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Wisconsin health insurance

No Medicaid expansion, but no coverage gap; state has one of only four remaining CO-OPs in the nation.

Health insurance in Wisconsin

State legislative efforts to preserve or strengthen provisions of the Affordable Care Act

Wisconsin is one of the states that has done the least to preserve the Affordable Care Act’s provisions.

Wisconsin is doing fairly well in terms of insurance coverage and access to health care: The uninsured rate in 2017 was 5.4 percent, versus 8.7 percent nationwide.

Wisconsin’s health marketplace

Open enrollment for 2020 health plans has ended, although Wisconsin residents with qualifying events can still enroll or make changes to their coverage for 2020. The next open enrollment period, for plans effective in 2021, will begin November 1, 2020.

Wisconsin’s federally facilitated exchange offers a robust number of carrier options for 2020 when compared with most other exchanges. Thirteen insurers are offering plans for 2020, albeit with localized coverage areas:

  • 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
  • Molina
  • Network Health
  • Quartz Health Benefits
  • Security Health Plan of Wisconsin, Inc
  • Unity Health Insurance

The state’s reinsurance program is successfully keeping a lid on premiums as it heads into year two, with overall average premiums decreasing again for 2020, by 3.2 percent

Read our full overview of the Wisconsin health insurance marketplace.

No Medicaid expansion, but also no coverage gap

Wisconsin has not accepted federal funding to expand Medicaid 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 indicates that Wisconsin’s uninsured rate (5.4 percent in 2017) was by far the lowest of any of the states that had not expanded Medicaid at that point.

Governor Walker took a unique approach to Medicaid in Wisconsin. The state’s BadgerCare Medicaid program used to cover people with incomes up to 200 percent of poverty, but with the availability of subsidies in the exchange starting at 100 percent of poverty, Walker cut BadgerCare eligibility down to poverty level, with the intention that people with incomes between 100 and 200 percent of poverty would instead receive subsidies to purchase plans in the exchange (they qualify for both premium subsidies and cost-sharing subsidies at that income level).

About 72,000 people lost eligibility for BadgerCare under the new rules, but 83,000 others gained access to the program. It’s not clear how many of the 72,000 who lost their Medicaid coverage were able to successfully transition to the exchange. Walker’s approach has drawn praise from conservatives, but critics have noted that a straight expansion of Medicaid as written in the ACA would likely have benefitted more people and made access to health care more affordable for people living just above poverty level.

Under Walker’s plan, 36 percent of the previously uninsured population in Wisconsin became eligible for Medicaid or CHIP. In 2015, an estimated 27,628 Wisconsinites were determined or assessed eligible for Medicaid or CHIP through the Wisconsin exchange. From 2013 to August 2017, Wisconsin’s average monthly Medicaid enrollment increased by 5 percent (this was unchanged from late 2016).

Although Wisconsin Governor Scott Walker has been vocal in his opposition to the ACA, he wants the federal government to maintain current funding for Medicaid, saying in February 2017 “You can’t cut Medicaid. There’s just no way about it.” The various ACA repeal bills that Republican lawmakers proposed in 2017 would  have cut Medicaid funding significantly, but none of them had enough support to pass. For the time being, the ACA remains intact, as does Medicaid funding

Medicaid work requirement

In October 2018, Wisconsin became the fourth state to gain federal approval for a Medicaid work requirement (technically, the fifth, but Kentucky’s previously approved waiver has been blocked by a judge).

Under the terms of Wisconsin’s waiver, the state can make various policy changes to its Medicaid (BadgerCare) program, including:

  • An $8 copay for non-emergency use of the emergency room.
  • Premiums of $8/month for childless adults with income between 51 and 100 percent of the poverty level (the premiums can be reduced if the enrollee exhibits various healthy behaviors).
  • Requiring enrollees to complete health and wellness questionnaires.
  • Providing full coverage for residential substance abuse treatment.
  • Childless adults between the ages of 19 and 49 can only receive BadgerCare coverage for a maximum of 48 months, unless they qualify for an exemption. But any month that a person works (or participates in job training or other community engagement) at least 80 hours doesn’t count towards the 48 month cap. However, a person who works 80 hours per month might end up earning too much to qualify for Medicaid, since the eligibility cutoff in Wisconsin is the poverty level ($12,140/year — just over $1,000/month — for a single person in 2018).

Just a week after Walker’s Administration received federal approval to implement the Medicaid work requirement and benefit cap, Walker lost his re-election bid. Democrat Tony Evers, who wants to expand Medicaid — and take it a step further, with “BadgerCare for All,” won the gubernatorial election in Wisconsin. It’s unclear at this point whether the Evers Administration will have to move forward with implementing the new Medicaid waiver (which was called for in the state’s last budget bill), or if they’ll be able to avoid the changes.

Short-term health plans in Wisconsin

Wisconsin allows short-term health plans to have 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 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.

How has Obamacare helped Wisconsin residents?

Prior to ACA implementation, U.S. Census data put Wisconsin’s uninsured rate at 9.1 percent – already significantly lower than the national average. The uninsured rate dropped to 5.7 percent by 2015, and to 5.3 percent by 2016, although it climbed slightly, to 5.4 percent, by 2017. From 2013 to 2017, the uninsured rate for the whole country fell from 14.5 percent to 8.7 percent.

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 or exchange subsidies; there is no coverage gap in Wisconsin.

Wisconsin enrollment in qualified health plans

Early in the first open enrollment period, the Kaiser Family Foundation estimated the size of the potential exchange market in Wisconsin to be 482,000 residents, and that 301,000 of them would be eligible for premium subsidies.

As of Feb. 15, 2015, after the second open enrollment period ended, 207,349 people had finalized their enrollment in qualified health plans through the Wisconsin exchange, and HHS reported that 90 percent of them received subsidies to lower their premiums. By the end of March, some had canceled their plans or failed to pay their initial premiums, leaving a total enrollment of 183,155 — nearly 91 percent were receiving advanced premium tax credits.

The city of Milwaukee won the White House “Healthy Communities Challenge” to build outreach efforts and enroll as many uninsured residents as possible during the 2016 open enrollment period. Milwaukee had 38,000 newly enrolled residents.

Statewide, exchange enrollment reached 239,034 during 2016 open enrollment. By March 31, effectuated enrollment stood at 224,208. Of those enrollees, 85 percent were receiving subsidies that averaged $322 per month.

During the 2017 open enrollment period (November 1, 2016 through January 31, 2017), 242,863 enrolled in private plans through the Wisconsin exchange. Effectuated enrollment in early 2017 stood at 216,355 people.

During the open enrollment period for 2018 coverage, enrollment declined somewhat, to 225,435. And effectuated enrollment as of early 2018 stood at 200,557.

Enrollment dropped about 9% for 2019, after falling about 7% in 2018.

Wisconsin Common Ground CO-OP

As a provision of the ACA, Wisconsin received $56.6 million in federal funds to create a Consumer Operated and Oriented Plan (CO-OP). Nationwide, more than $2 billion was granted for CO-OP creation, divided among the 22 states that participated.

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 and is offering coverage for 2019. It is one of only four CO-OPs still operational, out of 23 original CO-OPs.

Common Ground Healthcare CO-OP also decreased its premiums substantially for 2019. Average CO-OP premiums in Wisconsin are nearly 19 percent lower in 2019 than they were in 2018.

Wisconsin and the Affordable Care Act

In 2010, both of Wisconsin’s US Senators – Russell Feingold and Herbert Kohl – voted yes on the health reform law. In the House, the five Democratic Representatives voted yes, while the three Republicans voted no. Paul Ryan is among the nay votes and has been vocal on the national stage in his opposition to the ACA. Ryan is pushing the American Health Care Act, introduced under his leadership by House Republicans in March 2017, as an alternative to the ACA.

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, and is up for reelection in 2018. Her Republican challenger, Leah Vukmir, wants to repeal the ACA.

In the House of Representatives, representation from Wisconsin has switched to a Republican majority. As of 2018, there are five Republicans and three Democrats representing Wisconsin in the U.S. House.

Republican Governor Scott Walker has long been strongly opposed to the Affordable Care Act, and the state defaulted to a federally run marketplace using But Walker has touted his approach to Medicaid as an innovative solution, even though it relies more on private health insurance and less on Medicaid than the ACA originally planned.

Although Wisconsin is among the 18 states that have not expanded Medicaid, Wisconsin does not have a coverage gap. In the other 17 non-expansion states, there are 2.2 million people caught in the coverage gap — ineligible for Medicaid, but also ineligible for premium subsidies in the exchange (subsidies in the exchange aren’t available for most applicants with income below the poverty level). But in Wisconsin, Medicaid (BadgerCare) is available to people with income up to the poverty level, which eliminates the coverage gap.

Walker’s administration shepherded a waiver proposal, approved by CMS in October 2018, that allows the state to impose a 48-month limit on BadgerCare enrollment for adults under age 50 who aren’t working at least 80 hours per month. Wisconsin became the fifth state granted federal permission to impose a work requirement for Medicaid, although Kentucky’s work requirement was blocked by a judge.

Walker is in a neck-and-neck race with Democrat Tony Evers in 2018. Evers has vowed to pull Wisconsin out of the Texas v. Azar lawsuit that would gut the ACA, and to accept federal funding to expand Medicaid to 138 percent of the poverty level — something Walker has long refused to do (lawmakers in the state would have to approve an Evers budget that included funding for Medicaid expansion).

CHIP Wisconsin

Wisconsin’s Children’s Health Insurance Program (CHIP) is provided via BadgerCare Plus.

Children’s Community Health Plan (CCHP) is an HMO owned by Children’s Hospital of Wisconsin, and is the largest BadgerCare health plan in the state. CCHP also began offering qualified health plans (QHPs, as opposed to BadgerCare/Medicaid/CHIP plans) in the Wisconsin exchange during the 2017 open enrollment period.

Does Wisconsin have a high-risk pool?

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.

Medicare in the state of Wisconsin

Wisconsin Medicare enrollment stood at about 1.1 million people as of September 2018. About 85 percent of Medicare enrollees in Wisconsin qualify based on age, while 15 percent are eligible due to disability.

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.

About 42 percent of Wisconsin Medicare enrollees have coverage under Medicare Advantage plans. And 40 percent of Medicare beneficiaries in Wisconsin have coverage under stand-alone Part D prescription drug plans.

Helpful Wisconsin health insurance links

Other state-level health reform legislation:

Scroll to the bottom of the page to see a summary of recent Wisconsin legislation related to health care and health policy reform.

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 Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.