BadgerCare Plus Covered Services and Copays

Covered Services

BadgerCare Plus covers the services listed below. These services could change, so you should always check with your provider or call ForwardHealth Member Services at 800-362-3002 for the most up-to-date information about whether a service you need is covered and if there are any limits on the services you need.

  • Case management services
  • Chiropractic services
  • Dental services
  • Family planning services and supplies
  • HealthCheck: Preventive health care for children and young adults through age 20 (Early and Periodic Screening, Diagnosis and Treatment benefit)
  • Some home and community-based services
  • Home health services or nursing services if a home health agency is unavailable
  • Hospice care
  • Inpatient hospital services other than services in an institution for mental disease
  • Inpatient hospital, skilled nursing facility, and intermediate care facility services for patients in institutions for mental disease who are:
    • Under 21 years of age
    • Under 22 years of age and were getting services when they turned 21 years of age
    • 65 years of age or older
  • Intermediate care facility services, other than services at an institution for mental disease
  • Laboratory and X-ray services
  • Medical supplies and equipment
  • Mental health and medical day treatment
  • Mental health and psychosocial rehabilitative services, including case management services, provided by staff of a certified community support program
  • Nurse midwife services
  • Nursing services, including services performed by a nurse practitioner
  • Optometric/optical services, including eye glasses
  • Outpatient hospital services
  • Personal care services
  • Physical and occupational therapy
  • Physician services
  • Podiatry services
  • Prenatal care coordination for women with high-risk pregnancies
  • Prescription drugs and over-the-counter drugs
  • Respiratory care services for ventilator-dependent individuals
  • Rural health clinic services
  • Skilled nursing home services other than in an institution for mental disease
  • Smoking cessation treatment
  • Speech, hearing, and language disorder services
  • Substance abuse (alcohol and other drug abuse) services
  • Transportation to obtain medical care 
  • Tuberculosis (TB) services

Copays

A copay is a set amount of money you pay for a medical service. You pay this amount each time you get a service.

Who has to pay copays?

Many BadgerCare Plus members have to pay copays. You may have to pay copays if your monthly income is more than the amount listed in the table below for your family size. You still may not need to pay copays though. See the Who doesn't have to pay copays? section for more information.

Family Size Monthly Income
1 $531
2 $718
3 $905
4 $1,091
5 $1,278
6 $1,465

Who doesn't have to pay copays?

The following BadgerCare Plus members do not have to pay copays:

  • Children under age 19
  • Children in foster care
  • Children in adoption assistance
  • Youth who were in foster care on their 18th birthday who enroll in BadgerCare Plus until age 26
  • Pregnant women during the pregnancy and for at least 60 days after the end of the pregnancy
  • American Indians or Alaska Natives of any age or income level, who get or have gotten health items or services from an Indian health care provider or by referral under contract health services
  • People getting hospice care who are terminally ill
  • Nursing home residents
  • Members who enroll by Express Enrollment

How much are copays?

Most copays are between $0.50 and $3.00, depending on the service. If you get more than one service, you may have more than one copay.

Cost of Service Copayment
Up to $10.00 $0.50
From $10.01 to $25.00 $1.00
From $25.01 to $50.00 $2.00
Over $50.00 $3.00

 

BadgerCare Plus members who are age 19-64, are not pregnant, and do not have children under age 19 living with them, have an $8 copay if they choose to get medical care in the emergency room when it is not an emergency. There is no copay for getting care when it is an emergency.

Is there a limit to the amount I pay each month?

Yes. Your copay amount will never be more than 5% of your total income before taxes or other deductions. Your monthly copay limit is based on your income, your family size, and who in your household has copays. If you also pay premiums for your BadgerCare Plus coverage, we will subtract your monthly premium from your copay limit.

If you owe copays, you will get a letter titled "About Your Benefits," letting you know how much your monthly copay limit is.

If your copays reach your limit before the end of a month, we will send you a letter letting you know. You will not have to pay copays for the rest of the month.

Last Revised: July 1, 2020