State of Wisconsin
Department of Health Services

Release 22-02
August 1, 2022

View History

38.2 List of Covered Services and Copayments

38.2.1 Introduction

A BadgerCare Plus member may be required to pay a part of the cost of a service. This payment is called a "copayment" or "copay." The following table shows some of the covered services and copayments under BadgerCare Plus.

Services Description

Chiropractic Services

Full coverage.

 

Copayment $.50 to $3 per service (varies by service provided).

Dental

Full coverage of preventive, restorative and palliative services.

 

Copayment $.50 to $3 per service

(varies by service provided).

Disposable Medical Supplies (DMS)

Full coverage.

 

Copayment $0.50 to $3.00 per service.

Drugs  (See also 38.7 Impact on Dual Eligible Individuals)

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

 

Members are limited to 5 prescriptions per month for opioid drugs.

 

Copayments:

 

$0.50 for OTC Drugs

$1.00 for Generic Drugs

$3.00 for Brand Name Drugs

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

Durable Medical Equipment (DME)

Full coverage.

 

C-payment $0.50 to $3.00 per item (varies by item provided).

 

Rental items are not subject to a co-payment.

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.

Hearing Services

Full coverage.

 

Copayment $.50 to $3 per procedure.

 

No copayments for hearing aid batteries.

Home Care Services (home health, private duty nursing and personal care)

Full coverage.

 

No copayment.

Hospice

Full coverage.

 

No copayment.

Hospital - Inpatient

Full coverage.

 

Copayment $3 per day with a $75 cap per stay.

Hospital - Outpatient

Full coverage.

 

Copayment $3 per visit.

Hospital - Outpatient Emergency Room

Full coverage.

 

No copayment.

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 or for residential substance use disorder treatment services.

Nursing Home

Full coverage.

 

No copayment.

 

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

Full coverage.

 

C-payment $.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.)

Physician Visits

Full coverage, including laboratory and radiology.

 

Copayment $.50 to $3 copayment per service (varies by service provided).

 

Limited to $30 per provider per calendar year.

 

No copayment for emergency services, anesthesia or clozapine management.

Podiatric Services

Full coverage.

 

Copayment $.50  to $3 per service.

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.

Reproductive Health Services

Full coverage, excluding infertility treatments, surrogate parenting and related services, including but not limited to artificial insemination, and subsequent obstetrical care as a non covered service, and the reversal of voluntary sterilization.  

 

No copayment for family planning services.

Routine Vision

Full coverage including coverage of eye glasses.

 

Copayment $.50 to $3 per service (varies by service provided).

Smoking Cessation Services

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

 

Copayment (see drugs)

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.

 

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

38.2.2 Copay Exempt Populations

Providers are prohibited from collecting copayment from the following members:

38.2.3 Copay Exempt Programs

Copays will not be charged for members enrolled in the following subprograms:

38.2.4 Copay Exempt Services

The following services do not require copayment:

This page last updated in Release Number: 21-01
Release Date: 03/29/2021
Effective Date: 02/01/2021


The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10171