21.5 Copayment

21.5.1 Introduction

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.”

21.5.2 Copay Exempt Populations

Providers are prohibited from collecting copays from the following members:

Children under age 19 regardless of income or benefit program.
Children in foster care, regardless of age. or
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

21.5.3 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

21.5.4 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.
School-based services.
Substance abuse day treatment services.
Surgical assistance.

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: 20-03
Release Date: 08/03/2020
Effective Date: 07/01/2020

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