- While Wisconsin has not opted to expand Medicaid under the ACA, there is no coverage gap in the state.
- Adult enrollment in Wisconsin Medicaid has grown by 105,000 people during the COVID pandemic.
- An approved 1115 waiver calls for premiums and 48-month benefit cap, but with an exemption for those who are working. However, these provisions were suspended or delayed as a result of the coronavirus outbreak, and the work requirement provision was officially eliminated by CMS in 2021.
No ACA Medicaid expansion, but no coverage gap either
Although Wisconsin has not expanded Medicaid under the guidelines laid out in the Affordable Care Act (ACA), the state’s Medicaid program (which is called BadgerCare) does cover all legally present residents with incomes under the poverty level. Wisconsin is the only non-Medicaid-expansion state that does not have a coverage gap; all low-income residents either have access to Medicaid or subsidies to help them purchase private coverage in the exchange.
Premium subsidies in the marketplace are only available if a person’s income is at least the poverty level. In most states, subsidy eligibility actually starts above 138% of the poverty level, as Medicaid expansion covers adults with income up to that level. But there are 12 states that have not expanded Medicaid under the ACA. Wisconsin is one of them, but Wisconsin does make Medicaid available to adults with income up to the poverty level. So there’s a seamless transition from Medicaid eligibility to premium subsidy eligibility in Wisconsin.
That’s not the case in the other 11 states that have not expanded Medicaid. Instead, Medicaid for adults under 65 is not available at all in those states unless a person is disabled, pregnant, or caring for a minor child. And the income limits for parents tend to be quite low — well below the poverty level.
Wisconsin’s approach ensures that there’s no coverage gap, but it’s also expensive for the state. Because Wisconsin hasn’t fully expanded Medicaid eligibility to 138% of the poverty level, the state is only receiving its normal federal Medicaid funding. If it were to expand Medicaid, the federal government would start to pay 90% of the cost of covering the Medicaid expansion population, including the adults with income up to the poverty level who are already covered under Wisconsin Medicaid.
There’s also a provision in the American Rescue Plan that would provide additional federal funding for a state that newly expands Medicaid, which would make it even more financially beneficial to the state. In total, Wisconsin would get $1.6 billion in federal funding over the next two years by expanding Medicaid to 138% of the poverty level, but the Wisconsin budget committee has continued to reject Medicaid expansion proposals, despite the financial benefits it would provide to the state.
of Federal Poverty Level
It’s also important to note that in the other 11 states that have not expanded Medicaid, these people would not be eligible for Medicaid. And since their income is below the poverty level, they would also not be eligible for premium subsidies in the marketplace, and would fall into the coverage gap instead.
Former Governor Scott Walker, who was opposed to the ACA, opted not to accept federal funding for Wisconsin Medicaid expansion under the ACA, in part because he was concerned that the federal government would not keep its promise to continue to pay at least 90% of the cost. But because Wisconsin has not expanded Medicaid, the state is only receiving its regular federal match rate of 59.36%, and the state is paying the rest (the federal matching rate has been temporarily increased by federal legislation, in order to address the COVID-19 pandemic; Wisconsin’s federal Medicaid funding has been increased to 65.56% during the pandemic). If the state were to expand Medicaid to cover adults earning up to 138% of the poverty level, the federal government would pay 90% of the cost of covering able-bodied, childless adults.
A 2020 analysis by the Robert Wood Johnson Foundation estimated that 120,000 people would gain access to Medicaid if the state were to accept federal funding to fully expand coverage, and that the state’s uninsured rate would drop by 16%. And because Wisconsin is currently covering adults with income up to the poverty level under the state’s regular state/federal funding split, Wisconsin is the only non-expansion state that would see a direct reduction in state spending by expanding Medicaid (since the federal government would start to pay 90% of the cost of covering the entire Medicaid expansion population, including non-disabled adults with income under the poverty level who are already covered under the state’s non-expansion approach).
Wisconsin’s approach means that the state has essentially expanded Medicaid using its own funds, which no other state has done. Governor Tony Evers, who took office in early 2019, wants to expand Medicaid but lawmakers have thus far rejected that option.
Wisconsin has not accepted federal Medicaid expansion
BadgerCare Reform Demonstration has been suspended/delayed due to COVID-19
In June 2017, Wisconsin submitted a proposed 1115 waiver to CMS, detailing reforms that the state wanted to make to its existing Medicaid program for childless adults ages 19-64. The proposed changes were called for under the terms of the 2015-2017 budget bill (Act 55) that the state enacted. CMS approved the waiver in October 2018, but with some modifications. And the state submitted a proposal in late 2020, seeking permission to amend the BadgerCare Reform Demonstration by adding a health savings account component; that request was still pending federal approval as of late 2021.
The state’s reforms for childless adult BadgerCare Plus enrollees were slated to take effect in 2020. But in response to the COVID-19 pandemic, Wisconsin enacted Assembly Bill 1038 (Act 185) in April 2020, implementing a wide range of measures. Section 105 of the legislation allowed the state to suspend or delay the reforms called for the BadgerCare Reform Demonstration. This enabled Wisconsin to comply with federal requirements for the state to receive the additional federal Medicaid funding that’s being provided to states in order to address the pandemic (in order to receive the funding, states cannot impose new premiums after January 1, 2020, and cannot disenroll people from Medicaid during the COVID-19 emergency; new premiums and a work requirement would run counter to those rules).
And in April 2021, CMS notified Wisconsin that the federal government was revoking its approval for the community engagement (work) requirement portion of the BadgerCare Reform Demonstration. Here’s a look at what else is in the demonstration project, if and when the state is able to implement the changes:
The 2018 waiver approval extends Wisconsin Medicaid through the end of 2023, and although it initially allowed the state to implement a work requirement for enrollees aged 19 to 49 (that approval has since been revoked), CMS did not approve the state’s proposal to require drug testing as a condition of eligibility for Medicaid. Instead, Wisconsin revised its proposal to include the completion of a health risk assessment as a condition of eligibility. People can be referred for substance abuse treatment based on their health risk assessments, but would not lose their Medicaid eligibility for Medicaid (the substance use disorder monitoring protocol has received specific federal approval).
The state has an FAQ page about the waiver extension and amendment. The approved changes include:
- A Medicaid premium of $8 per month for childless adults with household income between 51 and 100% of the poverty level. There is an option for enrollees to reduce this premium by half if they either don’t engage in behaviors that create a health risk, or if they do but also attest to managing the behavior to improve their health. Healthy behaviors include things like wearing a seat belt, avoiding tobacco products, and maintaining a healthy weight. The premium requirements have been suspended during the COVID-19 pandemic, in order to allow the state to receive additional federal Medicaid funding.
- An $8 copay for non-emergency use of the emergency department.
- Completion of a health and wellness questionnaire as a condition of eligibility. This replaced the originally proposed drug screening/testing as a condition of eligibility. Although enrollees whose questionnaire answers indicate a need for drug treatment can be referred to treatment options, they will not lose their eligibility for coverage. The health assessment program has also been suspended during the COVID-19 pandemic.
- Increased coverage for substance abuse treatment, including full residential treatment as an option for all BadgerCare members.
- The work requirement portion of the BadgerCare Reform Demonstration has been eliminated altogether. It was designed to limit Wisconsin Medicaid eligibility to 48 months for non-disabled, non-pregnant enrollees age 19 to 49. After a person reached a total of 48 months of coverage, Wisconsin Medicaid eligibility would have ceased for six months. However, any month during which a Wisconsin Medicaid enrollee was working or engaged in work training for at least 80 hours would not count towards the 48-month limit. Coverage in Wisconsin for childless, non-disabled adults is limited to those with income under the poverty level ($12,880 for a single adult in 2021), so avoiding the lifetime benefit cap while continuing to receive benefits would have involved working enough to satisfy the 80-hour-per-month requirement, while not earning more than $12,880 during the year (the poverty level is adjusted slightly higher each year). But implementation of the work requirement was delayed as a result of COVID-19, and the work requirement approval was entirely revoked by the Biden administration in April 2021.
Wisconsin Medicaid history
Prior to 2014, Wisconsin Medicaid had much more generous eligibility guidelines than programs in most other states. It was still limited to children, pregnant women, and parents with dependent children, but it covered them with incomes up to 200% of poverty level (300% for children and pregnant women).
Medicaid expansion under the ACA would have extended Medicaid coverage to everyone — including adults without dependent children — with incomes up to 138% of poverty. But the Supreme Court ruled in 2012 that states could not be penalized if they didn’t expand their programs, and Wisconsin Governor Scott Walker saw an opportunity to revamp the state’s Medicaid program, providing access to coverage for everyone while relying as much as possible on private coverage.
ACA subsidies to purchase private plans in the exchange are only available to people with incomes of at least 100% of the poverty level. So Governor Walker decided to make Wisconsin Medicaid available to everyone with incomes up to 100% of poverty level (pregnant women and children are still eligible with household incomes up to 300% of poverty level). This meant that about 83,000 adults without dependent children became newly eligible for Wisconsin Medicaid on April 1, 2014.
But in trade, Walker’s plan called for switching to private coverage through the exchange for about 72,000 residents with incomes between 100% and 200% of poverty level. This group was comprised almost entirely of parents with dependent children, and they were eligible for Wisconsin Medicaid under the old rules. Although this group is now eligible for significant subsidies in the exchange, there are concerns among consumer advocates that the people who were previously insured through Wisconsin Medicaid might not have been able to afford private coverage in the exchange (including the out-of-pocket costs for claims), even with subsidies. (Fortunately, the American Rescue Plan has made robust coverage much more affordable for people in this income range, at least for 2021 and 2022.)
For the people who lost Medicaid eligibility, the exchange provided a special enrollment period that ran through the end of June 2014. But by September 2014, the state estimated that there were still 28,500 former Wisconsin Medicaid enrollees who had not enrolled in coverage through the exchange. As a result, a new special enrollment period was enacted, running from September 4 to November 2, 2014. Ultimately, the state estimated that less than 60% of the people who lost access to Medicaid were able to transition to a private plan in Wisconsin’s exchange.
An expensive choice
By not accepting federal funding to expand Medicaid under the ACA, Wisconsin has missed out on billions in federal funding since the beginning of 2014. If the state had accepted Medicaid expansion to cover adults with income up to 138% of the poverty level, the federal government would have paid 100% of the cost through the end of 2016, and would be paying 90% of the cost in 2020 and beyond. But because Wisconsin cuts off Medicaid eligibility at 100% of the poverty level, they aren’t eligible for the enhanced federal match provided by the ACA.
Under the Obama and Trump administrations, some states proposed expanding Medicaid to 100% of the poverty level with full federal funding. But HHS did not agree to that provision, insisting that in order to receive ACA Medicaid expansion funding, states had to expand coverage all the way to 138% of the poverty level (133%, with a built-in 5% income disregard).
Because Wisconsin has taken a unique approach to partially expanding Medicaid, they have been paying more in state funds than they would if they had expanded Medicaid as called for in the ACA. According to the Robert Wood Johnson Foundation, Wisconsin’s direct costs for Medicaid would drop by nearly 7% if the state expanded Medicaid, despite the fact that more people would be covered.
Who is eligible for Medicaid in Wisconsin?
BadgerCare Medicaid is available for the following legally present Wisconsin residents
- Pregnant women with household income up to 300% of poverty.
- Children 19 and under with household income up to 300% of poverty.
- Adults with household income up to 100% of poverty.
How does Medicaid provide financial help to Medicare beneficiaries in Wisconsin?
Many Medicare beneficiaries receive assistance from Medicaid with Medicare premiums, prescription drug costs, and expenses not covered by Medicare – including long-term care.
Our guide to financial assistance for Medicare enrollees in Wisconsin includes overviews of these benefits, including Medicare Savings Programs, Medicaid nursing home coverage, and eligibility guidelines for assistance.
How do I enroll in Medicaid in Wisconsin?
- You can enroll online at HealthCare.gov or the BadgerCare website.
- You can enroll by phone at 1-800-318-2596.
- You can also enroll in person or by phone at a local Wisconsin Income Maintenance Agency (this map shows the agency for each region – you can click on your region and it will show you the address and phone number of your local office).
- You can print a paper application and take it to your local Income Maintenance Agency or submit it by mail (the address to use depends on whether you live in Milwaukee County or not).
Wisconsin Medicaid enrollment
As of May 2021, there were 1,269,139 people enrolled in Wisconsin’s Medicaid/CHIP program, which is a 29% increase since the end of 2013. And enrollment has continued to grow: The state’s enrollment report indicated a total Medicaid/CHIP enrollment of more than 1.5 million people as of November 2021.
States that have expanded Medicaid have seen substantial increases in their Medicaid enrollment. Although Wisconsin did allow childless adults with income up to the poverty level to enroll starting in 2014, they cut eligibility for parents with dependent children whose income was between 100% and 200% of the poverty, offsetting much of the enrollment gains.
Just over 9% of Wisconsin residents were uninsured in 2013, and that fell to just 5.3% by 2016, according to U.S. Census data. By 2017, it had crept slightly higher, to 5.4%, and it grew again by 2019, when 5.7% of the state’s population was uninsured. As of May 2020 — with job losses and the subsequent loss of employer-sponsored health insurance — Wisconsin’s uninsured rate was 10%.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.