21.5 Copayment

An EBD Medicaid member may be required to pay a part of the cost of a service. This payment is called a “copayment” or “copay.”

The following members do not have to pay a copayment:

Children eligible for BadgerCare Plus who are:
- Under age 1 with income at or below 150 percent of the FPL
- Age 1 through 5 with income at or below 191 percent of the FPL
- Age 6 through 18 with income at or below 133 percent of the FPL
Children under age 18 who are eligible for SSI
Children eligible for Katie Beckett
Pregnant women
People who are eligible to receive services from Indian Health Services or an Urban Indian Health Center, members of a federally recognized tribe, or the child or grandchild of a tribal member
Nursing home residents

The following are medical services that are exempt from copayments:

Emergency hospital and ambulance services and emergency services related to the relief of dental pain.
Services related to pregnancy.
Family planning services and supplies.
Home health services
Personal care services.
Case management services.
Outpatient psychotherapy services received that exceed 15 hours or $500, whichever occurs first, during one calendar year.
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).
Hospice care services.
Substance abuse (alcohol and other drug abuse) day treatment services.
Respiratory care for ventilator-assisted members.
CSP 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.

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