in prison who reported a substance use disorder in the year before their admission.32
Vaccinations. About one-quarter of prison systems with copays (13) waive them for vaccinations explicitly. Even when vaccinations are exempt from copays, there are often additional caveats: in West Virginia, the waiver only applies to vaccinations and preventative care “provided or made available to all inmates.” While these exemptions may clearly apply to the distribution of the COVID-19 vaccine in 2021, it is unclear how this may play out when an incarcerated person requests a specific vaccine that may not be offered to the entire facility population, like the HPV vaccine,33 the pneumococcal vaccine,34 or Hepatitis B vaccine.35
In addition to these highlighted findings, we have categorized the state copay policies we found according to the conditions or types of medical care that are exempt (and under what circumstances) and compiled this information in our appendix table.
Conclusion“Copay” fees for medical care in prison are unaffordable at prison wages. They deter necessary care for an incarcerated population that faces many medical conditions — often at higher rates than national averages — and that routinely receives inadequate health services behind bars. The copay waiver policies ostensibly meant to “fix” this problem of copays deterring necessary care are, in many states, extremely limited with only a handful of care types or medical conditions exempted. Oftentimes, the exemptions are so ill-defined and inconsistent that it is hard to imagine any fair, consistent implementation of these policies. Many incarcerated people may be unaware that such waivers exist at all; even if they are aware, the complexity of the waiver criteria makes it nearly impossible for them to determine whether, when, or how a waiver might apply to their care.
Ultimately, we conclude that these copay exemption policies fail to make the copay system any less harmful for incarcerated people, especially the large number of incarcerated people with chronic medical needs. Instead, these exemptions simply give cover to prison systems that limit access to care and prioritize their bottom lines by imposing medical fees on a largely poor, medically vulnerable population with no other options.36 Rather than tinkering with the edges of these policies through waivers and exemptions, prison systems should drop copays altogether.
Appendix Table Jurisdiction Copay amount Intake or transfer Routine Vaccinations Communicable diseases Chronic conditions Diagnostics Pregnancy-related Sexual-assault related treatment Mental health treatment Substance use Emergency Staff-initiated Prescription medications Medical or mobility devices Infirmary, hospitalization, and/or inpatient care Work-assignment related Other notable exemptions Relevant legislation Sources Alabama $4.00 Intake only (includes mental health and dental) Yes (includes dental) Yes (includes sexually transmitted infections) Yes, in chronic care clinic if staff-initiated If on-site Pregnancy-related or postpartum care If on-site If on-site If “non-self-inflicted” (includes dental) Yes Some (chronic condition refills) Infirmary Yes (if not subject to workers compensation or job insurance) Missed appointments (for some reasons) DOC Admin. Reg. 703 (2023) Alaska37 $5.00 Intake only Yes Yes, but initial visit subject to copay and must pay $5.00/year for ongoing treatment of chronic condition after first year Pregnancy-related care Assessments and screenings Some (communicable diseases, psychiatric) Medication line visits DOC Policy 807.07 (2016) Arizona $5.00 (maximum) At reception centers or when returned to custody Only Hepatitis C-related (in ADCRR) or HIV/AIDS related (in ADCRR and contracted beds) Yes Pregnancy-related care If serious mental illness is present (in ADCRR and contracted beds); if ASPC-Phoenix psychiatric hospital or mental health center Yes (includes people requiring administrative examinations like “response to suicide prevention/watch”) People with developmental disabilities; people “who require additional feminine hygiene products due to medical issues;” minors DOC Dept. Order 1101 (2018) and Glossary of Terms Arkansas $5.00 (maximum) Intake only (includes dental) Yes (includes dental) Only if related to testing/prevention Yes, in chronic care clinic Yes Yes Yes (includes dental) DOC Policy AR 0893 (2005) Colorado $3.00 Intake only Yes If instituted by department for public health reasons or related to a state/national emergency Yes (includes initial sick call requested later determined to be due to chronic condition) Yes, unless “no-show” Pregnancy-related care Yes (includes mental health) Intake screenings, emergencies, in residential treatment program, or if serious mental illness is present If related to chronic care condition Yes (includes dental) Infirmary Comfort and/or end-of-life care; disability status screenings; medical care related to a “vision, hearing, or lower extremity mobility disability”; “A $5.00 co-pay fee will be charge dfor self-declared emergencies that may or may not require transport outside of the facility” Proposed legislation to end medical copays in prison (Colo. H.B. 25-1026 (2025)) DOC Admin. Reg. 700-30 (2024) Connecticut $3.00 If scheduled Yes If necessary per staff Yes (includes dental) If court commitment conflicts with specialty appointment DOC Administrative Directive 3.12 (2020) Delaware $4.00 Intake only Yes Yes, in chronic care clinic (includes mental health) Yes Yes Yes Yes Some (psychiatric) Glasses (first pair) Infirmary Health assessments required by policy; “Co-pays will not be charged when seen by one or more providers for the same problem three times in a seven-day period.” DOC Policy E-01.1 (2021) Federal $2.00 Yes For chronic infectious diseases If staff-approved Prenatal care Yes Yes Yes Yes BOP Program Statement 6031.02 (2005) Florida $5.00 Intake only If follow-up routine care If instituted by department for public health reasons, requires medical action to protect others from a communicable disease, or is a voluntary HIV test request If staff-initiated Yes Yes Care that is “provided in connection with an extraordinary event that could not reasonably be foreseen, such as a disturbance or a natural disaster” 2024 Fla. Stat. S 945.6037 Georgia $5.00 Intake only Yes (excludes “minor infections such as a cold or influenza”) Prenatal and obstetrical care Yes Yes38 Yes Some (communicable diseases, chronic conditions, antibiotics) If “deemed necessary” by staff Examination following use of force DOC Policy 507.04.05 (2022) Hawaii $3.00 Yes (includes mental health and dental) Yes (includes sexually transmitted infections) Yes Pre- and post-natal care Yes (includes patient-initiated) Infirmary Yes “Special needs incarcerated individuals with mental health disabilities or disorders that interfere with the ability to carry our normal activities are exempt from the copayment plan. This includes, but is not limited to, instances of self-mutilation, suicide attempts or incarcerated individuals in special holding or therapeutic housing units.” DOC Policy COR.10.A.11 (2024) Idaho $2.00 Yes (includes dental) Only tuberculosis prophylaxis Yes, in chronic care clinic Yes Yes Yes Yes Yes Glasses (once every two years with prescription) Infirmary for chronic condition Yes DOC Procedure Control Number 411.06.03.001 (2018) Indiana $5.00 Yes Yes (annual) Yes If instituted by department for public health reasons Yes Yes Yes Yes Yes Some (psychiatric, chronic, neuroleptic) Glasses, dentures, ostomy supplies, stockings, braces Yes “The service is provided as a result of an injury received while in the custody of the department” 210 Ind. Admin. Code Article 7 (2025) Iowa $3.00 Yes (includes mental health and dental) Yes (includes eye exams) Sexually transmitted infections testing and prophylaxis If staff-initiated (includes mental health) or if civilly committed For emergency care, forensic medical examinations, and STI prophylaxis Intake screenings or if staff-initiated If determined by staff Yes Some (see policy) If not associated with patient negligence Skilled care; exposure to chemical agents “not associated with patient negligence” DOC Policy HSP-505 (2020) Kansas $2.00 Intake only Yes If staff-initiated or for group sessions Yes Yes Infirmary Evaluations requested by the Prisoner Review Board Kan. Admin. Regs. S 44-5-115c (2024) Kentucky $3.00 Yes Yes, in chronic care clinic Yes DOC Policy 13.2 (2025) Louisiana $2.00 Yes Yes (annual) Yes If instituted by department for public health reasons or patient-initiated requests related to “pandemic threat” Yes (includes DNA testing) Prenatal care PREA assessments If provided by mental health staff If provided by mental health staff Yes Some (communicable diseases, psychiatric) Glasses, prosthetics, dentures, Durable Medical Equipment (DME) Yes (as determined by the warden) “Any other instance the Secretary deems appropriate, expressed in writing.” DPSC Dept. Regulation No. HCP14 (2024) via email Maine $5.00 All care while pregnant Only if serious mental illness or developmental disability is present39 or if inpatient at a state-funded mental health facility If necessary per staff (includes dental) Yes Proposed legislation to raise the copay maximum to $25.00 (L.D. 18 (132nd Legis. 2025)) 34-A ME Rev Stat S 3031 (2024) Maryland $2.00 Yes Yes Yes Yes PREA assessments Yes Yes Yes DOC Executive Directive OPS.130.0001 (2015) and Md. Code, CS S 2-118 (2024) Massachusetts $3.00 Intake only (includes mental health and dental) Yes (includes pre- and post-test HIV counseling) Yes Yes Prenatal and delivery care Yes Yes Yes (includes dental) Yes Yes Yes Care for terminally ill patients; care for patients hospitalized more than thirty (30) days successively during their incarceration; care for minor; “non-compliance counseling including counseling regarding medication compliance” Proposed legislation to end medical copays in prison (Mass. H.2372 (2023)) 103 DOC 763 (2024) Michigan $5.00 Testing only (includes sexually transmitted infections) Yes If medical care is received or referred “within one hour” and is not “an intentional self-inflicted injury” Yes (with incident report) DOC Policy Directive 03.04.101 (2022) Minnesota $5.00 Yes Yes If staff-initiated Yes Yes40 Yes Some (chronic conditions) Yes (with incident report) Initial evaluation and treatment of injuries from an assault DOC Policy 500.100 (2018) Mississippi $6.00 Yes Yes If instituted by department for public health reasons Yes, in chronic care clinic or if “felt non-chargeable by the medical staff” Yes Prenatal care Yes (includes patient-initiated) Yes Yes Missed appointments (for some reasons) Inmate Handbook (2023) New Hampshire $3.00 At reception centers or in first 14 days of incarceration If staff-initiated Pregnancy-related care If emergency, secure psychiatric unit or if serious mental illness or developmental disability is present If staff-verified (includes dental) Yes Sick-call visit for medication refills Initial prosthetics or functional aid devices determined to be medically necessary Inpatient Care for minors; people in maximum security and “punitive segregation” unless they request medical care NH DOC Policy Dir. Health Services 6.16 (2009) via email and NH Rev Stat S 622:31-a (2024) New Jersey $5.00 Yes Yes If instituted by department for public health reasons Yes (includes patient-requested HIV testing) Yes Yes If requiring emergency transport to hospital Yes (includes dental) Some (psychiatric) Infirmary Medication provided immediately during a medical visit N.J.A.C. 10A:16-1.5 (2025) North Carolina $5.00 Intake only Yes Yes Yes Yes, in chronic care clinic if staff-initiated If staff-verified If occurring within 14 days of initial visit Yes and residential facilities (including for mental health) Yes (with incident report) Medical examinations or treatment required following use of force, automobile accidents, fire and smoke incidences, and extraordinary events such as a riot or natural disaster; people in private substance abuse treatment centers, county jails, “safekeepers”41, out-of-state facilities, community transition center, or assigned to residential mental health, inpatient mental health, medical infirmary, or medical inpatient. DAC Policy S.1300 (2023) North Dakota $3.00 Yes “Pre-existing conditions must have been diagnosed within the past 60 days to quality for exemption from the co-pay, unless the 60-day time frame is waived by DOCR medical or by appeal;” “Pre-existing conditions are subject to co-pay at least every 60 days” DOC Handbook (2021) Ohio $2.00 Yes Yes If “an actual emergency exists” Yes (includes services following staff reports of sexual assaults and use of force) Medication refills (even if through sick-call) Yes Yes, for accidents Dental services DRC Policy 68-MED-15 (2022) Oklahoma $4.00 Intake only Yes Yes If prescribed for public health reasons Yes Prenatal, perinatal, and postpartum care Yes Yes Yes (includes dental) Some (chronic conditions) Yes, initial acute treatment DOC Policy OP-140117 (2024) Pennsylvania $5.00 Yes (includes mental health and dental) If requested by department (includes dental and mental health) Yes If prescribed for public health reasons If staff-initiated Yes Prenatal care Yes Yes Unless “self-inflicted” (as determined by staff) Yes Some (chronic conditions, psychiatric) Glasses, dentures, prosthetics (excludes customized items and orthotics) Yes42 Yes “Long-term care for an inmate who is not in need of hospitalization, but whose needs are such that they can only be met on a long-term basis or through personal or skilled care, and who needs the care because of age, illness, disease, injury, convalescence or physical or mental infirmary.” DOC Policy DC-ADM 820 (2021) Rhode Island $3.00 Yes Yes, for people 40+ years of age (annual) Yes If instituted by department for public health reasons If staff-initiated (includes mental health) If on-site Prenatal care If on-site Yes If provided in an emergency room/urgent care center (includes emergency transportation) Yes Some (chronic conditions) Initial prosthetic limbs, “essential” mechanical aids as determined by department Annual dental cleaning; people who have applied for Medical Parole, but were denied for non-medical reasons; missed appointments (for some reasons) DOC Policy No. 2.28-3 (2007) South Carolina $5.00 Yes Yes If instituted by department for public health reasons or during a known public health disease outbreak Yes, in chronic care or infectious disease clinic Yes Yes Some (psychiatric)43 Infirmary Yes (with incident report or if sent by supervisor) Hospice care DOC Policy HS-18.17 (2023) South Dakota $3.00 Intake only If instituted by department for public health reasons Yes, in chronic care clinic Yes Pregnancy-related care Yes (includes mental health) Yes If resulting in hospital admission (includes dental) Yes (includes referrals to external specialty health care services) Medical housing unit Hospice or end-of-life care; disability status screenings DOC Policy 700-30 (2024) Tennessee $3.00 Yes (includes mental health and dental) Yes Only tuberculosis testing/screening Yes, in chronic care clinic if staff-initiated Yes Yes, excludes initial visit for pregnancy test Yes (includes mental health) Yes Yes Yes (includes dental) Infirmary Yes DOC Policy 113.15 (2020) Texas $13.5544 Yes (includes mental health and dental) Yes (annual) Yes Yes, in chronic care clinic (includes mental health) As part of intake process Prenatal care (includes counseling) Yes Yes (includes mental health and dental) Yes (includes dental) Yes Infirmary Physical evaluations following use of force incidents; procedures or testing ordered by a court or pursuant to state law; testing on behalf of third parties (paternity tests, compatibility for donation tests); medical treatment of self-inflicted injuries; no copay charged for “no-shows” because a visit did not occur Tex. Gov’t Code S 501.063 (2023) and DOC Admin. Dir. AD-06.08 (rev. 7) (2019) via public records request Utah $5.0045 Utah Code S 64-13-30 (2024) and UT Division of Correctional Health Services FAQ Washington $4.00 Intake only Yes (includes mental health) In residential treatment units or if staff-initiated If staff initiated and not for “self-induced injury” Yes (includes dental) Yes (with incident report) Medication distribution; court ordered evaluations DOC Policy 600.025 (2023) West Virginia $3.00 If provided or made available to total custody population Yes Yes Treatment for severe mental illness Unless “self-induced” Yes Some (chronic conditions) Care required by state law DOC Policy Dir. 424.01 (2023) Wisconsin $7.50 Intake only (includes dental) If determined by staff (includes dental) Yes (includes dental) Yes Medical, dental, or nursing care for people in juvenile correctional facilities who do not have “the opportunity to earn wages” Wis. Admin. Code DOC 316.04 (2024)A handful of states have ended their use of copays and are therefore not included in this appendix table: California, Illinois, Missouri,46 Montana,47 Nebraska, Nevada, New Mexico, New York, Oregon, Vermont, Virginia,48 and Wyoming.
DefinitionsSee the appendix table and footnotes
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