To: All Members
Copayments and Other Information, October 1997
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The following information is contained within this Recipient Update:
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.
-
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.
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]
Providers will ask you for more than one copayment if you get
more than one service at an appointment. For example:
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:
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)
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