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Service/Item Co-payment Limitations/Cumulative Maximum Durable Medical Equipment $0.50 to $3 per service  Co-payment amount is based on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the item:

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

 DME rental items are not subject to co-payment.

Family Planning Services and Supplies No co-payment n/a HealthCheck Screenings (EPSDT) for Children under age 21 years. $1 per screen Co-payment obligation is limited to members who are 18, 19, and 20 years old. Hearing Services $0.50 to $3 per procedure  Co-payment amount depends on the Wisconsin Medicaid and BadgerCare Plus maximum allowable fee for the service provided:

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

 No co-payment obligation for hearing aid batteries

WISCONSIN

Effective Date:

Approval Date: 47