Frequently asked questions about health insurance coverage options in Wisconsin
Wisconsin has a federally facilitated marketplace/exchange, which means people shopping for individual and family health plans use HealthCare.gov to enroll (as opposed to a state-run website). 187,950 Wisconsin residents enrolled in plans through the exchange during the open enrollment period for 2022 coverage.
The exchange is used by people who need to buy their own health insurance, including early retirees (not yet eligible for Medicare), anyone employed by a small business that doesn’t offer health insurance, and the self-employed.
The open enrollment period for individual/family health coverage runs from November 1 to January 15 in Wisconsin. Outside of open enrollment, a qualifying event is necessary to enroll or make changes to your coverage.
Learn more about enrollment opportunities in our comprehensive guides:
In Wisconsin, consumers may be able to buy affordable individual and family health insurance by enrolling through the ACA marketplace (HealthCare.gov). More than 90% of consumers who enrolled in 2022 coverage through HealthCare.gov received premium subsidies.
Wisconsinites may also find affordable coverage through Medicaid if they’re eligible. See Medicaid eligibility guidelines in Wisconsin.
Short-term health insurance is also a lower-cost coverage option in Wisconsin, where seven insurers offer short-term plans.
Wisconsin’s exchange is robust in terms of insurer participation, with 13 insurers offering individual/family plans for 2023, including five that have expanded their coverage areas for 2023. There were 14 participating insurers in 2022, but WPS Health Plan Inc. opted to leave the exchange at the end of 2022 and only offer coverage outside the exchange for 2023. The following insurers offer plans through the Wisconsin exchange for 2023:
- Aspirus Health Plan
- Children’s Community Health Plan
- Common Ground Healthcare Cooperative
- Compcare Health Services Insurance Corporation
- Dean Health Plan
- Group Health Cooperative of South Central Wisconsin
- HealthPartners Insurance
- Medica Health Plans of Wisconsin
- MercyCare HMO Inc
- Molina
- Network Health Plan
- Quartz Health Benefits
- Security Health Plan of Wisconsin, Inc
The state’s reinsurance program, which took effect in 2019, has been keeping a lid on individual market premiums; average rates decreased each year from 2019 through 2022. For 2023, the state’s exchange insurers filed average rate increase that range from about 2% to nearly 15%. This is in keeping with what we’re seeing nationally as well, with a modest uptick in rates in nearly every state for 2023.
Enrollment climbed to more than 212,000 people in 2022, after dropping for the four previous years. The boost in enrollment in 2022 is due in large part to the subsidy enhancements created by the American Rescue Plan (these subsidy improvements have been extended through 2025 by the Inflation Reduction Act).
Wisconsin’s Common Ground Healthcare Cooperative was created under the ACA ‘s Consumer Operated and Oriented Plan (CO-OP) Program. While the majority of the co-ops have closed under financial strain, Common Ground CO-OP Wisconsin remains operational.
Common Ground is one of only three CO-OPs that are still operational as of 2022, out of 23 original CO-OPs.
Prior to ACA implementation, U.S. Census data put Wisconsin’s uninsured rate at 9.1% – already significantly lower than the national average. The uninsured rate dropped to 5.3% by 2016, although it climbed slightly, to 5.7%, by 2019 (nationwide, there was an uptick in the uninsured rate under the Trump administration, but Wisconsin’s uninsured rate was still well below the national average as of 2019).
Although the state has not participated in full Medicaid expansion as written in the ACA, all low- and moderate-income legal residents have access to either Medicaid coverage or exchange subsidies; there is no coverage gap in Wisconsin.
During the open enrollment period for 2022 coverage, more than 212,000 people enrolled in private health plans through the Wisconsin exchange. Eighty-eight percent of them were receiving premium subsidies to make their monthly premiums much less costly, and 34% were receiving cost-sharing reductions that make healthcare services more affordable.
Wisconsin’s current Senators have both joined the Senate since 2010: Ron Johnson and Tammy Baldwin. Johnson is an ACA opponent, and brought a lawsuit against the federal government over the issue of subsidies for Congress members and their staff (the suit was thrown out by a federal judge in July 2014). But Baldwin is a strong proponent of the ACA.
In the House of Representatives, representation from Wisconsin has switched to a Republican majority. As of 2021, there are five Republicans and three Democrats representing Wisconsin in the U.S. House.
Former governor Scott Walker opposed the Affordable Care Act, but he was defeated by Democrat Tony Evers in the 2018 election. Evers pulled Wisconsin out of the California v. Texas (Texas v. Azar) lawsuit. The states led by Texas were attempting to overturn the ACA, but Wisconsin left that group of states (ultimately, the Supreme Court upheld the ACA).
Wisconsin has not accepted federal funding to expand Medicaid eligibility under the ACA, but Wisconsin Medicaid is available to adults with income up to the poverty level, so there’s no coverage gap in Wisconsin (unlike every other state that hasn’t implemented the ACA’s Medicaid expansion). U.S. Census data indicate that Wisconsin’s uninsured rate (5.7% in 2019) was by far the lowest of the states that had not expanded Medicaid at that point.
Wisconsin’s former governor, Scott Walker, took a unique approach to Medicaid in Wisconsin. The state’s BadgerCare Medicaid program used to cover people with incomes up to 200% of poverty, but with the availability of subsidies in the exchange starting at 100% of poverty, Walker cut BadgerCare eligibility down to poverty level. So now people with incomes between 100% and 200% of poverty instead receive subsidies to purchase plans in the exchange (they qualify for both premium subsidies and cost-sharing subsidies at that income level).
But because Wisconsin has not expanded Medicaid eligibility to 138% of the poverty level, the state does not receive the enhanced federal funding that the ACA provides for Medicaid expansion (in Medicaid expansion states, the federal government pays 90% of the cost of covering the Medicaid expansion population). So it would be less costly for the state to just expand Medicaid to people with income up to 138% of the poverty level, and receive the enhanced federal funding for the adult population from 0-138% of the poverty level.
This is especially true now that the American Rescue Plan has been enacted. The legislation provides two years of additional federal Medicaid funding for states that newly expand Medicaid. In Wisconsin, that would amount to an additional $1 billion in federal funding, and 90,000 residents would gain coverage.
Read more about Medicaid in Wisconsin, including details of the work requirement that was approved by the Trump administration, never implemented (due to COVID), and then revoked by the Biden administration.
Wisconsin allows short-term health insurance plans to have a total initial duration of up to 12 months. But if the plans are renewable, the total duration, including the renewal period, can’t exceed 18 months.
This is more restrictive than the federal government rules implemented by the Trump administration, but state rules take precedence over federal rules in this case, so a short-term plan cannot have a duration of more than 18 months in Wisconsin.
Read more about short-term health insurance in Wisconsin.
Nearly 1.25 million Wisconsin residents were enrolled in Medicare as of mid-2022.
Wisconsin is one of just three states that does its own standardization for Medigap plans. And Medicare enrollees under age 65 are guaranteed access to Medigap plans in Wisconsin, as long as they enroll within six months of enrolling in Medicare Part B.
Read more about Medicare plans and Medicare enrollment in Wisconsin, including details about Medicare Advantage plans and Part D prescription drug plans (Original Medicare does not include coverage for prescription drugs, but enrollees can obtain prescription benefits by selecting a stand-alone Part D plan or a Medicare Advantage plan that includes integrated Part D prescription coverage).
There are also still some Medicare Cost plans available in Wisconsin.
- BadgerCare PLUS
- Black Health Coalition of Wisconsin
- Medicaid for the Elderly, Blind, or Disabled
- Wisconsin Department of Health Services
- Medicare Counseling for Wisconsin Residents
- Medicare Rights Center (a nationwide resource that can provide information and assistance related to Medicare)
Before Obamacare brought guaranteed issue coverage to the individual health insurance market, pre-existing conditions could result in application denials, exclusions, and initial rate-ups in nearly every state, including Wisconsin. The Wisconsin Health Insurance Risk-Sharing Plan (HIRSP) was created to cover people who could not get individual health insurance because of pre-existing conditions.
Now that the ACA requires all health insurance plans to be guaranteed issue, there is no longer a need for high-risk pools. As a result, HIRSP coverage terminated on April 1, 2014, and members needed to have applied for a new, ACA-compliant plan by March 15 in order to have continuous coverage.