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Service/Item Co-payment Limitations/Cumulative Maximum Narcotic Treatment Services No co-payment n/a Nursing Home Services No co-payment n/a Personal Care Services No co-payment n/a Occupational Therapy $0.50 to $3 per procedure  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 30 hours or $1,500, whichever occurs first, during one calendar year. Physical Therapy $.50 to $3 per procedure  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

WISCONSIN

Effective Date:

Approval Date: 49