Policy For 38.2 Standard and Benchmark Plans

Release 08-02, January 31, 2008

BC+ members can be covered under either the Standard or Benchmark Plan. The following chart shows a comparison of some of the covered services and co-payments for each plan. Which plan the member is enrolled in depends on the member’s status or the countable income used to determine eligibility for that member.

 

Services

BadgerCare Plus Standard Plan

BadgerCare Plus Benchmark Plan

Drugs

Comprehensive drug benefit with coverage of generic prescription drugs, brand prescription drugs and some over-the-counter (OTC) drugs.   Co-payments:

 

$0.50 for OTC Drugs

$1.00 for Generic Drugs

$3.00 for Prescription Drugs

Coypayments are limited to $12.00 per member, per provider, per month.  OTCs are excluded from this $12.00 maximum.

Generic drug only formulary with a few generic OTC drugs with a $5.00 co-payment.  Brand drugs are only available through the Badger Rx Gold plan, administered by Navitus, which provides for a discount on the cost.

Physician Visits

Full coverage with $1.00 co-payment per visit.

Full coverage with a $15 co-payment per visit.  Clozapine management is covered with no co-payment.

Prenatal Care/Maternity

Full coverage and prenatal care coordination for high risk pregnancy and preventive mental health and substance abuse screening and counseling for pregnant women at risk of depression.

Full coverage and prenatal care coordination for high risk pregnancies.  Full coverage of preventive mental health and substance abuse screening and counseling for pregnant women at risk of depression.

Inpatient Hospital

Full coverage with a $3 co-payment per day, but capped at a total of $75 per enrollment year.

Full coverage with a $100 co-payment per hospital stay (medial surgery) and a $50 co-payment per stay for mental health and or substance abuse treatment.  Hospital stays in a general acute care hospital for substance abuse are limited to $6300.  Hospital stays in an “IMD” for substance abuse are limited to $7,000.

Outpatient Hospital

Full coverage with a $3 co-payment per visit.

Full coverage with a $15 co-payment per visit (although multiple visits to the same provider in the same day will be treated as a single visit).

Emergency Room (ER)

Full coverage with a $3 co-payment per visit

Full coverage with a $60 co-payment for non-emergent use of the emergency room.  

 

Non-emergent use is defined as no admission to the hospital.

Nursing Home

Full coverage

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

Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST)

Full coverage with a $1 co-payment for each procedure Prior authorization is required after 35 visits per therapy discipline.

Full coverage of 20 visits per therapy discipline per enrollment year.  (For cardiac rehabilitation the number of visits is increased to 36 visits).  There is a $15 co-payment per visit.  The enhancement for Birth to 3 services is reimbursed.

Durable Medical Equipment (DME)

Full coverage with a sliding co-payment amount ($0.50 to $3.00 per item) based upon the cost of the item.

Full coverage with a $5 co-payment per item and capped at $2,500 of paid amount in an enrollment year.  Rental items are not subject to co-payment but count toward the $2,500 cap.

Disposable Medical Supplies (DMS)

Full coverage with a co-payment of $0.50 per item.

Coverage of syringes, diabetic pens and DMS that is required with use of a DME item.

Mental Health and Substance Abuse Treatment

Full coverage (not including room and board) with a $1 co-payment per visit.

Coverage of this service is based upon coverage in the Wisconsin State Employees’ Health Plan.

 

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, child/adolescent mental health day treatment, and inpatient hospital stays for mental health and substance abuse.

 

Services not covered are crisis intervention, community support program (CSP), Comprehensive Community Services (CCS), out patient services in the home and community for adults, and substance abuse residential treatment.

 

Mental health services have no dollar maximum.   Inpatient hospital stays (mental health and substance abuse) have a 30 day limit.

 

Substance abuse services are limited to a $7,000 limit.  Costs of mental health services apply to this overall limit.

 

Also, there are separate dollar limits for specific substance abuse services:

 

  • $1,800 outpatient services (including narcotic treatment).

  • $2,700 outpatient services (including narcotic treatment) and substance abuse day treatment.

  • $6,300 inpatient hospital stays in a general acute care hospital.
     

Inpatient hospital stays in an “IMD” apply to the overall $7,000 dollar limit.

Home Health

Full coverage of private duty nursing, home health care, personal care without a co-payment.

Full coverage of in-home skilled nursing services, home health aide services and therapies (PT, OT, ST) with a co-payment of $15 per visit.  Coverage is limited to 60 visits per enrollment year.

Transportation

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

 

A $1 co-payment per round trip applies to non-emergency services.  The $1 co-payment does not apply to emergency services or transportation provided by common or private motor vehicle (if authorized in advance by a county or tribal agency).   

 

Transportation services are also exempt from co-payment if provided to the following individuals:

 

  • a person receiving care as an inpatient in a skilled nursing home or intermediate care facility.
     

  • a person under 18 years of age.

 

  • a pregnant woman, if the service relates to the pregnancy or to other conditions that may complicate the pregnancy.

 

Full coverage of emergency transportation with a $50 co-payment per trip.

 

Non-emergency services are not covered under the Benchmark Plan.

Health Screenings for Children

Full coverage of Health Check screenings and other service for individuals under age 21 years.

Full coverage of HealthCheck screenings (but not HealthCheck other services unless coverage elsewhere in the BC+ Benchmark Plan) for individuals under age 21 years.  

Dental

Full coverage of preventive, restorative and palliative services with a $1 to $3 co-payment (varies by service provided).

50% of allowable charges as defined by DHFS for preventive, diagnostic, simple restorative, periodontics, extractions for both pregnant women and children.  A $200 deductible applies to all services except preventive and diagnostic services.  Coverage is limited to $750 per year.

Vision

Full coverage including eye glass benefit with a $1 to $3 co-payment (varies by service provided).

Full coverage of one eye exam every two years with a $15 co-payment per visit.

Smoking Cessation Services

Coverage includes prescription and over-the-counter tobacco cessation products.  

Coverage includes prescription and over-the-counter tobacco cessation products.  

Hospice

Full coverage

Full coverage with a $2 co-payment per day and limited to 360 days lifetime.

Reproductive Health Services

Full coverage, excluding infertility treatments, surrogate parenting and the reversal of voluntary sterilization.  Contraceptive services are available without a co-payment.

Full coverage, excluding infertility treatments, surrogate parenting and the reversal of voluntary sterilization.  Contraceptive services are available without a co-payment.

Chiropractic Services

Full coverage with a $1 to $3 co-payment per visit (varies by service provided).

Full coverage with a $15 co-payment per visit.

Podiatric Services

Full coverage with a $1 to $3 co-payment per visit (varies by service provided).

Full coverage with a $15 co-payment per visit.

 

 

If you or the member has additional questions, contact Member Services at 1-800-362-3002.

 

38.2.1 CO-PAYMENT

A BC+ member may be required to pay a part of the cost

of a service. This payment is called a “co-payment” or “co-pay”.

 

Members who do not have to pay a co-payment are:

 

  1. Children under age 18 whose income is below 100% of the FPL,

  2. Pregnant Women, and

  3. Children that are members of a federally recognized Tribe.

 

Medical Services that do not require a co-payment are:
 

  1. Emergency Services

  2. Services related to a pregnancy

  3. Family Planning Services

  4. Services provided to residents of Nursing Homes.

 

Members covered under the Standard plan will have co-payments ranging from $0.50 to $3.00. Providers are required to make a reasonable effort to collect the co-payment but may not refuse services to a member who fails to make that payment.

 

Members covered under the Benchmark plan may be refused services if the co-payment is not paid in advance.

 

This page last updated in Release Number: 08-02

Release Date: 01/31/08

Effective Date: 02/01/08