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
copay.
BadgerCare Plus Benchmark Plan
|
|
Ambulatory Surgical Centers |
|
Coverage of certain surgical procedures
and related lab services.
$15 copay per visit. |
|
Chiropractic Services |
| Full coverage — $15 copay per
visit. |
|
Dental Services |
|
Limited coverage of preventive,
diagnostic, simple restorative, periodontics, and extractions for
pregnant women and children.
Coverage limited to $750 per enrollment
year.
A $200 deductible applies to all
services except preventive and diagnostic.
Cost-sharing equal to 50% 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 copay per prescription for
diabetic supplies.
No copay for other
DMS. |
|
Drugs (Prescription) |
|
Generic drug-only formulary with a few
generic over-the-counter (OTC) drugs.
Limit of 5 opioid prescription fills per
month.
Members will be automatically enrolled
in the Badger Rx Gold plan. This is a separate program, which is
not run by the state. It provides for a discount on the cost of
drugs. For more information, go to
badgerrxgold.com.
$5 copay with no upper limits. |
|
End-Stage Renal Disease (ESRD) |
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Full coverage.
No copay. |
|
Health Screenings for Children |
|
Full coverage of
HealthCheck screenings
and other services for individuals under age 21 years.
$1 copay per screening for 18, 19,
and 20 year olds. |
|
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
are not covered.
$15 copay per visit. |
|
Hospice |
|
Full coverage, up to 360 days per
lifetime.
No copay. |
|
Inpatient Hospital Services |
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Full coverage — Copays are as
follows:
|
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Mental Health and Substance Abuse Treatment |
|
Covered services include outpatient
mental health, outpatient substance abuse (including narcotic
treatment), mental health day treatment for adults, substance
abuse day treatment for adults and children, and child/adolescent
mental health day treatment and inpatient hospital stays for
mental health and substance abuse.
$10 to $15 copay per visit for all
outpatient services:
-
$10 per day for all day treatment
services.
-
$15 per visit for narcotic treatment
services (no copay for lab tests).
-
$15 per visit for outpatient mental
health diagnostic interview exam, psychotherapy — individual
or group (no copay for electro-convulsive therapy and
pharmacological management).
- $15 per visit for outpatient substance abuse services.
|
|
Nursing Home Services |
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Full coverage for stays at skilled
nursing homes limited to 30 days per enrollment year.
No copay. |
|
Outpatient Hospital - Emergency Room |
|
Full coverage — $60 copay per
visit (waived if admitted to hospital). |
|
Outpatient - Hospital |
|
Full coverage.
$15 copay per visit. |
|
Physician Services |
|
Full coverage, including laboratory and
radiology.
$15 copay per visit.
No copay for emergency services,
preventive care, anesthesia or clozapine management. |
|
Podiatry Services |
| Full coverage — $15 copay per
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 copay. |
|
Reproductive Health Services — Family
Planning Services |
|
Full coverage, excluding infertility
treatments, surrogate parenting and the reversal of voluntary
sterilization.
No copay. |
|
Therapy — Physical Therapy (PT),
Occupational Therapy (OT), and Speech and Language Pathology (SLP) |
|
Full coverage — limited to 20 visits
per therapy type per enrollment year. 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.)
Also 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.
$15 copay per visit, per provider.
There are no monthly or annual copay
limits. |
|
Transportation – Ambulance, Specialized
Medical Vehicle (SMV), Common Carrier |
|
Coverage limited to emergency
transportation by ambulance.
-
$50 copay per trip for emergency
transportation by ambulance.
-
$1 copay per trip for
transportation by SMV (Specialized Medical Vehicle).
-
No copay for transportation by
common carrier or emergency ambulance.
|
|
Vision -Routine Services |
| One eye exam every two years, with
refraction — $15 copay 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.
