This site is privately owned and is not affiliated with any government agency. Learn more here.

Learn About Medicaid Costs and Coverage in Wisconsin

When residents begin learning about the types of Medicaid insurance in Wisconsin, they want to know what services are covered by Medicaid and how much coverage will cost. Prospective petitioners should also discover what does Medicaid not cover in terms of services and medical professionals, as non-covered treatments will result in out-of-pocket expenses. Although WI Medicaid coverage groups include claimants with low earnings and high health care needs, there may still be costs associated with receiving medical services. How much does Medicaid cost in Wisconsin? Medicaid cost estimates fluctuate depending on funding each year, the Medicaid eligibility of the enrollee and the services rendered. Potential Medicaid beneficiaries may be subject to copayments, deductibles and premiums. However, most Medicaid participants receive medical attention for little to no cost. Continue reading out outlined topics to find out how much is Medicaid in Wisconsin and which health care services it covers.

What services does Medicaid not cover in Wisconsin?

Wisconsin Medicaid coverage is health care insurance that pays a portion or all of the expense for medical services. Depending on the type of Wisconsin Medicaid insurance the beneficiary has, some health care treatments and procedures are free of charge or have a nominal fee. However, the program will cover not all medical services. For instance, the state will only cover health care services considered medically necessary and performed by a medical professional in the Medicaid network. Medicaid will not pay for services, even standard care, if rendered by an out-of-network professional without prior approval. After applying for Medicaid and receiving approval from the state, Wisconsin enrollees will be able to select their in-network medical professionals.

Knowing what Medicaid does not cover is beneficial for enrollees to prevent unexpected charges. Medicaid coverage will not include personal comfort items or non-essential equipment like a dehumidifier. The program will also not cover any cosmetic procedures unless medically necessary. However, a physician may make a request for Medicaid to cover a health care service that he or she considers vital to the patient’s health.

Petitioners should also understand that the services Wisconsin Medicaid does not cover may be subject to Medicaid eligibility criteria or because of annual limits. For instance, enrollees may have a specific services covered for a fixed number of times such as dental visits covered only twice a year. By understanding what services Medicaid does not cover, WI Medicaid beneficiaries will be able to avoid unexpected charges

What services are covered by Medicaid in Wisconsin?

Wisconsin Medicaid covered services are those that the state and federal government as well as Medicaid medical professionals consider medically necessary. The federal government determines basic Medicaid coverage that all qualified enrollees receive, while the state can opt for additional benefits to provide residents. Although the Wisconsin’s optional benefits for Medicaid participants can change based on funding and local policy, the federal essential health benefits are mandatory. Several, but not all, of these core benefits are listed below:

  • Behavioral health, mental health and substance abuse treatment
  • Emergency and non-emergency transportation to medical facilities
  • Inpatient and outpatient hospital services
  • Nursing home and skilled nursing facility services
  • Pregnancy and family planning supplies and services
  • Primary physician appointments and services

However, it is important to know that Medicaid beneficiaries may have copayments for services rendered depending on their eligibility level in the program. By means of example, children enrolled in the program receive more comprehensive Medicaid coverage than adult participants do.

Learn more about the services Medicaid covers in our free guide.

How much does Medicaid cost in Wisconsin?

Medicaid cost estimates in Wisconsin are difficult to determine since there are different types of insurance available and a varying level of need for each participant. Some enrollees will be subjected to monthly premiums for Medicaid coverage, while others may receive comprehensive health care assistance from the state. However, since the program is assists low-income claimants, any out-of-pocket costs will be minimal. Some Medicaid applicants will be exempt from paying any copayments altogether. Financial requirements on behalf of the enrollee are based on his or her family income compared to the federal poverty line. Higher earners may qualify for certain types of Medicaid insurance provided they share in some of the cost.

Any services that are covered by WI Medicaid that have a copay will have a maximum amount the medical facility can charge the beneficiary for its services. Once the medical facility establishes the maximum copay amount, it may not charge more for the service. However, the copayment amount may fluctuate based on the participant’s household earnings or state funding.

What services and individuals are exempt from WI Medicaid costs?

Wisconsin beneficiaries receive information about any Medicaid costs for coverage as well as a list of covered services under the program upon enrolling in Medicaid insurance. Medicaid coverage in Wisconsin may be free of cost for certain applicants. These beneficiaries are exempt from any cost-sharing requirements. The exempt beneficiaries include:

  • Children in foster care or subsidized adoption, regardless of their age.
  • Children in households with incomes less than the program threshold.
  • Nursing home residents.
  • Terminally-ill enrollees on hospice care.
  • Women enrolled in the WI Well Woman Medicaid Program.

Find out more about services covered by Medicaid in our free guide.