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The five percent cost share limit applies to members eligible for BadgerCare Plus, SSI Medicaid, and most EBD Medicaid programs. Members enrolled in MAPP and SeniorCare do not have a cost-sharing limit. For members subject to the cost-sharing limit, a copay limit will be set on a monthly basis. The copay limit is based on the assistance group’s income used to determine eligibility. Copays are tracked based on copays the individual has incurred, not the amount of copays actually paid. 21.11.1 Copay Limits for Members and Programs exempt from copays Members who are in a copay exempt category (21.5.2 COPAY EXEMPT POPULATIONS) will not have a copay limit while they are copay exempt since they have no copays. Members who are enrolled in any copay exempt subprograms (21.5.3 COPAY EXEMPT PROGRAMS) will have a copay limit of $0 as there are no copays for members enrolled in these programs. 21.11.2 Programs Excluded from the Five Percent Cost Share Limit Members enrolled in the following subprograms will continue to be charged premiums and copays with no five percent cost share limit set based on their income: • Medicaid Purchase Plan (MAPP) • SeniorCare Note: Members who are enrolled only in Medicare Savings Programs (except for Qualified Medicare Beneficiaries (QMB)) do not receive Medicaid card services and thus do not have copays. 21.11.3 Determining the Copay Limit For members enrolled in a health care program that has a copay limit, copay limits will be based on the assistance group’s income used to determine eligibility. Per-member copay limits will be set based on the income tiers (see SECTION 39.12 FIVE PERCENT COPAY LIMIT TIERS). If the member is married and both spouses are enrolled in a health care program that has a copay limit (and neither spouse is exempt from copays), the copay limit will be prorated between them. If one spouse is exempt from copays (for example, due to pregnancy), the other spouse will have the full individual copay limit for their income tier. Example 1: Jane and Benji are married and enrolled in SSI-Related Medicaid. The assistance group has counted income which puts their household income in the 50-100% of FPL income tier for an assistance group size of two. Since both Jane and Benji are eligible and have to pay copays, the $26 copay limit for the household will be prorated between Jane and Benji. They will each have a monthly copay limit of $13.

Note: If needed, use the following formula to determine the assistance group income FPL percentage and the appropriate tier: Assistance Group Income / (100% FPL for the group size) = Assistance Group Size % FPL. If spouses are enrolled in two different health care programs (and both programs have a copay limit), the copay limit for the household will be calculated based on the assistance group with lower income and prorated between spouses. This will prevent the spouse with lower income from paying cost sharing expenses in excess of the five percent limit.