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Table of Contents>>Core Plan Covered Services>>

BadgerCare Plus Core Plan

Core Plan — Covered Services and Copays

Please Note: Core Plan covered services and copays can change. To see if the service you need is covered or if there are any limits, you should ask your health care provider.

You may be required to pay a copay. You may have more than one copay if you get more than one service.

Example: If you saw your doctor and you also had an X-ray, you would have two copays — one for the doctor’s visit and one for the X-ray. Members covered under the Core Plan may be refused services if the copay is not paid at the time the service is provided.

Core Plan Covered Services/Copay/Limits
Ambulatory Surgical Centers (ASC)
Coverage of certain surgical procedures and related lab services. $3 copay per service.
Chiropractic Services
Full coverage — $0.50 to $3 copay per service.
Dental
Coverage limited to certain emergency services. No copay.
Disposable Medical Supplies (DMS)

Coverage of certain diabetic supplies, ostomy supplies, and other DMS that are required with the use of durable medical equipment. $0.50 to $3 copay per service and $0.50 per prescription for diabetic supplies.
Drugs - Prescription

Generic-only formulary drug benefit with a limited number of over-the-counter drugs. Some brand name drugs are covered. Up to $4 copayment for generic drugs and up to $8 for brand name drugs with a $24 copay limit per month, per provider.

Limit of 5 opioid prescription fills per month.

Members will be automatically enrolled in BadgerRx Gold. This is a separate program administered by Navitus Health Solutions. More information about Rx Gold can be found at badgerrxgold.com.
Durable Medical Equipment (DME)

Full coverage up to $2,500 per enrollment year — $0.50 to $3 copay per item.

Rental items are not subject to copay but count toward the $2,500 annual limit.
End Stage Renal Disease (ESRD)
Full coverage — No copay.
Home Care Services (Home Health, Private Duty Nursing [PDN], and Personal Care
Coverage of home health services for 30 days following an inpatient stay if discharge from the hospital is contingent on the provision of follow-up home health services. Coverage is limited to 100 visits within the 30-day post-hospitalization period. No copay.
Hospice
Full coverage. — No copay
Hospital — Emergency Room
Full coverage. $3 copay for members with income up to 100 % of the FPL. $60 copay per visit for members with income from 100 % to 200 % of the FPL (waived if the member is admitted to a hospital).
Hospital — Inpatient

Full coverage (not including inpatient psychiatric stays in either an Institute for Mental Disease [IMD] or the psychiatric ward of an acute care hospital and inpatient substance abuse treatment).

$3 copay per day for members with income up to 100 % of the Federal Poverty Level (FPL) with a $75 cap per stay.

$100 copay per stay for members with income from 100 % to 200 % of the FPL.

There is a $300 total copay cap per enrollment year for inpatient and outpatient hospital services for all income levels.
Hospital — Outpatient

Full coverage — $3 copay per visit for members with income up to 100% of the FPL.

$15 copay per visit for members with income from 100% to 200% of the FPL.

$300 total copay cap per enrollment year for inpatient and outpatient hospital services for all income levels.

Outpatient mental health and substance abuse treatment services are not covered.
Mental Health and Substance Abuse Treatment

Coverage limited to services provided by a psychiatrist under the physician services benefit. $0.50 to $3 copay per service, limited $30 per provider, per enrollment year.
Physical Therapy (PT), Occupational Therapy (OT), and Speech and Language Pathology (SLP)

Full coverage, limited to 20 visits per therapy discipline, per enrollment year. $0.50 to $3 copay per service. Copay obligation limited to the first 30 hours or $1,500, whichever occurs first, during one enrollment year (copay limits calculated separately for each discipline). Cardiac rehabilitation visits count towards the 20-visit limit for PT.
Physician (Doctors)

Full coverage, including laboratory and radiology. $0.50 to $3 copay per service, limited to $30 per provider per enrollment year.

No copay for emergency services, anesthesia or clozapine management.
Podiatry
Full coverage — $0.50 to $3 copay per service, limited to $30 per provider per enrollment year.
Reproductive Health (Family Planning)

Family planning services provided by family planning clinics will be covered separately under Family Planning Only Services. For more information, see Family Planning Only Services.
Transportation - Ambulance
Coverage limited to emergency transportation by ambulance. No copay.

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Last Revised: February 07, 2013