For Dates of Service Before January 1, 2011

BadgerCare Plus Standard Plan, BadgerCare Plus Core Plan, and Medicaid

Copayment amounts for most physician services are determined per procedure code under the BadgerCare Plus Standard Plan, the BadgerCare Plus Core Plan, and Wisconsin Medicaid. They are either based on the maximum allowable fee or are a fixed amount as indicated in the following chart. Providers should use the following chart to determine copayment. Under the Core Plan, there is no copayment for emergency services, anesthesia, or clozapine management.

Copayment amounts for the laboratory and radiology service areas are a fixed amount. Refer to the laboratory and radiology service areas for copayment amounts.

Copayment Amounts
E&M services (each office visit, hospital admission, or consultation), based on the maximum allowable fee	Up to $10.00	$0.50
	From $10.01 to $25.00	$1.00
	From $25.01 to $50.00	$2.00
	Over $50.00	$3.00
Surgery services	Each	$3.00
Diagnostic services	Each	$2.00
Allergy testing	Per DOS	$2.00

BadgerCare Plus Benchmark Plan

Copayment for medical services provided under the BadgerCare Plus Benchmark Plan is $15.00 per visit regardless of number of services provided during that visit. There are no annual limits to copayments under the Benchmark Plan.

Copayments apply to the following:

• ESRD services (CPT procedure codes 90951-90970).
• E&M visits (except preventive visits), such as consultations and hospital, outpatient, clinic, nursing home, and home visits.
• Ambulatory surgery facility fees.
• Ophthalmologic exams and refractions.
• Osteopathic manipulations.
• Physical medicine.
• Surgeries.

BadgerCare Plus Basic Plan

The copayment for physician office visits covered under the BadgerCare Plus Basic Plan is $10.00 per visit. Under the Basic Plan, a provider has the right to deny services if the member fails to make his or her copayment.

Note: There is no copayment for SBIRT, laboratory, and radiology services.