Recipient cost sharing.

Except as provided in pars. (am) to (d), and subject to par. (ag), any person eligible for medical assistance under s. 49.46, 49.468, or 49.47, or for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471 shall pay up to the maximum amounts allowable under 42 CFR 447.53 to 447.58 for purchases of services provided under s. 49.46 (2). The service provider shall collect the specified or allowable copayment, coinsurance, or deductible, unless the service provider determines that the cost of collecting the copayment, coinsurance, or deductible exceeds the amount to be collected. The department shall reduce payments to each provider by the amount of the specified or allowable copayment, coinsurance, or deductible. No provider may deny care or services because the recipient is unable to share costs, but an inability to share costs specified in this subsection does not relieve the recipient of liability for these costs.

Except as provided in pars. (am), (b), and (c), and subject to par. (d), a recipient specified in par. (ac) shall pay all of the following: 1. A copayment of $1 for each prescription of a drug that bears only a generic name, as defined in s. 450.12 (1) (b). 2. A copayment of $3 for each prescription of a drug that bears a brand name, as defined in s. 450.12 (1) (a).

1. Except as provided in subd. 2., no person is liable under this subsection for services provided through prepayment contracts. 2. A person who is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471 is liable under this subsection for services provided through a prepayment contract in the amounts and according to the procedures specified by the department.

The following services are not subject to recipient cost sharing under this subsection: 1. Any service provided to a person receiving care as an inpatient in a skilled nursing home or intermediate care facility certified under 42 USC 1396 to 1396k. 2. Any service provided to a person who is less than 18 years old. This subdivision does not apply if the person’s family income exceeds 100 percent of the poverty line and he or she is eligible for the benefits under s. 49.46 (2) (a) and (b) under s. 49.471. 3. Any service provided under s. 49.46 (2) to a pregnant woman, if the service relates to the pregnancy or to other conditions that may complicate the pregnancy. 4. Emergency services. 5. Family planning services, as defined in s. 253.07 (1) (b). 6. Transportation by common carrier or private motor vehicle, if authorized in advance by a county department under s. 46.215 or 46.22. 7. Home health services or, if a home health agency is unavailable, nursing services. 11. Personal care services. 12. Case management services.

The department may limit any medical assistance recipient’s liability under this subsection for services it designates.

No person who designates a pharmacy or pharmacist as his or her sole provider of prescription drugs and who so uses that pharmacy or pharmacist is liable under this subsection for more than $12 per month for prescription drugs received.