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Updates for local agencies, community-based organizations, and providers who provide assistance to members of Wisconsin's health and nutrition public assistance programs.
Some Member Copays for BadgerCare Plus and Medicaid Services Will Start Again on July 1, 2020, With Copay Limits
Background
On January 1, 2020, the Wisconsin Department of Health Services (DHS) temporarily suspended copays for prescriptions and health care services for Medicaid and BadgerCare Plus members. The temporary suspension was part of planned system changes to ensure that members enrolled in Medicaid programs were not charged premiums and copays that exceed 5% of their income. For simplicity, this limit is referred to in this communication and member letters as a “copay limit.”
While these system changes were being made, Medicaid-enrolled providers did not collect any copays for services provided to Medicaid and BadgerCare Plus members. The temporary suspension did not apply to members enrolled in SeniorCare or the Wisconsin Chronic Disease Program.
Changes for BadgerCare Plus and Medicaid Members
Starting July 1, 2020, some BadgerCare Plus and Medicaid members will have copays again for some prescriptions and services. There will now be limits to the copay amount most members pay each month. This limit will be based on the member’s income and who in their household has copays. If members pay a monthly premium, that premium will count toward their copay limit.
Monthly copay limits will stay the same unless a member has a relevant change in their circumstances, such as in income or the number of people living in their household. When a member reaches their copay limit for the month, they will receive a letter telling them the date their copay limit was reached. Once the limit is reached, members will not have to pay copays the rest of the month after the date listed.
DHS will track member copay limits, copays, and premiums. Members do not have to take any action.
Note: Members enrolled in the Medicaid Purchase Plan or SeniorCare will not have copay limits based on their income. Their premiums and copays may exceed 5% of their monthly income.
Members Without Copays
Starting July 1, 2020, children age 18 and younger will not have copays for prescriptions or health care services. Any youth in foster care on their 18th birthday who enrolls in BadgerCare Plus will not have copays until they turn 26.
There are also a number of adults who are exempt from paying copays. This includes tribal members, pregnant women, members enrolled in Wisconsin Well Woman Medicaid, nursing home residents, and members in hospice care. Members who are temporarily enrolled through Express Enrollment also do not have copays.
$8 Emergency Room Copay for Nonemergency Visits
BadgerCare Plus members who are age 19–64, are not pregnant, and do not have dependent children living in their home (often referred to as childless adults) will have to pay an $8 copay for every visit to the emergency room (ER) that is not determined to be an emergency. There will not be a copay for using the emergency room in an emergency. When there is not an emergency, ER staff are required to advise members of the $8 copay and provide them with the names and locations of other providers where they may go for medical help, such as an urgent care facility, without having the copay.
BadgerCare Plus providers will begin collecting the $8 ER copay for nonemergency visits on and after July 1, 2020. The $8 ER copay for nonemergency visits will count toward the monthly copay limit.
Notification
Members will receive letters in June informing them that copays will start again on July 1, 2020. Members will then receive a letter titled “About Your Benefits,” indicating if they will have a copay limit and how much it is. Letters will be sent to the following three populations:
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