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Covered Services and Co-payments — Benchmark Plan

The following lists the services covered under the Benchmark Plan as well as any limitations on the services.  Some services require you to make a co-payment.  

Please Note: If you are enrolled in the Benchmark plan and can’t pay your co-payment right away, the provider may refuse to provide the service.  

• Chiropractic Services — Co-payment of $15 per visit

• Dental services — Coverage is limited to $750 per year.  Co-payment of 50% of allowed amount plus $200 each year.  Limited coverage of preventive, diagnostic, simple restorative, periodontics, extractions for both pregnant women and children.  

• Disposable Medical Supplies (DMS) — $0.50 for syringes and diabetic pens for use with durable medical equipment

• Drugs — (Prescription drugs) Generic drugs only with a co-payment of $5 for each prescription.  Brand drugs are available through Badger Rx Gold plan, administered by Navitus, which provides a discount on the cost.  Members will be automatically enrolled in the Badger RX Gold Plan which can be used for brand name drugs.  

• Durable Medical Equipment (DME) — $5 each item.  Limited to $2,500 of paid amount in an enrollment year.  Rental items are not subject to co-payment but count toward the $2,500 cap.

• Emergency Room — $60 per visit for non-emergencies.  You will not have to pay this co-payment if you are admitted to the hospital.

• Family Planning Services

• Health Screenings for Children — No co-payment.

• Home Care Services (home health, private duty nursing and personal care) — $15 each visit.  Coverage is limited to 60 visits per enrollment year.

• Hospice Care — Co-payment $2 per day.  Services are limited to 360 days lifetime.

• Hospital (Includes mental health and substance abuse) — Inpatient co-payments are $100 per stay, $50 for mental health or substance abuse.  Outpatient co-payments are $15 for each visit.  Stays in a general acute hospital for substance abuse are limited to $6,300 each year. Inpatient stays for mental health and substance abuse are limited to $7,000 each year. Other limits include:

• Outpatient services - $1,800

• Transitional services - $2,700 each year

• Alcohol and drug services - $7,000 each year,

• Inpatient acute hospital care - $6,300 each year for substance abuse services

• Inpatient Institution for Mental Disease services - $7,000 each year (including the $7,000 limit for substance abuse)

• Nursing Home — Co-payment is 10% of allowed amount.  Services are limited to 30 days per enrollment year.

• Physicians Visits (doctors) includes laboratory and radiology — Co-payments $15 per visit.  No co-payment for emergency services, preventive care, anesthesia or clozapine management.

• Podiatry Services — Co-payment of $15 each visit

• Smoking Cessation Services (Prescription) — $5 each generic drug (Prescription)

• Therapy; Physical, Occupational, Speech — 20 visits per each type of therapy 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.  Co-payment $15 per visit.  There are no monthly or annual co-payment limits.

• Transportation (Emergency/Ambulance) — Co-payment $50 per trip.

• Vision — One eye exam every two years, with refraction.  Co-payment $15 per visit.

*Allowed amount is the amount BadgerCare Plus allows for the service and not what the provider bills. For more information, contact 1-800-362-3002.

You will not have a co-payment if you are a:

• Child under age 19 with family income up to 100% of the FPL.

• Child under age 6 with family income above 100% up to 150% of the FPL, except for newborns enrollment because his/her mother was enrolled on the newborns birth date.

• Child ages 1 through 5 who are Tribal members with family income from 185% to 300% of the FPL.

• Child ages 6 through 18 who are Tribal members with family income from 150% to 300% of the FPL.

• Child under age 19 enrolled through Express Enrollment.

• Child under age 19 in an institution.

• Child under age 19 enrolled in a BadgerCare Plus Extension

• Pregnant woman, except for pregnant woman under age 19 with family income above 300% of the FPL.

• Pregnant woman who was enrolled through Express Enrollment.

• Pregnant woman enrolled in BadgerCare Plus Prenatal Services benefit.

Last Revised: March 13, 2009