Medicaid Copays

By the GWAAR Legal Services Team

If you or a loved one is enrolled in a Medicaid program such as BadgerCare+, SSI Medicaid, or the Medicaid Purchase Plan (MAPP), you may have copays for certain items or services that range from $0.50 - $3.00. Similarly, if you are in the Qualified Medicare Beneficiary (QMB) program, you may also be charged copays. For most Medicaid programs, however, there is a limit on how much you can be charged per month. Qualifying members may may not pay more than five percent of their household income for monthly premiums and copays. 

Exempt Programs

There are some Medicaid programs where members will not be charged copays. Those programs are: 

• Family Planning Only Services 

• Institutional Medicaid (not including childless adults (CLAs) enrolled in BadgerCare Plus and residing in an institution) 

• Katie Beckett 

• Wisconsin Well Woman Medicaid 

Exempt Services 

The following services do not require copayment: 

• Case management services 

• Crisis intervention services 

• Community support program services 

• Emergency services 

• Family planning services, including sterilizations 

• HealthCheck 

• HealthCheck "Other Services" 

• Home care services 

• Hospice care services 

• Immunizations 

• Independent laboratory services 

• Injections 

• Private Duty Nursing (PDN) and PDN services for ventilator-dependent members 

• Pregnancy related services 

• Preventive services with an A or B rating from the U.S. Preventive Services Task Force 

• Residential substance use disorder treatment services 

• School-based services 

• Substance abuse day treatment services 

• Surgical assistance 

Five Percent Cost Share Limit 

Members enrolled in Medicaid programs and QMB may not pay more than 5% of their household income for monthly premiums and copays combined (total cost share). This limit does not apply to deductibles, or patient liability or cost share for long-term care Medicaid services. However, this cost share limit does not apply to members enrolled in MAPP and SeniorCare. 

Misinformation 

Oftentimes, national sources unfamiliar with the specifics of the Wisconsin Medicaid program will incorrectly state that Medicaid or QMB members have $0 copays. However, with the exception of the exempt Medicaid programs or medical services listed above, most Medicaid members may be charged copays of up to $3.00 per item or service up to the monthly maximum, if applicable. This even applies to members who are in dual eligible special needs Medicare Advantage plans (D-SNPs) where the plan’s evidence of coverage states that copays are $0. 

For more information, contact your health plan directly or call the number on the back of your ForwardHealth card.