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Service/Item Co-payment Limitations/Cumulative Maximum Home Health Services No co-payment n/a Hospice Services No co-payment n/a Hospital Services - Inpatient $3 per day Co-payment obligation limited to $75 per stay. Hospital Services - Outpatient $3 per visit Multiple visits to the same provider on the same day are treated as a single visit. Mental Health and Substance Abuse Outpatient Treatment $0.50 to $3 per visit  Visit co-payment based 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

 Co-payment obligation limited to the first 15 hours or $500 of services, whichever comes first, per calendar year.

 No co-payment for services provided in a hospital setting. Mental Health Day Treatment Services $0.50 per day Co-payment obligation limited to the first 15 hours or $500 of services, whichever comes first, per calendar year.

WISCONSIN

Effective Date:

Approval Date: 48