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To:  All Members

Copayments and Other Information, October 1997

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The following information is contained within this Recipient Update:

Copayment changes

The new state budget has added a copayment for ambulatory surgery services and has changed the copayment amounts for some other services. 

We are sending this information to all Medicaid recipients because it may affect them now or in the future. All recipients are responsible for copayments except:

  • Persons in HMOs and other Medicaid managed care programs for HMO-covered or managed care-covered services.

  • Persons living in a nursing home.

  • Children under the age of 18.

The chart below is a copayment schedule. Use it to find out how much of your medical cost you will be asked to share.

Copayments are between $.50 and $3 for each service. Your provider will tell you if you need to pay a copayment for the services you get.

You are responsible for your copayment but a provider cannot deny you services if you cannot pay them right away. Tell your provider if you cannot pay the copayment.

Recipients generally have the right to a hearing to appeal actions affecting their benefits. However, because the copayment changes (including adding a copayment for ambulatory surgery services), are a result of state law, recipients do not have a right to a hearing to contest these changes.

Having recipients share in the cost of care encourages recipients to choose their medical services more carefully.

Other Medicaid tips

  • If you need help with rides by car, bus, or taxi, call your county human service or social service agency or tribal agency. If you are in an HMO, you may also call your HMO.

  • If your ID card shows health insurance you don't have, call your employer or the insurance company. Make sure your record is correct.

  • If you make a medical appointment, be sure to keep it. Missed appointments are costly to providers.

When you go to Medicaid services...

Medicaid recipients are responsible for paying all copayments but a provider cannot deny a recipient services if they cannot pay them right away. Recipients need to tell their providers if they cannot pay the copayment. [Social Security Act 1916(d); Reg. 447.15]

pay your share.

Providers will ask you for more than one copayment if you get more than one service at an appointment. For example:

  • Your doctor will ask for copayment for the office visit and each lab test he or she does.

  • Your pharmacist will ask for copayment for each prescription he or she fills.

Wisconsin Medicaid Recipient Copayment Amounts

Physician and nurse practitioner services
  • Each office visit, hospital admission, or consultation
  • Each surgery
  • Each lab service
  • Each x-ray service
  • Each diagnostic service
$1.00 to $3.00

$3.00
$1.00
$3.00
$2.00
Copayment is limited to $30 per year per provider.

Ambulatory surgery
Each surgery service $3.00

Chiropractic services
  • Urinalysis

  • X-ray

  • Office visits

  • Manipulation

$1.00
$3.00
$1.00
$1.00

Dental services
Each service costing:
  • Up to $10.00
  • From $10.01 to $25.00
  • From $25.01 to $50.00
  • Over $50.00
$0.50
$1.00
$2.00
$3.00

Disposable medical supplies
Each item costing:
  • Up to $10.00
  • From $10.01 to $25.00
  • From $25.01 to $50.00
  • Over $50.00

Urine or blood test strips

$0.50
$1.00
$2.00
$3.00

$0.50

Drugs
Each item costing:
  • Over-the-counter drugs, each prescription
    (no monthly limit)
  • All other prescription drugs, each new and refilled prescription 
$0.50

$1.00
No more than $5.00 per month at each pharmacy.

Durable medical equipment purchase
Each item costing:
  • Up to $10.00
  • From $10.01 to $25.00
  • From $25.01 to $50.00
  • Over $50.00
$0.50
$1.00
$2.00
$3.00

Hearing services
  • Audiology testing
  • Each purchased item
  • Each accessory or repair
$1.00
$3.00
$1.00

Hospital services
  • Inpatient (each day)
  • Outpatient, except emergency treatment (per visit)
$3.00
$3.00
Inpatient copayment is limited to $75.00 per stay.

HealthCheck services
  • Children under age 18 
  • Recipients age 18 to 20 
none
$1.00

Mental health/alcohol and other drug abuse therapy (includes individual and group therapy, and psychiatric evaluation)

Each service costing:

  • Up to $10.00
  • From $10.01 to $25.00
  • From $25.01 to $50.00
  • Over $50.00
$0.50
$1.00
$2.00
$3.00
Mental health services, AODA, and biofeedback copayment is limited to the first 15 hours or $500 of services per calendar year.

Physical therapy, occupational therapy, and speech-language pathology services (not provided in a hospital or school)

Each service costing:

  • Up to $10.00
  • From $10.01 to $25.00
  • From $25.01 to $50.00
  • Over $50.00
$0.50
$1.00
$2.00
$3.00
Copayment is limited to the first 30 hours or $1,500 of services per therapy, per calendar year.

Podiatry services
  • Office visit
  • Each surgery
  • Each lab service
  • Each x-ray service
  • Surgery/mycotic condition treatment
  • Routine foot care
  • Casting and strapping
$1.00 to $3.00
$3.00
$1.00
$3.00
$3.00
$1.00
$1.00 to $3.00

Rural health clinics
Each visit  $2.00
Copayment limited to $30.00 per year.

Transportation
Each nonemergency ambulance trip  $2.00

Vision care
  • Optometric services:
    • Each office visit
    • Each special and low vision service, test, therapy
    • Each contact lens service

$1.00 to $3.00
$0.50 

$3.00
  • Eyeglasses:
    • New
    • Frame, lens, or temple replacement
    • Each repair

$3.00/pair
$2.00/each
$0.50

COPAYMENT LIMITATIONS...

These Medicaid services DO NOT require copayment:

  • Emergency services.

  • Family planning services and supplies.

  • Pregnancy-related medical services.

  • School-based services.

These people DO NOT pay copayment:

  • Children under 18 years old.

  • People in nursing homes.

  • People in HMOs and other managed care programs getting HMO-covered or managed care-covered services.

 

Wisconsin Medicaid is administered by the Bureau of Health Care Financing, Division of Health, Wisconsin Department of Health and Family Services, P.O. Box 309, Madison, WI 53701-0309. For recipient questions, call Recipient Services at 1-800-362-3002 (voice or TDY)

POH 1579 (10/29/1997)