Medicaid in Wisconsin, primarily known as BadgerCare Plus, covers a broad range of medical services including doctor visits, hospital stays, prescription drugs, mental health care, dental work, and preventive screenings. Wisconsin’s Medicaid program is notable for covering adults without children up to 100% of the federal poverty level, which many states do not offer, though the state has not expanded Medicaid under the Affordable Care Act to the 138% threshold.
How Wisconsin Medicaid Programs Work
Wisconsin runs several Medicaid programs under different names, and the one you qualify for depends on your age, income, and health situation. BadgerCare Plus is the largest, covering low-income adults, children, and pregnant women. Other programs include Medicaid for the Elderly, Blind, and Disabled, as well as long-term care programs like Family Care and IRIS (Include, Respect, I Self-Direct).
Most BadgerCare Plus members receive coverage through a managed care organization, meaning you choose a health plan and get most services through that plan’s network of providers. The health plan assigns you a primary care provider who coordinates your care. If you’re in the fee-for-service program instead, you can see any provider who accepts Wisconsin Medicaid.
Medical Services Covered
Wisconsin Medicaid covers the core medical services you’d expect from health insurance and then some. Covered services include visits to primary care doctors, specialists, and urgent care clinics. Hospital stays, both inpatient and outpatient, are fully covered, along with emergency room visits. Lab work, X-rays, MRIs, and other diagnostic testing fall under the benefit as well.
Preventive care is covered without cost-sharing for most members. This includes annual wellness exams, immunizations, cancer screenings like mammograms and colonoscopies, and routine bloodwork. Children receive a comprehensive set of preventive services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which requires the state to cover virtually any medically necessary service for anyone under 21, even if that service isn’t normally covered for adults.
Prescription drugs are covered under Wisconsin Medicaid, though the program maintains a preferred drug list. If your doctor prescribes a medication not on the preferred list, they can request prior authorization. Generic drugs are typically dispensed when available. Copays for prescriptions are minimal, usually between $0.50 and $3 depending on the drug and your eligibility category.
Dental Coverage
Wisconsin provides dental benefits for both children and adults on Medicaid, which is worth noting because adult dental coverage is optional for states and many choose to offer limited or no dental benefits. For adults, covered services include exams, cleanings, fillings, extractions, root canals, dentures, and crowns. There are some limits on frequency: for example, routine cleanings are generally covered once every 12 months for adults.
Children’s dental coverage is more generous under the EPSDT requirement. Kids can receive preventive dental care, fluoride treatments, sealants, orthodontics when medically necessary, and restorative work without the same frequency limits that apply to adults.
Mental Health and Substance Use Treatment
Mental health services are a covered benefit across all Wisconsin Medicaid programs. This includes outpatient therapy, psychiatric evaluations, medication management, and crisis intervention. Inpatient psychiatric hospitalization is covered when medically necessary. Wisconsin also covers intensive outpatient programs, day treatment, and community-based mental health services like community support programs and comprehensive community services.
Substance use disorder treatment is covered at multiple levels of care: outpatient counseling, intensive outpatient programs, residential treatment, medically supervised detox, and medication-assisted treatment for opioid and alcohol use disorders. Wisconsin has expanded access to these services in recent years as part of its response to the opioid crisis.
Vision and Hearing
Eye exams are covered for all Medicaid members. For children, eyeglasses are a standard covered benefit. Adult vision coverage is more limited. Routine eye exams are covered, and glasses may be covered after cataract surgery or in certain medical situations, but standard corrective eyeglasses for adults have restrictions.
Hearing services include audiological evaluations and hearing aids. Children are entitled to hearing aids and related services under EPSDT. Adults can receive hearing evaluations, and hearing aids are covered in some circumstances, though prior authorization is typically required.
Pregnancy and Maternity Care
Pregnant women in Wisconsin can qualify for BadgerCare Plus with household income up to 306% of the federal poverty level, which is significantly higher than the standard income limit. Coverage includes all prenatal visits, ultrasounds, lab work, delivery (vaginal or cesarean), and postpartum care for 60 days after delivery. Wisconsin extended postpartum coverage to 12 months, giving new mothers a full year of Medicaid benefits after giving birth.
Midwife services and birthing center deliveries are covered alongside traditional hospital births. Breastfeeding support, breast pumps, and lactation consultation are included benefits as well.
Long-Term Care and Home Services
Wisconsin’s approach to long-term care is distinctive. The state operates Family Care, a managed long-term care program for elderly adults and people with physical or intellectual disabilities. Family Care covers nursing home stays, assisted living, adult day care, home modifications, personal care services, and supportive home care. The program emphasizes keeping people in their homes and communities rather than institutions whenever possible.
The IRIS program is a self-directed option where participants manage their own long-term care budgets, hiring their own workers and choosing their own services. Both programs require a functional screen to determine eligibility based on your care needs, not just income.
For people who need help with daily activities but don’t qualify for Family Care or IRIS, personal care services through standard Medicaid cover assistance with bathing, dressing, eating, and other tasks in your home.
Therapy and Rehabilitation Services
Physical therapy, occupational therapy, and speech-language therapy are covered benefits. These can be provided in outpatient clinics, in your home through home health services, or as part of a hospital stay. For adults, there may be limits on the number of visits per year, but additional visits can be authorized if medically necessary. Children face no hard caps on therapy services due to the EPSDT requirement.
Home health services more broadly include skilled nursing visits, wound care, and medical equipment in the home. Durable medical equipment like wheelchairs, walkers, hospital beds, oxygen equipment, and prosthetics are covered with a prescription and prior authorization for higher-cost items.
Transportation to Medical Appointments
Wisconsin Medicaid covers non-emergency medical transportation if you have no other way to get to appointments. This includes rides to doctor visits, therapy sessions, pharmacy trips, and other covered services. Your managed care plan coordinates these rides, or if you’re in fee-for-service Medicaid, you arrange transportation through your county. Some members can also get reimbursed for mileage if they drive themselves or have a family member drive them.
What Wisconsin Medicaid Does Not Cover
Cosmetic procedures are excluded unless they’re reconstructive after an injury or medically necessary. Experimental treatments not approved for general use are not covered. Over-the-counter medications are generally not covered unless specifically listed on the formulary. Weight loss surgery requires meeting strict medical criteria and prior authorization, though it is available for qualifying members.
Cost-sharing in Wisconsin Medicaid is minimal. Most children and pregnant women pay no copays at all. Adults may have small copays for some services, but no one can be turned away for inability to pay a copay. There are no deductibles and no monthly premiums for most BadgerCare Plus members, though some higher-income members in certain categories may pay a small monthly premium.
How to Check Your Specific Benefits
Your exact covered services can vary depending on which Medicaid program you’re enrolled in and which managed care plan you chose. The most reliable way to confirm coverage for a specific service is to call the number on the back of your ForwardHealth card or contact your managed care organization directly. You can also check the ForwardHealth member portal online, where you can view your eligibility details, claims history, and plan information. Your managed care plan sends a member handbook when you enroll that lists covered services, copay amounts, and how to request prior authorization when needed.