38.2 Standard Plan

38.2.1 Introduction

Effective April 1, 2014, all BadgerCare Plus members are covered under the Standard Plan. The following chart shows some of the covered services and co-payments under the Standard Plan.

Services	BadgerCare Plus Standard Plan
Chiropractic Services	Full coverage. Co-payment $.50 to $3 per service (varies by service provided).
Dental	Full coverage of preventive, restorative and palliative services. Co-payment $.50 to $3 per service (varies by service provided).
Disposable Medical Supplies (DMS)	Full coverage. Co-payment $0.50 to $3.00 per service.
Drugs (See also 38.7 Impact on Dual Eligible Individuals)	Comprehensive drug benefit with coverage of generic and brand name prescription drugs and some over-the-counter (OTC) drugs. Members are limited to 5 prescriptions per month for opioid drugs. Co-payments: $0.50 for OTC Drugs $1.00 for Generic Drugs $3.00 for Brand Name Drugs Co-payments are limited to $12.00 per member, per provider, per month. OTCs are excluded from this $12.00 maximum.
Durable Medical Equipment (DME)	Full coverage. Co-payment $0.50 to $3.00 per item (varies by item provided). Rental items are not subject to a co-payment.
Health Screenings for Children	Full coverage of Health Check screenings and other services for individuals under age 21 years. Co-payment $1 per screening for those 18, 19 and 20 years of age.
Hearing Services	Full coverage. Co-payment $.50 to $3 per procedure. No co-payments for hearing aid batteries.
Home Care Services (home health, private duty nursing and personal care)	Full coverage. No co-payment.
Hospice	Full coverage. No co-payment.
Hospital - Inpatient	Full coverage. Co-payment $3 per day with a $75 cap per stay.
Hospital - Outpatient	Full coverage. Co-payment $3 per visit.
Hospital - Outpatient Emergency Room	Full coverage. No co-payment.
Mental Health and Substance Abuse Treatment	Full coverage (not including room and board). Co-payment $.50 to $3 per visit (limited to the first 15 hours or $500 of services, whichever comes first, provided per calendar year). Co-payment not required when services are provided in a hospital setting.
Nursing Home	Full coverage. No co-payment.
Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST)	Full coverage. Co-payment $.50 to $3 per provider, per date of service. Co-payment obligation is limited to the first 30 hours or $1,500 whichever occurs first, during one calendar year (co-payment limits are calculated separately for each discipline.)
Physician Visits	Full coverage, including laboratory and radiology. Co-payment $.50 to $3 co-payment per service (varies by service provided). Llimited to $30 per provider per calendar year. No co-payment for emergency services, anesthesia or clozapine management.
Podiatric Services	Full coverage. Co-payment $.50 to $3 per service.
Prenatal/Maternity Care	Full coverage, including prenatal care coordination and preventive mental health and substance abuse screening and counseling for pregnant women at risk of mental health or substance abuse problems. No co-payment.
Reproductive Health Services	Full coverage, excluding infertility treatments, surrogate parenting and related services, including but not limited to artificial insemination, and subsequent obstetrical care as a non covered service, and the reversal of voluntary sterilization. No co-payment for family planning services.
Routine Vision	Full coverage including coverage of eye glasses. Co-payment $.50 to $3 per service (varies by service provided).
Smoking Cessation Services	Coverage includes prescription and over-the-counter tobacco cessation products. Co-payment (see drugs)
Transportation	Full coverage of emergency and non-emergency transportation to and from a certified provider for a BadgerCare Plus covered service. Co-payments are: $2 for non-emergency ambulance trips. $1 per trip for transportation by an SMV. No co-payment for transportation by common carrier or emergency ambulance.

If you or the member has additional questions, contact Member Services at 1-800-362-3002.

38.2.2 Copayment

A BadgerCare Plus member may be required to pay a part of the cost of a service. This payment is called a "co-payment” or "co-pay”.

Through March 31, 2014, the co-payment policy is as follows:

Exempt from Co-payments

Children under age 19 with family income up to 100% of the FPL.
Children under age 6 with family income above 100% up to 150% of the FPL, except for Continuously Eligible Newborns.
Children ages 1 through 5 who are Tribal members with family income from 185% to 300% of the FPL.
Children ages 6 through 18 who are Tribal members with family income from 150% to 300% of the FPL.
Children under age 19 eligible through Express Enrollment.
Children under age 19 in an institution.
Children under age 19 eligible under a BadgerCare Plus Extension
Pregnant women, except for pregnant girls under age 19 with family incomes above 300% of the FPL.
Pregnant women eligible through Express Enrollment.
Pregnant women eligible for the prenatal benefit.

Standard Plan - Nominal Co-payments

Continuously Eligible Newborns with family incomes above 100% up to 200% of poverty.
Children under age 6 with family income above 150% up to 200% of poverty.
Children ages 6 through 18, with family income above 100% up to 200% of poverty.
Children under age 19 with family income above 150% of poverty who have met a deductible.
Parents and caretakers up to 200% of poverty.
Parents and caretakers in BadgerCare Plus Extensions.
Youths Exiting Out-of-Home Care.
Transitional Grandfathered parents and caretakers.

Members covered under the Standard plan will have co-payments ranging from $0.50 to $3.00. Providers are required to make a reasonable effort to collect the co-payment but may not refuse services to a member who fails to make that payment.

Effective April 1, 2014, the co-payment policy is as follows:

Providers are prohibited from collecting co-payment from the following members:

Children in a mandatory coverage category. In Wisconsin, this includes:
- Children in foster care, regardless of age.
- Children in adoption assistance, regardless of age.
- Children under age one with income up to 150 percent of the FPL.
- Children ages 1 through 5 with income up to 185 percent of the FPL.
- Children ages 6 through 18 years of age with incomes at or below 133 percent of the FPL.

Children in the Katie Beckett program, regardless of age.
Children under 19 eligible through Express Enrollment.
Children who are American Indian or Alaska Natives who are enrolled in the state's CHIP.
American Indians or Alaskan Natives, regardless of age or income level, when they receive items and services either directly from an Indian health care provider or through referral under contract health services.
Terminally ill individuals receiving hospice care.
Nursing home residents.
Women enrolled in Wisconsin Well Woman Medicaid.

The following services do not require co-payment:

Case management services.
Crisis intervention services.
Community support program services.
Emergency services.
Family planning services, including sterilizations.
HealthCheck.
HealthCheck "Other Services."
Home care services.
Hospice care services.
Immunizations.
Independent laboratory services.
Injections.
PDN and PDN services for ventilator-dependent members.
Pregnancy related services.
Preventive services with an A or B rating from the U.S. Preventive Services Task Force.
School-based services.
Substance abuse day treatment services.
Surgical assistance.

This page last updated in Release Number: 14-02

Release Date: 05/14/14

Effective Date: 04/01/14