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Attachment 3 Wisconsin Description of the Amount, Duration and Scope of Services Covered Section 6.2
The following chart shows the amount, duration and scope of covered benefits provided to members of the Standard and Benchmark Plans. Members with income at or below 200% of the FPL receive the Standard Plan benefits, and members with income above 200% FPL receive the Benchmark Plan benefits.
BadgerCare Plus Standard Plan BadgerCare Plus Benchmark Plan
Case Management Services Limited to case management provided by public entities or AIDS service organizations. No coverage.
Chiropractic Services Full coverage Full coverage
Dental Services Full coverage Limited coverage of preventive, diagnostic, simple restorative, periodontics, and extractions for pregnant women and children
Coverage limited to $750 per enrollment year.
Disposable Medical Supplies (DMS) Full coverage Coverage of syringes, diabetic pens and DMS that is required with the use of a durable medical equipment (DME) item.
Drugs Comprehensive drug benefit with coverage of generic and brand name prescription drugs, and some over-the-counter (OTC) drugs Generic drug-only formulary with a few generic OTC drugs
Members will be automatically enrolled in the Badger Rx Gold plan. This is a separate program administered by Navitus, which provides for a discount on the cost of drugs.
Durable Medical Equipment (DME) Full coverage Full coverage up to $2,500 per enrollment year
Health Screenings for Children Full coverage of HealthCheck screenings and other services for individuals under age 21 years Full coverage of HealthCheck screenings
HealthCheck “Other” services and Interperiodic services for individuals under age 21 years are not covered.
WISCONSIN
Effective Date:
Approval Date: 79