Page 54
Service/Item Co-payment Home Health Services $15 per visit Hospice Services No co-payment Inpatient Hospital Services • $50 per stay for mental health and/or substance abuse treatment
• $100 per stay for medical stays Mental Health and Substance Abuse Outpatient Treatment $10 to $15 per visit for all outpatient services, except laboratory test, electroconvulsive therapy, and pharmacological management
Nursing Home Services No co-payment Occupational Therapy $15 per visit Outpatient Hospital Services • $15 per visit (multiple visits to the same provider in the same day will be treated as a single visit)
• $60 for emergency room visits (waived if admitted to hospital) Physical Therapy $15 per visit Physician/Clinic Services (including Nurse Practitioner, Nurse Midwife, Laboratory and Radiology services) $15 per visit , except for clozapine management, preventive medicine, and diagnostic services Podiatry Services $15 per visit
WISCONSIN
Effective Date:
Approval Date: 54