13-01 Version of 21.5 Co-Payment
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State of Wisconsin
Department of Health Services

HISTORY

The policy on this page is from a previous version of the handbook. 

21.5 CoPayment

An EBD Medicaid memberA recipient of Medicaid; formerly referred to as a "client." may be required to pay a part of the cost of a service. This payment is called a “copayment” or “copay.”

 

Members who do not have to pay a copayment are:

 

1. Children under age 18 whose income is at or below 100 percent of the FPLFederal Poverty Level,

2. Pregnant women,

3. Children that are members of a federally recognized tribe, and

4. Nursing home residents

 

Medical services exempt from copayments are:

  1. Emergency hospital and ambulance services and emergency services related to the relief of dental pain.

  2. Services related to pregnancy.

  3. Family planning services and supplies.

  4. Home Health Services

  5. Personal care services.

  6. Case management services.

  7. Outpatient psychotherapy services received that exceed 15 hours or $500, whichever occurs first, during one calendar year.

  8. Occupational, physical, or speech therapy services received that exceed 30 hours or $1,500 for any one therapy, whichever occurs first, during one calendar year.

  9. Hospice care services.

  10. Substance abuse (alcohol and other drug abuse) day treatment services.

  11. Respiratory care for ventilator-assisted members.

  12. CSPCommunity Support Program services.

 

Providers are required to make a reasonable effort to collect the copayment. Copayments range from $0.50 to $3.00 for each procedure or service. Providers may not refuse services to an EBD Medicaid member who fails to make a copayment.

 

 

 

This page last updated in Release Number: 13-01

Release Date: 08/28/13

Effective Date: 08/28/13

The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10030