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Service/Item Co-payment Limitations/Cumulative Maximum • Limited to $30 per member, per provider, per calendar year

Private Duty Nursing No co-payment n/a Respiratory Care Services No co-payment n/a Specialized Medical Vehicle (SMV) Services $1 per trip n/a Speech and Language Pathology $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. Vision Care Services $0.50 to $3 per service  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

WISCONSIN

Effective Date:

Approval Date: 51