Services

BadgerCare Plus Benchmark Plan Coverage

Drugs

Generic-only formulary drugs and a limited number of generic over-the-counter drugs with a $5.00 copayment per item.

Brand name drugs are only available through the Badger Rx Gold plan, which provides a discount on the cost. Benchmark Plan members are automatically enrolled in this plan.

Physician, Anesthesia, X-Ray, and Laboratory

Same coverage as Wisconsin Medicaid with a $15.00 copayment per visit.

Prenatal Care/Maternity

Same coverage as Wisconsin Medicaid including prenatal care coordination for high-risk pregnancies. Coverage of mental health and substance abuse screening, preventive mental health counseling, and substance abuse intervention services for pregnant women at risk of mental health or substance abuse problems.

Inpatient Hospital

Same coverage as Wisconsin Medicaid with a $100.00 copayment per hospital stay (medical surgery) and a $50.00 copayment per stay for psychiatric treatment.

Outpatient Hospital

Same coverage as Wisconsin Medicaid with a $15.00 copayment per visit (although multiple visits to the same provider on the same day will be treated as a single visit).

Emergency Room

Same coverage as Wisconsin Medicaid with a $60.00 copayment if the member is not admitted to the hospital.

Nursing Home

Same coverage as Wisconsin Medicaid with a limit of 30 days per enrollment year in a nursing home.

Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP)

20 visits per therapy discipline per enrollment year.
An additional 36 visits are covered for cardiac rehabilitation.

There is a $15.00 copayment per visit.

Durable Medical Equipment

Same coverage as Wisconsin Medicaid with a $5.00 copayment per item. Reimbursement is capped at $2,500.00 of paid amount in an enrollment year.

Disposable Medical Supplies

Coverage is limited to syringes, diabetic pens, and DMS that are required with the use of a DME item. There is a $0.50 copayment for syringes and diabetic pens.

Mental Health and Substance Abuse Treatment

Coverage and coverage limitations for these services are based upon the Wisconsin State Employees’ Health Plan.

Covered services include outpatient mental health, outpatient substance abuse (including narcotic treatment), mental health day treatment for adults, child/adolescent mental health day treatment, and substance abuse day treatment for adults and children.

Noncovered services include crisis intervention, Community Support Program, Comprehensive Community Services, outpatient mental health and substance abuse services in the home and community for adults, and substance abuse residential treatment.

Substance abuse services will be subject to specified dollar amount limits established under the Wisconsin State Employees’ health plan, which are as follows:

• $4,500.00 for outpatient substance abuse services. Only $2,700.00 can be applied toward substance abuse day treatment services.
• $6,300.00 for inpatient acute general care hospital stays for substance abuse treatment.
• $7,000.00 OVERALL limit. The paid amount for all substance abuse and mental health services count toward the overall limit. Once the overall limit is reached, no substance abuse services will be covered.

Coverage of mental health services are not subject to any dollar amount limits.

Inpatient hospital stays for mental health or substance abuse treatment are limited to 30 days per enrollment year. This limit applies to general acute care and hospital stays at institutions for mental disease.

Home Health

Coverage of in-home skilled nursing services, home health aide services, and therapies (PT, OT, SLP) with a copayment of $15.00 per visit. Coverage is limited to 60 visits per enrollment year.

Ambulance

Full coverage of emergency transportation only with a $50.00 copayment per trip.

HealthCheck

Same coverage as Wisconsin Medicaid of HealthCheck for individuals under 21 years old.

HealthCheck “Other Services” are not covered unless coverage is specified elsewhere.

Dental

50 percent allowable charges as defined by the Department of Health and Family Services for preventive, diagnostic, simple restorative, periodontics, and surgical extractions for both pregnant women and children. Deductibles are not applied to preventive and diagnostic services.

Vision

Coverage of one routine eye exam every two years with a $15.00 copayment per visit. This limit only applies to optometrists.

Smoking Cessation

New expanded coverage of over-the-counter tobacco cessation gum products for all BadgerCare Plus members.

Hospice

Same coverage as Wisconsin Medicaid with a $2.00 copayment per day and limited to 360 days lifetime.

Reproductive Health

Same coverage as Wisconsin Medicaid.
Family planning services are available without a copayment.

Chiropractic

Same coverage as Wisconsin Medicaid with a $15.00 copayment per visit.

Podiatric

Same coverage as Wisconsin Medicaid with a $15.00 copayment per visit.