Medicaid Costs and Coverage in Wisconsin

“How much does Medicaid cost in Wisconsin?” is one question that you may be asking yourself now that your application has been approved by the state. To answer the question of how much is Medicaid, you must know that the cost will vary from one service to another and if the service also requires supplies. Medicaid cost estimates will also depend on the type of coverage that a beneficiary obtains. A covered Medicaid service is a treatment, supply or item for which Medicaid reimbursement is made available when all program requirements have been met. In Wisconsin, services covered by Medicaid include family planning, dental, hospice care, transportation, physical therapy, and inpatient and outpatient care. However, federal law regarding Medicaid coverage permits states to charge Medicaid recipients copayments for certain services, and the Wisconsin legislature will occasionally revise Medicaid copayments.

How much does Medicaid cost in Wisconsin?

In Wisconsin, how much does Medicaid cost will depend on the types of Medicaid insurance a beneficiary has, and it will also depend on the number of services that have a copayment. If you qualify for Wisconsin Medicaid coverage, then you might be required to cover the cost of a copayment, which is a small fee, for some medical services offered by the Medicaid program, while other programs require no copayments. After completing the Medicaid application process in WI, approved beneficiaries will receive information on expected costs. Coverage for Medicaid in Wisconsin states that Medicaid reimbursement is granted only for services that are deemed medically necessary. The state may deny or recoup a payment if a service fails to meet Wisconsin’s Medicaid necessity requirements. Services that are covered by Medicaid and are defined as “medically necessary” mean that the service is required to prevent, identify or treat a beneficiary’s illness, injury or disability. Medically necessary services in Wisconsin must meet standards that are set by the state. Download our comprehensive Medicaid guide for details about mandatory services that are covered by the program.

Services Covered by Medicaid in Wisconsin but Require Copayments

Knowing what services are covered by Medicaid is important Medicaid information to be aware of once you are enrolled in the program. In Wisconsin, many services fall under full Medicaid coverage, and it is important that each beneficiary knows which of these services will require copayments. Full coverage of Medicaid is given to HealthCheck screenings and other services for beneficiaries who are younger than 21 years of age. There will be a copayment per screening for beneficiaries between 18 and 20 years of age. Medicaid covered services that require copayments in Wisconsin also include the following:

  • Durable Medical Equipment (DME), a copayment is required per item, while rental items are not subjected to copayments
  • Inpatient hospital, a copayment per day is required with a cap per hospital stay
  • Outpatient hospital, a copayment is required per visit
  • Physical Therapy (PT), Occupational Therapy and Speech and Language Pathology (SLP), a copayment is required per service
  • Physician, including laboratory and radiology, a copayment per service is required

Medicaid coverage in Wisconsin that require copayments per service also include podiatry services, coverage of certain surgical producers and the related lab services, chiropractic, dental services and Disposable Medicaid Supplies (DMS). While a routine vision screening includes the coverage of glasses, there is a copayment per service. Hearing services are also covered under Medicaid coverage for adults, and there are copayments per procedure, but there are no copayments for hearing aid batteries.

Full Medicaid coverage in WI also covers many transportation services, such as ambulance, Specialized Medical Vehicles (SMVs) and common carrier. These services include emergency and non-emergency transportation to and from a provider that is certified for covered service. Copayments include services for nonemergency ambulance trips and copayments per trip for transportation by an SMV. Under Wisconsin Medicaid coverage, there are no copayments for an emergency ambulance or common carrier.

As for prescription drugs, Wisconsin Medicaid coverage costs includes comprehensive drug benefits with coverage of both generic and brand-name prescriptions drugs. Some over-the-counter (OTC) drugs are also included. For opioid drugs, beneficiaries are limited to five prescriptions per month. Wisconsin Medicaid coverage of generic, brand-name and OTC drugs will all have a copayment. Learn more about coverage and costs from the government health insurance program by downloading our detailed Medicaid guide here.

Services Covered by Medicaid in Wisconsin With No Copayments Under the cost of Medicaid coverage, there are many services offered that do not require a copayment. In Wisconsin, these Medicaid covered services include the following:

  • Home care services, such as home health, private duty nurse (PDN) and personal care
  • Hospice
  • Nursing home services
  • Outpatient hospital and emergency room
  • Services for End-Stage Renal Disease (ESRD)

Services under Wisconsin Medicaid Coverage that also do not require a copayment include family planning services, such as prenatal and maternity care, Prenatal Care Coordination (PNCC). Medicaid covered services such as preventive mental health and substance abuse screening and counseling for women who are at risk of mental health or a substance abuse problem may also not have a copayment. For physician Medicaid coverage, there is no copayment for emergency services, clozapine management or anesthesia.

Additional services that are covered by Wisconsin Medicaid but do not require copayments from a beneficiary enrolled in Wisconsin Medicaid include community recovery services, community support program services and comprehensive community services as well as crisis intervention services and immunization, which include approved vaccines that are recommended to adults by the Advisory Committee on Immunization Practices. Lastly, services that are covered by Medicaid in Wisconsin that does not require copayments include independent laboratory services, injections and surgical assistance.

Information about Medicaid copayments and costs are influenced by the eligibility of beneficiaries. Providers who comply with Wisconsin Medicaid coverage are not allowed to collect copayments from Medicaid beneficiaries who are children in a mandatory coverage category, children in the Katie Beckett program regardless of their age and children and adults who are Alaskan Natives and are American Indians. Providers of Medicaid coverage in Wisconsin are also not allowed to collect copayments from terminally ill beneficiaries. They also cannot receive copayments from nursing home residents, beneficiaries enrolled in Wisconsin Well Woman Medicaid and those eligible through Express Enrollment. Children younger than 18 years of age who are in a Supplemental Security Income (SSI) or SSI-related eligibility group are also exempt from copayments.

What does Medicaid not cover in Wisconsin?

While Wisconsin Medicaid coverage includes mental health and substance abuse treatments, it does not include room and board, and beneficiaries will be subjected to a copayment per service. Services per year are limited to the first 15 hours, a specific price of service or whichever occurs first. Copayments for Wisconsin Medicaid costs are not required when these services are provided in a hospital setting.

In Wisconsin, undocumented immigrants are eligible only for Medicaid coverage for emergency health services if they would have otherwise been eligible for Medicaid. Pregnant immigrants may be able to enroll in prenatal services. While reproductive health services receive full coverage of Medicaid in Wisconsin, it does not include infertility treatments and surrogate parenting. It also does not include related services including but not limited to artificial insemination and subsequent obstetrical care and the reversal of voluntary sterilization.