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Attachment 1 Co-payment Table Wisconsin SCHIP children with family income that does not exceed 200% FPL

Service/Item Co-payment Limitations/Cumulative Maximum Ambulance Services $2 for non-emergency trip only n/a Ambulatory Surgery Services $3 per surgery n/a Case Management Services No co-payment n/a Chiropractic Services $0 to $3 per procedure Co-payment obligation depends on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service:

Fee

Co-payment $10 or less…………………….$0.50 $10.01 to $25………………....$1.00 $25.01 to $50………………....$2.00 $50.01 or more…………….….$3.00

Clozapine Management No co-payment n/a Community Support Program No co-payment n/a

WISCONSIN

Effective Date:

Approval Date: 45