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Wisconsin Department of Health Services BadgerCare + Eligibility Handbook Release 08-07, September 10, 2008 |
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Wisconsin Department of Health Services BadgerCare + Eligibility Handbook Release 08-07, September 10, 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 copayments 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.
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Services |
BadgerCare Plus Standard Plan |
BadgerCare Plus Benchmark Plan |
|
Chiropractic Services |
Full coverage.
Copayment $.50 to $3 per service (varies by service provided). |
Full coverage.
Copayment $15 per visit. |
|
Dental |
Full coverage of preventive, restorative and palliative services.
Copayment $.50 to $3 per service (varies by service provided). |
Limited coverage of preventive, diagnostic, simple restorative, periodontics, extractions for both pregnant women and children.
Coverage is limited to $750 per year.
A $200 deductible applies to all services except preventive and diagnostic services.
Copayment is equal to 50% of allowable fee on all services as defined by DHFS. |
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Disposable Medical Supplies (DMS) |
Full coverage. Copayment $0.50 per item. |
Coverage of syringes, diabetic pens and DMS that is required with use of a durable medical equipment.) item.
No copayment. |
|
Drugs |
Comprehensive drug benefit with coverage of generic and brand name prescription drugs and some over-the-counter (OTC) drugs.
Copayments:
$0.50 for OTC Drugs $1.00 for Generic Drugs $3.00 for Prescription Drugs |
Generic drug only formulary with a few generic OTC drugs.
Copayment $5 with no limit.
Brand name drugs: Members will be automatically enrolled in the Badger RX Gold Plan. This is a separate program administered by Navitus, which provides for a discount on the cost of drugs. |
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Durable Medical Equipment (DME) |
Full coverage.
Copayment $0.50 to $3.00 per item (varies by item provided).
Rental items are not subject to a copayment. |
Full coverage up to $2,500 of paid amount in an enrollment year.
Copayment $5 per item.
Rental items are not subject to copayment but count toward the $2,500 cap. |
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Health Screenings for Children |
Full coverage of Health Check screenings and other services for individuals under age 21 years.
Copayment $1 per screening for those 18, 19 and 20 years of age. |
Full coverage of HealthCheck screenings.
No copayment.
Not covered: HealthCheck "Other" services and Interperiodic services for those under 21 years of age. |
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Hearing Services |
Full coverage.
Copayment $.50 to $3 per procedure.
No copayments for hearing aid batteries. |
Limited coverage of services provided by an audiologist.
Copayment $15 per procedure, regardless of the number of procedures performed during one visit.
Not covered: Hearing aids, hearing aid batteries, cochlear implants and bone-anchored hearing devices. |
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Home Care Services (home health, private duty nursing and personal care) |
Full coverage.
No copayment. |
Full coverage of home health services.
Copayment $15 per visit.
Coverage is limited to 60 visits per enrollment year. |
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Hospice |
Full coverage.
No copayment. |
Full coverage.
Copayment $2 per day.
Services limited to 360 days lifetime. |
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Hospital - Inpatient |
Full coverage.
Copayment $3 per day with a $75 cap per year. |
Full coverage with the following dollar amount limits per enrollment year:
— $6,300 for stays in a general acute care hospital for substance abuse. — $7,000 for stays in an Institute for Mental Disease (IMD) for substance abuse treatment.
Copayment $100 for medical stays and $50 per stay for mental health and/or substance abuse treatment.
Hospital stays for mental health and substance abuse services have a 30 day limit. |
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Hospital - Outpatient |
Full coverage.
Copayment $3 per visit. |
Full coverage.
Copayment $15 per visit. |
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Hospital - Outpatient Emergency Room |
Full coverage.
No copayment. |
Full coverage.
Copayment $60 per visit (waived if member is admitted to the hospital). |
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Mental Health and Substance Abuse Treatment |
Full coverage (not including room and board).
Copayment $.50 to $3 per visit (limited to the first 15 hours or $500 of services, whichever comes first, provided per calendar year).
Copayment not required when services are provided in a hospital setting. |
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.
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:
— $4,500 for outpatient substance abuse services including $2,700 for outpatient services (including narcotic treatment) for substance abuse day treatment. — $6,300 for inpatient hospital stays in a general acute care hospital.
Copayment $10 to $15 per visit for all outpatient services:
— $10 per day for all day treatment services. — $15 per visit for narcotic treatment services (no copayment for lab tests). — $15 per visit for outpatient mental health diagnostic interview exam, psychotherapy - individual or group (no copayment for electroconvulsive therapy and pharmacological management). — $15 per visit for outpatient substance abuse services.
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. |
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Nursing Home |
Full coverage.
No copayment.
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Full coverage for stays at skilled nursing homes limited to 30 days per enrollment year.
No copayment. |
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Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) |
Full coverage.
Copayment $.50 to $3 per provider, per date of service.
Copayment obligation is limited to the first 30 hours or $1,500 whichever occurs first, during one calendar year (copayment limits are calculated separately for each discipline.) |
Full coverage up to 20 visits per therapy discipline per enrollment year.
Also 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.
Copayment $15 per visit. There are no monthly or annual copayment limits. |
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Physician Visits |
Full coverage, including laboratory and radiology.
Copayment $.50 to $3 copayment per service (varies by service provided).
Copayments are limited to $30 per provider per calendar month.
No copayment for emergency services, anesthesia or clozapine management. |
Full coverage, including laboratory and radiology.
Copayment $15 per visit.
No copayment for emergency services, preventive care, anesthesia or clozapine management. |
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Podiatric Services |
Full coverage.
Copayment $.50 to $3 per service. |
Full coverage.
Copayment $15 per visit. |
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Prenatal/Maternity Care |
Full coverage, including prenatal care coordination and preventive mental health and substance abuse screening and counseling for pregnant women at risk of mental health or substance abuse problems.
No copayment. |
Full coverage, including prenatal care coordination and preventive mental health and substance abuse screening and counseling for pregnant women at risk of mental health or substance abuse problems.
No copayment. |
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Reproductive Health Services |
Full coverage, excluding infertility treatments, surrogate parenting and the reversal of voluntary sterilization.
No copayment for family planning services. |
Full coverage, excluding infertility treatments, surrogate parenting and the reversal of voluntary sterilization.
No copayment for family planning services. |
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Routine Vision |
Full coverage including coverage of eye glasses.
Copayment $.50 to $3 per service (varies by service provided). |
Full coverage of one eye exam every two years, with refraction.
Copayment $15 per visit.
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Smoking Cessation Services |
Coverage includes prescription and over-the-counter tobacco cessation products.
Copayment (see drugs) |
Coverage includes generic prescription and over-the-counter tobacco cessation products.
Copayment (see drugs) |
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Transportation |
Full coverage of emergency and non-emergency transportation to and from a certified provider for a BadgerCare Plus covered service.
Copayments are: — $2 for non-emergency ambulance trips. — $1 per trip for transportation by an SMV.
No copayment for transportation by common carrier or emergency ambulance. |
Full coverage of emergency transportation (ambulance).
Copayment $50 per trip. |
If you or the member has additional questions, contact Member Services at 1-800-362-3002.
A BC+ member may be required to pay a part of the cost of a service. This payment is called a “copayment” or “copay”.
Exempt from Co-payments
Children under age 19 with family income up to 100% of the FPL.
Children under age 6 with family income above 100% up to 150% of the FPL, except for Continuously Eligible Newborns.
Children ages 1 through 5 who are Tribal members with family income from 185% to 300% of the FPL.
Children ages 6 through 18 who are Tribal members with family income from 150% to 300% of the FPL.
Children under age 19 eligible through Express Enrollment.
Children under age 19 in an institution.
Children under age 19 eligible under a BadgerCare Plus Extension
Pregnant women, except for pregnant girls under age 19 with family incomes above 300% of the FPL.
Pregnant women eligible through Express Enrollment.
Pregnant women eligible for the prenatal benefit.
Standard Plan – Nominal Co-payments
Continuously Eligible Newborns with family incomes above 100% up to 200% of poverty.
Children under age 6 with family income above 150% up to 200% of poverty.
Children ages 6 through 18, with family income above 100% up to 200% of poverty.
Children under age 19 with family income above 150% of poverty who have met a deductible.
Parents and caretakers up to 200% of poverty.
Parents and caretakers in BC+ Extensions.
Youths Exiting Out-of-Home Care.
Transitional Grandfathered parents and caretakers.
Members covered under the Standard plan will have copayments ranging from $0.50 to $3.00. Providers are required to make a reasonable effort to collect the copayment but may not refuse services to a member who fails to make that payment.
Benchmark Plan – Co-payments
Continuously Eligible Newborns with family incomes above 200% of the FPL.
Children under age 19 with family incomes over 200% of the FPL.
Pregnant women under age 19 with family incomes over 300% of the FPL.
Self-employed parents and caretakers with family incomes above 200% of the FPL.
Members covered under the Benchmark plan may be refused services if the copayment is not paid in advance.
This page last updated in Release Number: 08-06
Release Date: 06/20/08
Effective Date: 06/20/08
