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Attachment 2 Co-payment Table Wisconsin SCHIP children with family income above 200% up to and including 300% FPL

Service/Item Co-payment Ambulance Services $50 per trip Ambulatory Surgery Services $15 per visit Chiropractic Services $15 per visit Dental Services 50% of allowable charges

(A $200 deductible applies to all services except preventive and diagnostic.) Disposable Medical Supplies $0.50 per item Drugs $5 per item Durable Medical Equipment $5 per item, except rentals Family Planning Services and Supplies No co-payment Health Screenings (EPSDT) for Children under age 21 years No co-payment Hearing Services $15 per procedure

WISCONSIN

Effective Date:

Approval Date: 53