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Table of Contents>>Covered Services and Copays>>

BadgerCare Plus Standard, Benchmark and Medicaid Plans

Covered Services and Copays

You may be required to pay a part of the cost of a service. This payment is called a copayment or copay. The following tables list what services are covered and what the copay will be for that services.

BadgerCare Plus Standard/Medicaid Plans

Providers are required to make a reasonable effort to collect the copay but cannot refuse services to a member who fails to make that payment.

BadgerCare Plus Benchmark Plan

Members covered under the Benchmark plan may be refused services, if the copay is not paid at the time of your appointment.

Please Note: Because copays could change, you should ask your provider what your copay amount will be. If you get more than one service during the same appointment, you may be asked for more than one copay.

A provider can charge you for services that are not covered by BadgerCare Plus or Medicaid, if:

  • The provider told you before providing the service that the service was not covered, and
  • You agreed to pay for the service.

Please Note: Not all plans cover the same services. The covered services listed may change. To see if the service you need is covered, ask your health care provider.

BadgerCare Plus Standard/Medicaid Plans

BadgerCare Plus Benchmark Plan
Ambulatory Surgical Centers

Coverage of certain surgical procedures and related lab services.

$3 copay per service.

Coverage of certain surgical procedures and related lab services.

$15 copay per visit.
Chiropractic Services
Full coverage— $.50 to $3 copay per service. Full coverage — $15 copay per visit.
Dental Services
Full coverage — $.50 to $3 copay per service.

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)

Full coverage.

$0.50 to $3 copay per service and $0.50 per prescription for diabetic supplies.

 

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)

Coverage of generic and brand name prescription drugs, and some over-the-counter (OTC) drugs.

Copays:

  • $0.50 for OTC drugs

  • $1.00 for generic drugs

  • $3.00 for brand

Copays are limited to $12 per member, per provider, per month. OTCs are excluded from this $12 maximum.

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)

Full coverage.

No copay.

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.

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 — $.50 to $3.00 copay per procedure.

No copay for hearing aid batteries.

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 private duty nursing, home health services, and personal care.

No copay.

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.

No copay.

Full coverage, up to 360 days per lifetime.

No copay.
Inpatient Hospital Services
Full coverage — $3.00 copay per day with a $75 cap per stay.

Full coverage — Copays are as follows:

  • $100 stay for medical stays.

  • $50 copay per stay for mental health and/or substance abuse treatment.
Mental Health and Substance Abuse Treatment

Full coverage (not including room and board).

$0.50 to $3.00 copay per service, limited to the first 15 hours or $825 of services, whichever comes first, provided per calendar year.

Copay is not required when services are provided in a hospital setting.

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
Full coverage— no copay.

Full coverage for stays at skilled nursing homes limited to 30 days per enrollment year.

No copay.
Outpatient Hospital - Emergency Room
Full coverage— no copay.

Full coverage — $60 copay per visit (waived if admitted to hospital).
Outpatient - Hospital

Full coverage.

$3 copay per visit.

Full coverage.

$15 copay per visit.
Physician Services

Full coverage, including laboratory and radiology.

$.50 to $3.00 copay per service limited to $30 per provider per calendar year.

No copay for emergency services, anesthesia or clozapine management.

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 — $.50 to $3.00 copay per service; limited to $30 per provider per calendar year. 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.

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.

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 — $.50 to $3.00 copay per service. Copay obligation limited to the first 30 hours or $1,500, whichever occurs first, during one calendar year (copay limits calculated separately for each discipline).

 

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

Full coverage of emergency and non-emergency transportation to and from a certified provider for a BadgerCare Plus covered service.

  • $2 copay for non-emergency ambulance trips.

  • $1 copay per trip for transportation by SMV (Specialized Medical Vehicle).

  • No copay for transportation by common carrier or emergency ambulance.

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

Full coverage including eyeglasses — $.50 to $3.00 copay per service.

 One eye exam every two years, with refraction — $15 copay per visit

Please Note: BadgerCare Plus services can change. Your health care provider can tell you if a service is covered and what your copay will be. 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.

Services Not Covered Under Any Plan

Services or items not covered include (but are not limited to):

  • Items such as televisions, radios, lift chairs, air conditioners, and exercise equipment (even if prescribed by a physician),

  • Procedures considered experimental or cosmetic in nature, and

  • Services that need approval (prior authorization) before you get them.

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Last Revised: February 07, 2013