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Acute Care Services
Long-Term Care Services


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Benefits by State: Wisconsin (October 2008) Notes
 
 
 
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Acute Care Services

Is the Benefit Covered? Copayment Requirement Prior Approval Requirement Coverage Limitations Reimbursement Methodology Populations Covered


Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes $3/surgical procedure Specified surgical procedures Specified surgical procedures require second opinion Fee for service CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
No
Federally Qualified Health Center Services
Yes $.50-$3/encounter, depending on services provided, maximum $30/year/provider Prospective cost based rate/visit CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes $3/day up to $75/admission, includes psych admissions Admissions for specified procedures Weekend admissions limited to hospitals providing full services every day Prospective payment/discharge using DRG, prospective per diem for rehab hospitals/units and for specified conditions CN & MN
Outpatient Hospital Services
Yes $3/visit, $.50/day for psych day treatment Specified surgical procedures and other services Outpatient psych services limited to 5 hours/day up to 120 hours/month and 40 hours/year for nursing facility residents; occupational therapy, physical therapy and speech pathology services must be billed as if rendered by the therapist and are reimbursed accordingly Cost based payment with limits CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes $.50-$3, depending on service, copayment for psychotherapy limited to 15 hours or $500 Substance abuse services limited to 15 hours or $500/year, in-home services not covered for adults Fee for service CN & MN
Rural Health Clinic Services
Yes $.50-$3/encounter, depending on services provided, maximum $30/year/provider Prospective cost based rate/visit CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes Fee for service CN & MN
Chiropractor Services
Yes $.50-$3, depending on service 20 visits for manual manipulation/spell of illness, x-ray covered only at initial visit Fee for service CN & MN
Dental Services
Yes $.50-$3/service depending on payment Specified services Exam and cleaning 1/year, frequency of x-rays limited by type, orthodontia not covered Fee for service CN & MN
Medical and Remedial Care - Other Practitioners
Medical/Surgical Services of a Dentist
Yes $.50-$3/service depending on payment Specified services Fee for service CN & MN
Nurse Midwife Services
Yes $.50-$3, depending on service, maximum $30/year/provider Fee for service at 90% of physician fee except injections CN & MN
Nurse Practitioner Services
Yes $.50-$3, depending on service, maximum $30/year/provider 1 nursing facility visit/month Fee for service CN & MN
Optometrist Services
Yes $.50-$3, depending on service Specified services Fee for service CN & MN
Physician Services
Yes $.50-$3, depending on service, $1/EPSDT screening for beneficiary over age 18, maximum $30/year/provider except copayment for psychotherapy limited to 15 hours or $500 Specified surgical procedures require second opinion, 1 nursing facility visit/month Fee for service CN & MN
Podiatrist Services
Yes $.50-$3, depending on service, maximum $30/year/provider Electric bone stimulation 1 routine foot care visit/61 days for specified systemic conditions, specified services not covered including treatment of flat feet Fee for service CN & MN
Psychologist Services
No
Prescription Drugs
Prescription Drugs
Yes $3/Rx up to $5/month, $.50/over the counter drug Specified drugs, including antibiotics costing more than $100/day and nutritional supplements Most drugs limited to 34 day supply with 100 day supply for some AWP-16%, plus $3.88 dispensing fee CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
Yes $.50-$3/service, depending on payment, up to 30 hours or $1,500/year Yes Fee for service CN & MN
Physical Therapy Services
Yes $.50-$3/service, depending on payment, up to 30 hours or $1,500/year Yes Fee for service CN & MN
Services for Speech, Hearing and Language Disorders
Yes $1/audiological testing service; $.50-$3/speech pathology service, depending on payment, up to 30 hours or $1,500/year Yes Fee for service CN & MN
Products and Devices
Dentures
Yes Yes Fee for service CN & MN
Eyeglasses
Yes $.50-$3, depending on service Items from other than state's contractor 1 pair eyeglasses/year and 1 replacement/year if eyeglasses lost or broken or if minimum diopter correction criteria met Most products provided by state's volume purchase contractor, dispensing provider paid fee for service, average acquisition cost for other items CN & MN
Hearing Aids
Yes $3/hearing aid, $.50-$2/accessory or repair, depending on payment New or replacement hearing aid 1 hearing aid/3 years, 1 repair/6 months Most products provided by state's volume purchase contractor, with dispensing fee, average acquisition cost for other items CN & MN
Medical Equipment and Supplies
Yes $.50-$3, depending on service or item Specified med equipment and med supply items, depending on cost Limited items available to nursing facility residents Fee for service for med equipment, med supplies paid cost plus mark-up CN & MN
Prosthetic and Orthotic Devices
Yes $.50-$3, depending on service or item Specified services or items, items costing more than established amounts Limited to post-surgery care, orthopedic shoes must be attached to brace Fee for service CN & MN
Transportation Services
Ambulance Services
Yes $2/non-emergency ambulance trip, $1/trip in specialized medical vehicle Fee for service CN & MN
Non-Emergency Medical Transportation Services
Yes $1/trip in specialized medical vehicle Long trips See service-specific FN CN & MN
Other Services
Diagnostic, Screening and Preventive Services
No
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women
Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes $1/day for lab test, $2/day for diagnostic lab test or x-ray, $3/day for other radiology service Portable x-ray services only in nursing facilities Fee for service CN & MN
Targeted Case Management
Yes Fee for service, per diem or percentage of charge CN & MN


Long-Term Care Services

Community Based Care
Home and Community Based Services Waiver
Yes Services for the following populations: 1, 2, 4, 7 & 8 - See service-specific FN Dependent upon the services provided CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes 30 visits/year Fee for service using Medicare cost ceilings CN & MN
Hospice Care
Yes Prospective rates based on Medicare methodology CN & MN
Personal Care Services
Yes 250 hours/year Fee for service using hourly rate for care and visit rate for supervision CN & MN
Private Duty Nursing Services
Yes $.50/hour up to $2/day Yes 2-tiered hourly rate based on level of care (RN or LPN) CN & MN
Program of All-Inclusive Care for the Elderly
Yes See service-specific FN Capitated payment CN & MN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes $3/day up to $75/admission if hospital IMD 15 hosp leave days/hospitalization, unlimited therapeutic leave days, facility must have 95% occupancy or fewer than 9 vacant beds to be paid Prospective payment/discharge using DRG for private hospital IMDs, prospective cost based per diem for nursing facility and state-operated IMDs CN & MN
Inpatient Psychiatric Services, under age 21
Yes Prospective cost based per diem CN & MN
Intermediate Care Facility Services for the Mentally Retarded
Yes 15 hosp leave days/hospitalization, unlimited therapeutic leave days, facility must have 95% occupancy or fewer than 9 vacant beds to be paid Prospective cost based per diem with some settlement, leave days paid at 85% of facility's rate CN & MN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes Specialized med equipment 15 hosp leave days/hospitalization, unlimited therapeutic leave days, facility must have at least 95% occupancy rate or fewer than 9 vacant beds to be paid Prospective per diem based on cost using peer groups with some settlement, leave days paid at 85% of facility's rate CN & MN
Religious Non-Medical Health Care Institution and Practitioner Services
Yes Care must be equivalent to inpatient hospital or nursing facility care Prospective cost based per diem CN & MN


Notes: This State has an approved Section 1115 Waiver from CMS, funded by both Title XIX and Title XXI, under which it extended Medicaid eligibility to children and their families with net income up to 185 percent of the federal poverty level (FPL) although coverage continues as long as income does not exceed 200 percent of the FPL. Families with income above 150 percent of the FPL pay an income-based monthly premium. This population receives full Medicaid benefits either directly or as a wrap-around for services included in an employer’s insurance package. The State has also added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997 in its Medicaid Purchase Plan. These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits, if their income is at or below 250 percent of the FPL. Beneficiaries in this group must pay an income-based monthly premium. Any identified copayment requirements are applicable to pregnant women if the service is unrelated to pregnancy.
 
 
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