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HEALTH COVERAGE TAX CREDIT (HCTC) WISCONSIN'S STATE
QUALIFIED HEALTH PLAN — BADGERCARE PLUS BENCHMARK PLAN
Printable Version (PDF 123KB)
HOW DO I QUALIFY FOR HCTC?
The HCTC allows workers displaced by foreign industries and
retirees that meet specific criteria to receive an advance federal tax credit
toward the purchase of a qualified private health insurance plan. Those with
questions about their eligibility for the program may call the HCTC Customer
Contact Center at 1-866-628-4282, or go to the HCTC Web site at http://www.irs.gov/
(key word HCTC).
WHAT IS WISCONSIN ’S STATE QUALIFIED HEALTH
PLAN?
Wisconsin’s state qualified plan is called the
BadgerCare Plus Benchmark plan.
WHAT DOES THE BADGERCARE PLUS BENCHMARK PLAN COVER?
COVERED SERVICES
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SERVICE LIMITS
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CO-PAYMENT
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Ambulatory Surgical Centers
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Coverage of certain surgical procedures and
related lab services.
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$15 copayment per visit.
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Chiropractic Services
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Full coverage
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$15 per visit
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Dental Services
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For pregnant women and children only,
limited coverage of preventive, diagnostic, simple restorative,
periodontics, extractions. Limited
to $750 each year.
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50% of allowed amount* plus $200 deductible each
year. Pregnant women are exempt from deductible and
cost-sharing requirements for dental services.
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Disposable Medical Supplies (DMS)
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Coverage of diabetic supplies, ostomy supplies,
and other DMS that are required with the use of durable medical equipment
(DME).
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$0.50 copayment per prescription for diabetic
supplies.
No copayment for other DMS.
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Drugs
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Generic drugs only.
Brand name drugs are available through the Badger
Rx Gold plan. This is a
separate program run by Navitus that provides a discount on the drug cost.
Benchmark plan members are automatically enrolled in this plan.
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$5 each prescription.
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Durable Medical Equipment (DME)
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Full coverage limited to $2,500 each
enrollment year including rental costs.
Hearing aid repairs are subject to the $2,500
enrollment year limit.
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$5 each item. Rental items are
not subject to copayments but count toward the annual limit.
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Emergency Transportation
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Limited to emergency transportation by
ambulance.
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$50 each trip.
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End-Stage Renal Disease (ESRD)
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Full Coverage
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No copayment
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Family Planning Services
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Full coverage, excluding infertility
treatments, surrogate parenting and the reversal of voluntary
sterilization.
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No copayment for family planning
services.
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Health Screenings for Children
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Full coverage of HealthCheck
screenings.
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N/A
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Hearing Services
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Full coverage for members 17 years of age and younger.
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$15 per visit, regardless of the number or type
of procedures administered during one visit.
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Home Health Services (Home Health, Private Duty Nursing
and Personal Care)
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Full coverage of home health services. Coverage
limited to 60 visits per enrollment year.
Private duty nursing and
personal care are not covered.
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$15 each visit.
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Hospice
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Limited to 360 days per lifetime.
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No copayment
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Hospital — Inpatient;
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Full coverage
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Copayments are as follows:
• $100 stay for medical stays.
• $50 copayment per stay for mental health
and/or substance abuse treatment.
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Hospital Outpatient;
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Full coverage
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$15 copayment per visit.
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Hospital Emergency Room
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Full Coverage
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$60 copayment per visit (waived if admitted to hospital).
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Mental Health and Substance Abuse,
including inpatient care
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Covered services include outpatient mental health,
outpatient substance abuse (including narcotic treatment), mental health
day treatment for adults and children, and child/adolescent mental health
day treatment and and inpatient hospital stays for mental health and
substance abuse.
Services not covered are crisis intervention,
community support program (CSP), Comprehensive Community Support (CCS),
outpatient services in the home and community for adults, and substance
abuse residential treatment.
Mental health services
have no dollar maximums.
Substance abuse services
are limited to $7,000. Costs
of mental health services, including inpatient stays, apply to this
overall limit. Also, there are
separate dollar limits for specific substance abuse services:
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$4,500 for outpatient
substance abuse services including
$2,700 for outpatient services (including narcotic treatment) for
substance abuse day treatment.
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$6,300
for inpatient hospital stays in a general acute care hospital.
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Co-payments range from $10 each day to
$15 each visit, depending on the service.
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Nursing Home
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Limited to 30 days each enrollment
year.
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No copayment
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Physician Visits
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Full coverage, including laboratory and
radiology.
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$15 each visit. No copayment for emergency
services, preventive care, anesthesia or clozapine management.
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Podiatry Services
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Full coverage.
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$15 each visit.
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Prenatal/Maternity Care
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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.
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No copayment.
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Routine Vision
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One
eye exam every two years, with refraction.
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$15 each visit.
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Smoking Cessation Services
(Prescription)
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Coverage includes prescription generic
and over-the-counter tobacco cessation products.
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$5 each generic drug.
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Therapy — Physical, Occupational,
Speech, Cardiac
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Therapy (Physical, Occupational and
Speech) is limited to 20 visits per each type of therapy each enrollment
year. Cardiac is limited to 36
visits.
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$15 each visit.
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Transportation
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Coverage limited to emergency transportation by
ambulance.
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$50 copayment per trip for emergency
transportation by ambulance.
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*
Allowed amount is the amount BadgerCare Plus allows for the service, and not
what the provider bills. For more
information, contact Member Services at 1-800-362-3002.
OTHER THINGS TO KNOW ABOUT SERVICES
In order to receive
services, the service must be determined to be medically necessary per Wisconsin
State Statute 101.03 (96m).
Providers know the
BadgerCare Plus coverage limits. The provider must tell you if BadgerCare Plus
doesn’t cover a service before the service is provided.
A provider can charge you
for services that are not covered by BadgerCare Plus if the provider told you
before providing the service that the service wasn’t covered, and you agreed
to pay for the service.
If
you are enrolled in the Benchmark plan and can’t pay your co-payment right
away, the provider may refuse to provide services.
HOW MUCH WILL MY PREMIUM BE?
Premiums for HCTC participants
are based upon age, gender, and the area of the state in which they live.
Based on these factors, individual total premium amounts (before HCTC
reduction) range from approximately $100-$400 per person per month.
HOW
WILL I ACCESS SERVICES?
Each
person who is enrolled in BadgerCare Plus will get a ForwardHealth card.
When
you go to a BadgerCare Plus provider make sure you take the card for the person
who has the appointment. You should
also have your Badger Rx Gold card with you in the event it is needed for brand
name prescriptions.
Providers don’t have to see a person who doesn’t have his/her card. If
you don’t have the card with you, you may be asked to pay for the services.
WHICH PROVIDERS MAY I USE?
For the first few months the
program is available in Wisconsin, HCTC participants will not be not enrolled in an HMO.
During this time, HCTC participants should check with their health care
providers to see if they accept the ForwardHealth card.
If not, call Member Services at 1-800-362-3002 and ask for help finding a
provider. All services must be
provided by a BadgerCare Plus provider.
If you get services from someone who is not, you will be responsible for
paying the cost of the service.
In
the future, new HCTC enrollees will be required to enroll in an HMO, and
existing members will be asked to choose an HMO in order to continue receiving
services.
HOW
CAN I ENROLL IN THE BADGERCARE PLUS BENCHMARK PLAN AS AN HCTC MEMBER, OR GET
MORE INFORMATION?
Call the HCTC Call Center at (608) 266-6740.
P-10181 (07/11)
Last Revised:
July 18, 2011
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