38.2 List of Covered Services and Copayments

38.2.1 Introduction
38.2.2 Copay Exempt Populations
38.2.3 Copay Exempt Programs
38.2.4 Copay Exempt Services

38.2.1 Introduction

A BadgerCare Plus member may be required to pay a part of the cost of a service. This payment is called a "copayment" or "copay." The following table shows some of the covered services and copayments under BadgerCare Plus.

Services	Description
Chiropractic Services	Full coverage. Copayment $.50 to $3 per service (varies by service provided).
Dental	Full coverage of preventive, restorative and palliative services. Copayment $.50 to $3 per service (varies by service provided).
Disposable Medical Supplies (DMS)	Full coverage. Copayment $0.50 to $3 per service.
Drugs (see also Section 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 five prescriptions per month for opioid drugs. Copayments: $0.50 for OTC Drugs $1 for Generic Drugs $3 for Brand Name Drugs Copayments are limited to $12 per member, per provider, per month. OTCs are excluded from this $12 maximum.
Durable Medical Equipment (DME)	Full coverage. C-payment $0.50 to $3 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. Copayment $1 per screening for those 18, 19 and 20 years of age.
Hearing Services	Full coverage. Copayment $.50 to $3 per procedure. No copayments for hearing aid batteries.
Home Care Services (home health, private duty nursing and personal care)	Full coverage. No copayment.
Hospice	Full coverage. No copayment.
Hospital - Inpatient	Full coverage. Copayment $3 per day with a $75 cap per stay.
Hospital - Outpatient	Full coverage. Copayment $3 per visit.
Hospital - Outpatient Emergency Room	Full coverage. No copayment.
Mental Health and Substance Abuse Treatment	Full coverage (not including room and board). Copayment $.50 to $3 per visit (limited to the first 15 hours or $500 of services, whichever comes first, provided per calendar year). Copayment not required when services are provided in a hospital setting or for residential substance use disorder treatment services.
Nursing Home	Full coverage. No copayment.
Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST)	Full coverage. C-payment $.50 to $3 per provider, per date of service. Copayment obligation is limited to the first 30 hours or $1,500 whichever occurs first, during one calendar year (copayment limits are calculated separately for each discipline.)
Physician Visits	Full coverage, including laboratory and radiology. Copayment $.50 to $3 copayment per service (varies by service provided). Limited to $30 per provider per calendar year. No copayment for emergency services, anesthesia, or clozapine management.
Podiatric Services	Full coverage. Copayment $.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 copayment.
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 copayment for family planning services.
Routine Vision	Full coverage including coverage of eye glasses. Copayment $.50 to $3 per service (varies by service provided).
Smoking Cessation Services	Coverage includes prescription and over-the-counter tobacco cessation products. Copayment (see drugs)
Transportation	Full coverage of emergency and non-emergency transportation to and from a certified provider for a BadgerCare Plus covered service. Copayments are: $2 for non-emergency ambulance trips. $1 per trip for transportation by an SMV. No copayment 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 Copay Exempt Populations

Providers are prohibited from collecting copayment from the following members:

Children under age 19, regardless of income or benefit program.
- Children in foster care, regardless of age.
- Children in adoption assistance, regardless of age.
American Indians or Alaskan Native Tribal members, the son or daughter of a tribal member, the grandson or granddaughter of a tribal member, or anyone otherwise eligible to receive Indian Health Services, 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.
Former Foster Care Youth
Anyone receiving services through Express Enrollment
Pregnant Women

38.2.3 Copay Exempt Programs

Copays will not be charged for members enrolled in the following subprograms:

Family Planning Only Services
Institutional Medicaid (not including childless adults (CLAs) enrolled in BadgerCare Plus and residing in an institution)
Katie Beckett
Wisconsin Well Woman Medicaid

38.2.4 Copay Exempt Services

The following services do not require copayment:

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.
Residential substance use disorder treatment services.
School-based services.
Substance abuse day treatment services.
Surgical assistance.

This page last updated in Release Number: 21-01
Release Date: 03/29/2021
Effective Date: 02/01/2021