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Covered Services and Co-payments — Benchmark Plan

The following lists the services covered under the Benchmark Plan as well as any limitations on the services.  Some services require you to make a copayment.  

Please Note: If you are enrolled in the Benchmark plan and cannot pay your copayment right away, the provider may refuse to provide the service.  

• Ambulatory Surgery Centers — Coverage of certain surgical procedures and related lab services.  Copayment of $15 per visit

• Chiropractic Services — Copayment of $15 per visit

• Dental services — Limited coverage of preventive, diagnostic, simple restorative, periodontics, and surgical procedures for pregnant women and children. Coverage is limited to $750 per enrollment year. A $200 deductible applies to all services except preventive and diagnostic. Cost-sharing equal to 50 percent of allowable fee on all services. Pregnant women are exempt from deductible and cost-sharing requirements for dental services. 

• Disposable Medical Supplies (DMS) — Coverage of diabetic supplies, ostomy supplies, and other DMS that are required with the use of durable medical equipment (DME). $0.50 copayment per prescription for diabetic supplies. No copayment for other DMS. 

• Drugs — (Prescription drugs) No copayment for other DMS. Members will be automatically enrolled in the BadgerRX Gold Plan.  This is a separate program administered by Navitus Health Solutions. $5 copayment with no upper limits.  

• Durable Medical Equipment (DME) — Full coverage up to $2,500 per enrollment year.  $5 copayment per item.  Rental items are not subject to copayment but count toward the $2,500 enrollment year limit.  Hearing aid repairs are subject to the $2,500 enrollment year limit.  The following items do not count towards the $2,500.00 enrollment year limit: 

  • Hearing aids, hearing aid batteries, and accessories.

  • Bone-anchored hearing aids.  

  • Cochlear implants. 

• End-Stage Renel Disease (ESRD) — Full coverage with no copayment.

• Health Screenings for Children — No copayment for individuals age 17 and under.  $1 copayment for members age 18, 19 and 20.

• Hearing Services — Full coverage for members 17 years of age and younger. $15 per visit, regardless of the number or type of procedures administered during one visit. 

• Home Care Services (home health, private duty nursing and personal care) — Full coverage of home health services. Coverage is limited to 60 visits per enrollment year.  Private duty nursing and personal care services are not covered.  $15 copayment per visit.  

• Hospice Care — No copayment.  Services are limited to 360 days lifetime.

• Inpatient Hospital  — Copayments are as follows:

  • $100 per stay for medical stays,

  • $50 for mental health or substance abuse.

• Mental Health and Substance Abuse Treatment — Covered services include outpatient mental health, outpatient substance abuse (including narcotic treatment), adult mental health day treatment for adults, substance abuse day treatment for adults and children, child/adolescent mental health day treatment, and inpatient hospital stays for mental health and substance abuse. Services not covered are crisis intervention, community support program, comprehensive community services, outpatient mental health services in the home and community for adults, and substance abuse residential treatment. $10 to $15 copayment per visit for all outpatient hospital services: 

  • $10 per day for all day treatment services

  • $15 per visit for narcotic treatment services (no copayment for lab tests)

  • $15 per visit for outpatient mental health diagnostic interview exam, psychotherapy — individual or group (no copayment for electroconvulsive therapy and pharmacological management).

  • $15 per visit for outpatient substance abuse services. 

• Nursing Home — Services are limited to 30 days per enrollment year. No copayment.

• Outpatient Hospital - Emergency Room — Full coverage.  $60 copayment per visit (waived if the member is admitted to a hospital). co-payments are $15 for each visit.  Stays in a general acute hospital for substance abuse are limited to $6,300 each year. Inpatient stays for mental health and substance abuse are limited to $7,000 each year. Other limits include:

• Outpatient Hospital — Full Coverage.  $15 copayment per visit.

• Physicians Visits (doctors) includes laboratory and radiology — Full coverage. Copayment or $15 per visit.  No copayment for emergency services, preventive care, anesthesia or clozapine management.

• Podiatry Services — Full coverage. Copayment of $15 each visit.

• Prenatal/Maternity Care  — Full coverage, including Prenatal Care Coordination and preventive mental health and substance abuse screening and counseling for women at risk of mental health or substance abuse problems. No copayment.

• Reproductive Health Services — Full coverage, excluding infertility treatments, surrogate parenting, and the reversal of voluntary sterilization. No copayment for family planning services. 

• Therapy Services: Physical Therapy (PT) , Occupational Therapy (OT), Speech and Language Pathology (SLP) — Full coverage.  Limited to 20 visits per each type of therapy per enrollment year.  Also covers up to 36 visits per enrollment year for cardiac rehabilitation provided by a physical therapist.  The cardiac rehabilitation visits do not count towards the 20 PT visits. Covers up to a maximum of 60 SLP therapy visits over 20-week period following a bone anchored hearing aid or cochlear implant surgeries for members 17 years of age and younger. These SLP services do not count towards the 20-visit limit for SLP. Copayment of $15 per visit.  There are no monthly or annual copayment limits.

• Transportation (Emergency Ambulance/Specialized Medical Vehicle/Common Carrier) — Full coverage of emergency and non-emergency transportation to and from a certified provider for a covered service. Copayment are as follows:

  • $50 per trip per trip for emergency transportation by ambulance.

  • $1.00 copayment per trip for transportation by SMV.

  • No copayment for transportation by common carrier. 

• Vision (Routine) — One eye exam per enrollment year, with refraction.  Copayment of $15 per visit.

*Allowed amount is the amount BadgerCare Plus allows for the service and not what the provider bills. For more information, contact 1-800-362-3002.

You will not have a co-payment if you are a:

• Child under age 19 with family income up to 100% of the FPL.

• Child under age 6 with family income above 100% up to 150% of the FPL, except for newborns enrollment because his/her mother was enrolled on the newborns birth date.

• Child ages 1 through 5 who are Tribal members with family income from 185% to 300% of the FPL.

• Child ages 6 through 18 who are Tribal members with family income from 150% to 300% of the FPL.

• Child under age 19 enrolled through Express Enrollment.

• Child under age 19 in an institution.

• Child under age 19 enrolled in a BadgerCare Plus Extension

• Pregnant woman, except for pregnant woman under age 19 with family income above 300% of the FPL.

• Pregnant woman who was enrolled through Express Enrollment.

• Pregnant woman enrolled in BadgerCare Plus Prenatal Services benefit.

Last Revised: June 21, 2011