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Welcome  » June 22, 2024 10:41 PM
Program Name: BadgerCare Plus and Medicaid Handbook Area: Physician

Reimbursement : Copayment

Topic #231


Wisconsin Medicaid and BadgerCare Plus Copay Exemptions

According to Wis. Admin. Code § DHS 104.01(12)(a), and 42 C.F.R. § 447.56, providers are prohibited from collecting any copays from the following Medicaid and BadgerCare Plus members:

  • Children under age 19
  • American Indians or Alaskan Natives, regardless of age or income level, who are receiving or have ever received items and services either directly from an Indian health care provider or through referral under contract health services (Note: Until further notice, Wisconsin Medicaid and BadgerCare Plus will apply this exemption policy for all services regardless of whether a tribal health care provider or a contracted entity provides the service. Providers may not collect copay from any individual identified in the EVS as an American Indian or Alaskan Native.)
  • Terminally ill individuals receiving hospice care
  • Nursing home residents
  • Members enrolled in Wisconsin Well Woman Medicaid
  • Individuals eligible through EE

The following services do not require copays from any member enrolled in Wisconsin Medicaid or BadgerCare Plus:

  • Behavioral treatment
  • Care coordination services (prenatal and child care coordination)
  • CRS
  • Crisis intervention services
  • CSP services
  • Comprehensive community services
  • COVID-19-related care
  • Emergency services for medical conditions that meet the prudent layperson standard (the prudent layperson standard is defined by 42 C.F.R. § 438.114, and may be expanded to include a psychiatric emergency involving a significant risk or serious harm to oneself or others, a substance abuse emergency in which there is significant risk of serious harm to a member or others or there is likelihood of return to substance abuse without immediate treatment, or emergency dental care, which is defined as an immediate service needed to relieve the patient from pain, an acute infection, swelling, trismus, fever, or trauma)
  • EMTALA-required medical screening exam and stabilization services
  • Family planning services and supplies, including sterilizations
  • HealthCheck services
  • Home care services (home health, personal care, and PDN services)
  • Hospice care services
  • Immunizations, including approved vaccines recommended to adults by the ACIP
  • Independent laboratory services
  • Injections
  • Pregnancy-related services
  • Preventive services with an A or B rating* from the USPSTF**, including tobacco cessation services
  • SBS
  • Substance abuse day treatment services
  • Surgical assistance
  • Targeted case management services

Note: Providers may not impose cost sharing for health-care acquired conditions or other provider-preventable services as defined in federal law under 42 C.F.R. § 447.26(b).

* Providers are required to add CPT modifier 33 to identify USPSTF services that are not specifically identified as preventive in nature. The definition for modifier 33 reads as follows:

    When the primary purpose of the service is the delivery of an evidence based service in accordance with a U.S. Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.

Since many of the USPSTF recommendations are provided as part of a regular preventive medicine visit, ForwardHealth will not deduct a copayment for these services (CPT procedure codes 99381–99387 and 99391–99397).

** The USPSTF recommendations include screening tests, counseling, immunizations, and preventive medications for targeted populations. These services must be provided or recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice.

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