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). 191,702 Wisconsin residents enrolled in plans through the exchange during the open enrollment period for 2021 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.
There is a COVID-related enrollment window in 2021, which continues through August 15, 2021. A qualifying event is not necessary during this window. Wisconsin residents can newly enroll through the marketplace during this window, or switch from one marketplace plan to another.
People with off-exchange coverage can switch to the exchange, which is an important step for anyone who is newly eligible for subsidies as a result of the American Rescue Plan. (Subsidies are only available through the exchange, and many people who weren’t previously subsidy-eligible can now qualify for a subsidy for 2021 and 2022).
After August 15, 2021, a qualifying event will again be necessary in order to enroll or make plan changes for 2021. Open enrollment for 2022 plans in Wisconsin will start on November 1, 2021, for coverage effective January 1, 2022.
The annual open enrollment period, like the COVID-related enrollment window in 2021, is an opportunity for people to change their coverage for the coming year, renew the plan they already have, or enroll for the first time.
Wisconsin’s exchange offers a robust number of carrier options for 2021 when compared with most other exchanges. Thirteen insurers are offering plans for 2021, albeit with localized service areas. (Some parts of the state have five or six different health insurance companies offering plans in the exchange, while other counties have just one.):
- Aspirus Arise
- Common Ground Healthcare Cooperative
- Children’s Community Health Plan
- Dean Health Plan
- Group Health Cooperative of South Central Wisconsin
- HealthPartners Insurance
- Medica Health Plans of Wisconsin
- MercyCare HMO Inc
- Network Health
- Quartz Health Benefits
- Security Health Plan of Wisconsin, Inc
- Unity Health Insurance
The state’s reinsurance program, which took effect in 2019, has been keeping a lid on individual market premiums; average rates decreased again for 2021, for the third year in a row.
Enrollment dropped to under 192,000 people in 2021, falling for the fourth straight year. But the COVID-related enrollment period and enhanced premium subsidies could push enrollment higher throughout the year.
During the first several weeks of the COVID/American Rescue Plan enrollment window (but before the ARP’s additional subsidies were available in real-time), more than 8,000 people enrolled in plans through Wisconsin’s exchange. That was up from a little over 5,000 people during the same time frame in prior years (when a qualifying event would have been necessary in order to enroll; a qualifying event is not necessary during the COVID/ARP enrollment window).
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.
For 2021, Common Ground decreased their average rates by more than 6%, which was the CO-OP’s third straight year of rate decreases — indicating a relatively stable financial position.
Common Ground is one of only three CO-OPs that are still operational as of 2021, 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. From 2013 to 2018, the uninsured rate for the whole country went from 14.5% to 9.2% (it had been even lower in 2017, but started increasing again under the Trump administration).
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.
As of 2020, there were more than 185,000 people enrolled in private health plans through the Wisconsin exchange. Eighty-seven percent of them were receiving premium subsidies to make their monthly premiums much less costly, and 37% 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 want to overturn the ACA, but Wisconsin is no longer part of that group of states.
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 any 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 has been approved but not yet implemented as of 2021 (the state suspended the work requirement implementation due to the COVID pandemic; its long-term future remains uncertain).
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.
More than 1.2 million Wisconsin residents were enrolled in Medicare as of January 2021.
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.
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.