Learn About Coverage For Medicaid in Wisconsin

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“What services are covered by Wisconsin Medicaid?” Applicants of WI Medicaid services usually have this question when they want to apply for the coverage. Moreover, applicants wonder what is not covered by Medicaid and how much they are going to pay for the service.

Wisconsin Medicaid coverage, also known as Healthy Wisconsin, is a health program jointly run by the federal government and State of Wisconsin. The Medicaid services program helps individuals and households with limited resources and incomes pay for medical costs, services and long-term support.

In this section, we cover the following:

How Much Does Medicaid Cost in Wisconsin?

Generally, Wisconsin Medicaid coverage allows qualified individuals to access quality healthcare for free or at a low cost. How much is Medicaid, exactly? The WI Medicaid cost estimates depend on an individual and the services or items sought.

The estimate Medicaid costs for copayments for members that are 21 years or older vary. The copays are made directly to the health care providers at the time that a service is offered. If you cannot make a copayment, the provider cannot deny you services. However, you will still be billed for the services.

Find out the Medicaid cost estimates in WI before requesting a particular service. The majority of services cost from zero to $30. Common services that require copayment include inpatient hospital stays, non-emergency visit to the hospital emergency room, outpatient hospital visit, visit to the physician office (including free-standing Urgent Care Centers), professional health services (vision, podiatry, hearing, dental and chiropractic) and prescription drugs(both generic and brand drugs).

WI Medicaid cost estimates can change over time. Confirm the cost of the service you need from your health provider. No copayments are required for preventive health care services, pregnancy-related products or services, or family planning products or services.

Download our informative guide to learn more about Medicaid coverage and costs.

What Services are Covered by Medicaid in Wisconsin?

WI Medicaid coverage caters for various services when you get them from providers in your health plan network. Moreover, the Medicaid services have to be deemed medically necessary. Some of the services covered include:

  1. Mental health and substance abuse services
    Medicaid services covered include treatment for emotional or mental needs or long-term severe mental conditions, inpatient treatment and intensive outpatient treatment. Medicaid coverage caters for up to 20 outpatient visits per year to a psychologist, licensed clinical social worker or counselor.
  2. Prescription drug program
    WI Medicaid coverage pays for prescription drugs. A copayment of $1 for generic drugs or $3 for brand name drugs may be required for enrollees that are over 21 years. Pregnancy and family planning related medications do not attract copayment.
  3. Vision, hearing and dental services
    Wisconsin Medicaid coverage pays for routine eye exams, frames and cover lenses for members. The services have to be sought from a participating eye doctor. A copayment of $2 may be required for enrollees that are over 21 years.
    Hearing exams are also covered by Medicaid. Members that are below 21 years are eligible for hearing aids. For dental care, various services, including fillings and crowns, are offered to enrollees below 21 years. Adult dental services are restricted to emergencies.
  4. Pregnancy-related services
    Medicaid services in WI covers pregnant women for various prenatal care services. The program covers the services required even when the baby is born. Childbirth-related services are covered up to 60 days after birth.
  5. Preventive and medical careWI Medicaid coverage caters for various preventive and routine medical services. The program also offers health education services. Services covered include family planning, allergy testing, injections and treatments, X-rays, vaccines, annual or regular well visits, doctor and specialist visits, rehabilitative therapy, urgent and emergency care services and weight reduction services that are medically necessary.

What does Medicaid not cover in WI? Health plans require Wisconsin Medicaid members to get medical services from their network of providers. Services offered outside the network providers are not covered.

Explore Medicaid coverage and costs by downloading our detailed guide.

What Does Medicaid Not Cover in Wisconsin?

Wisconsin Medicaid coverage does not apply to all health services. The services below are not covered:

  • Sports medicine
  • Services to treat infertility
  • Elective cosmetic surgery
  • Unproven, investigational or experimental drugs or procedures
  • Elective abortion and related services
  • Biofeedback
  • Pool/aquatic therapy that is not part of a physical therapy treatment plan

WI Medicaid coverage does also not cover services offered by an out-of-state or out-of-network providers. Moreover, any health care services deemed not medically necessary are not covered. The only exceptions are emergencies and prior authorized services. Finally, any services that you are not legally required to pay, for example those offered at a discount or voluntarily, are not covered by Medicaid.

Understanding the Types of Medicaid Insurance in Wisconsin

There are different types of WI Medicaid insurance you can choose. When approved for WI Medicaid coverage, you will have to choose a health plan. This is a managed care organization (MCO) contracted by the State of Wisconsin to offer health services to Medicaid enrollees.

What Medicaid services are covered by the health plans? The health plans provide the same basic services. However, they have different optional services. The Medicaid types of insurance you choose will determine the health plan you can sign up with. , you will have to seek health care services from its network of providers, clinics, and facilities.