BadgerCare Plus: Covered Services and Copays
BadgerCare Plus covers health care services. Some members get all services at no cost. Some members get some services at no cost and may have a copay for others. A copay is money you pay each time you get a health service. Here, we explain more about services BadgerCare Plus covers and copays.
Covered services
BadgerCare Plus covers services like those in the list below. To find out about coverage for a specific service, call ForwardHealth Member Services at 800-362-3002.
BadgerCare Plus covers:
- Care with a nurse or nurse practitioner.
- HealthCheck, which gives health care to kids and young adults (age 20 or below).
- Lab work and X-rays.
- Medical supplies and equipment.
- Physician services.
- Prescription drugs and over-the-counter drugs.
- At a hospital (called inpatient care).
- Outside a hospital (called outpatient care).
- At an intermediate care facility.
- At a rural health clinic.
- Specialty care
- Chiropractic care.
- Dental care.
- Eye care. Includes eyeglasses.
- Foot care (called podiatry).
- Physical and occupational therapy.
- Respiratory care for people who need a ventilator to breathe.
- Speech, hearing, and language disorder services.
- Tuberculosis (TB) care.
- Doctor and clinic visits.
- Family planning needs and supplies.
- Labor and delivery.
- Nurse midwife care.
- Prenatal care.
- Prenatal care coordination if you are having a baby and are at a high health risk.
- Treatment for patients in institutions for mental disease. Includes hospitals and skilled nursing and intermediate care facilities. You must be:
- Under 21.
- Under 22 and were getting care when you turned 21.
- 65 or older.
- Mental health and medical day treatment.
- Mental health and psychosocial rehab services. Includes case management from staff at certified community support programs.
- Some home and community-based services.
- Home health, plus nursing services if you cannot find a home health agency.
- Hospice care.
- Personal care that helps with day-to-day living.
- Skilled nursing home care.
- Case management, like meeting with a social worker.
- Help to quit smoking (called smoking cessation treatment).
- Help with getting to health care appointments.
- Substance abuse (alcohol and other drug abuse) care.
Copays
You may have to pay a copay for some health services. Members who don’t have copays include:
- Kids under age 19.
- Youth, no matter their age, in an out-of-home placement (also known as foster care) or court-ordered kinship care.
- Youth, no matter their age, in adoption assistance or a subsidized guardianship agreement.
- Youth who were in an out-of-home placement (also known as foster care) or subsidized guardianship, or court-ordered kinship care agreement on their 18th birthday, don’t have any copays until age 26.
- American Indians or Alaskan Native tribal members, children or grandchildren of a tribal member, or anyone who can get Indian Health Services from an Indian Health Services provider or from the Purchase and Referred Care program.
- Members who join by Express Enrollment.
- People getting hospice care are exempt from co-pays for hospice care services.
- People who are pregnant or who had a baby in the past 60 days.
Other members may have copays. This is based on if your family income is at or below the monthly limit based on family size. Use Table 1 below to find your family size and income limit.
For example: If you are a single parent with one child (age 4), your family size is two. That means your income each month must be lower than $851.67. If it’s lower, you won’t have a copay. If it’s higher, you will have a copay. You won’t have a copay for services for your child since they are under age 19.
| What is your family size | What is your income each month? |
|---|---|
| 1 | $627.50 |
| 2 | $851.67 |
| 3 | $1,075.83 |
| 4 | $1,300.00 |
| 5 | $1,524.17 |
| 6 | $1,748.33 |
Most copays cost from $0.50 to $3.00. The cost depends on the service. If you get more than one service, you may have more than one copay. Table 2 below shows copay costs.
| Cost or type of service | Copay amount |
|---|---|
| $10.00 or less | $0.50 |
| $10.01 to $25.00 | $1.00 |
| $25.01 to $50.00 | $2.00 |
| Over $50.00 | $3.00 |
Emergency Room visit when it's not an emergency* if you are:
*There's no copay if you do have an emergency | $8.00 |
Learn more about the Emergency Room Copay. View BadgerCare Plus: Some Adults Need to Pay a Copay for Going to the Emergency Room When It’s Not an Emergency, P-02580.
Yes. There is a limit on how much you pay for copays each month. When you join BadgerCare Plus, you will get an About Your Benefits letter. It explains your monthly copay limit. View a sample letter about monthly copay limits (PDF).
Your copay limit depends on a few factors:
- How much money you make.
- Who in your household has copays.
- Your family size.
What you pay in copays each month will never be more than 5% of your total gross income. Gross income is how much money you make before taxes or other deductions.
If you reach your copay limit, we will send you a letter. The letter lets you know you don’t have to pay copays for the rest of the month. View a sample letter about reaching your copay limit (PDF).