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Wisconsin Health Insurance

Wisconsin Medical Insurance Overview

There are quite a few options for residents living in Wisconsin to receive health insurance coverage.  Options include group, individual and state-funded coverage choices that offer varying levels of medical services based on a number of factors.  There are a good portion of Wisconsin’s residents who get coverage through the workplace, but a lot of people do not have this choice.  Because of this, these people may have to get coverage through an individual insurance plan through a private provider.  Another option is to select a state-funded program of which you may qualify depending on your income level.  Despite these options, the state of Wisconsin still has plenty of people who aren’t covered at all.

With the passing of the Affordable Care Act, it’s hoped that the overall health of the state of Wisconsin will see an improvement in the health of its residents.
Wisconsin’s Health Care Issues
According to rankings by the United Health Foundation, the state of Wisconsin is ranked in 24th place as of 2014.  This number has tanked significantly from 2011 when the state was in the 12th position compared to the rest of the country.  Still, the state does have its strengths and challenges as listed below:

High immunization among adolescents for TDAP
High rate of high school graduation
Low percentage of uninsured population

High prevalence of excessive drinking
Low per capita public health funding
High prevalence of obesity

Understanding Wisconsin’s Uninsured Population
According to data received from the Kaiser Family Foundation, 7 percent of the population of Wisconsin is without insurance coverage as of 2014.  In the same year, children between the ages of birth to 18 who had no insurance comprised 4 percent of the population of Wisconsin.  Adults between the ages of 19 to 64 were represented by 10 percent of the entire state’s population.

Of those who had no insurance, 28 percent of the population earned under 199 percent of the Federal Poverty Level.  Ten percent of the uninsured residents earned between 200 and 399 percent of the FPL, leaving 4 percent of residents earning over 400 percent of the FPL and still remaining uninsured.

Group Health Plans
Group health benefits are coverage options that you can obtain from your employer.  You can typically use this coverage to include your spouse and/or dependents, if needed.  Regarding pre-existing conditions in the state of Wisconsin, you cannot be rejected for coverage under a group plan.  A pre-existing condition is defined as an illness that you have had prior to enrolling into your company’s group plan.  You can be excluded from receiving treatment under your insurance plan for a specified period of time, but you cannot be excluded altogether.   You cannot be rejected because of a pregnancy or genetic predisposition to certain conditions or diseases without receiving an official diagnosis from your doctor.

COBRA, Continuation, and Conversion in Wisconsin
COBRA coverage is insurance coverage that continues beyond your employment or loss of status as a dependent on another’s insurance policy.  COBRA is available to former employees of companies that employ more than 50 workers.

Wisconsin’s continuation laws apply to most group health policies through the employer which provide medical or hospital coverage of any kind.  The law also applies to group policies that have been issued to employers with any numbers of employees. It does not apply to employers with self-funded health care plans or policies that are only used for covering accidental injuries or specified diseases.

Individual Health Plans
If you cannot obtain insurance through your workplace, you can buy an individual policy to suit your needs.  You should keep in mind the costs and coverage options available under the individual policy and you will almost always need to show proof that you are insurable.

After you apply for coverage, the insurance company will go through the underwriting process and in doing so, evaluate your eligibility for coverage.  It is at this time that the insurance company will use your application information to predict the likelihood that you will file a claim against the policy.  Underwriting information is gleaned from your applicant, your medical records, and the Medical Information Bureau.
Either the insurance company accepts your application or changes the benefits offered and increases your deductible amount.  They can also choose to charge you a higher premium amount, exclude medical conditions from coverage or simply reject your application altogether.

In the event that your application for coverage is declined, you can learn the reason for this from the insurance company because they are required to send you this information in writing.  Afterward, you can apply for coverage elsewhere, but if you can’t buy an individual policy, you may qualify for coverage through HIRSP, which is the state’s high risk pool.

Wisconsin Health Benefit Exchange
In 2012, the governor of the state of Wisconsin announced plans that would allow the state to default to a federally facilitated exchange.  In this manner, residents are able to use in order to obtain insurance and compare plan options.

Despite the implementation of the Affordable Care Act, Governor Scott Walker has been in favor of repealing the law.  After the open enrollment period through the federally managed exchange, residents are only able to purchase health insurance in the event of a qualifying life event.

Every plan available through the health care exchange in Wisconsin will be Qualified Health Plans that are metal based options for coverage.  Plans are currently available so that residents can properly research the offerings of coverage along with the costs associated with each.  The four plans that are available are below:

  • Bronze [This plan pays 60%]
  • Silver [This plan pays 70%]
  • Gold [This plan pays 80%]
  • Platinum [This plan pays 90%]

Wisconsin State Insurance Programs
There are a variety of public insurance programs that are available for people earning low incomes in the state of Wisconsin.

BadgerCare Plus
This plan is for low income families that have children along with women who are pregnant.  Children under the age of 19 can get coverage regardless of income level.  In addition, this program also covers parents who earn income levels of up to 200% of the FPL that have children in foster care, parents and caretakers whose income is over 200% of the FPL, adults reaching 18 who are leaving foster care, self-employed people and farm families.

Those residents approved for coverage under BadgerCare will get a Forward Health card as their method of using insurance coverage through this state-funded program.  Many services are covered including physician services, emergency care, vision and dental, x-rays and labs, mental health services, nursing services and more.

Wisconsin residents who are approved for BadgerCare will receive a Forward Health card, and this serves as full-benefit medical insurance funded by the state. Most services are covered under this program, some of which include the following:

Wisconsin Medicaid
In the state of Wisconsin, Medicaid offers a medical card that can be used to obtain medical care services.  This program is strictly for people who cannot afford to receive treatment otherwise.  In order to qualify, you must be a U.S. citizen living in Wisconsin, need health insurance coverage and earn low wages.  Services under this program are also available to seniors, people with disabilities, pregnant women and parents of minor children.  In order to qualify, you must meet certain income requirements and your assets will be scrutinized.

Medical Assistance Purchase Plan (MAPP)
This program gives disabled working individuals the ability to get health insurance benefits.  Depending on your income level, you may have no premium or one that is very inexpensive.  In order to qualify for eligibility, you must be a Wisconsin resident, be over the age of 18, have less than $15,000 worth of assets, have a disability that has been established by the Social Security Administration, meet income guidelines and be employed or interested in employment.

Katie Beckett
This program allows kids with long-term disabilities who have complicated medical needs receive medical benefits and assistance while remaining in their family home.  If you are unable to obtain Medicaid coverage because of assets or income, then you can apply for this type of coverage.  Children are also able to receive coverage even in the event they have coverage through a group or private insurance plan.

Wisconsin Well Woman
The Well Woman program offers breast and cervical cancer screenings along with screenings for multiple sclerosis if you are considered high risk.  In order to be eligible, you must be between 45 and 64 years of age and meet the income requirements.  Applicants under this plan may not otherwise have insurance coverage, but if insurance is present, it must not offer screenings and checkups.  If you have health insurance, but cannot afford the co-payment amounts or deductibles, you may also qualify for coverage under this program.

SeniorCare offers prescription assistance to residents over the age of 65 as long as the rules for enrollment are followed.  There is a yearly fee of $30 to enroll in the plan and income guidelines must be met in order to qualify.  Seniors who are eligible will have to pay for out of pocket expenses depending on their yearly income.  There are different rules and benefits according to the applicant’s level of income, their spouse’s income and where their spouse resides.

Family Care
This program serves residents who have developmental disabilities, people with physical disabilities and the state’s elderly.  The goals of this program are to improve access to health care, give people better choices on where to live and receive support and services and to create a cost-effective system of providing health care to residents.

This program is also dedicated to keeping individuals in their home and as independent for as long as possible using long-term care services.  Programs like this offer services like skilled nursing, home health care, occupational, speech and physical therapy, and mental health services.

Wisconsin Chronic Disease Program (WCDP)
The WCDP is a program that offers coverage to people who suffer from chronic renal disease, hemophilia and adult cystic fibrosis.  This is an entirely state-funded program that covers services and supplies related to the specified disease.  Participants must pay for their yearly deductibles and co-payment amounts.  In addition, those members who have a yearly income of 300% of the FPL or higher will have to pay a certain percentage of out of pocket expenses prior to being eligible for coverage under this program.
Wisconsin Health Insurance Risk Sharing Program (HIRSP)
The HIRSP was created in 1979 as a means to offer coverage to people who lost their insurance through the workplace or were unable to find insurance coverage because of a medical condition.  In 2013, there were two plan options available: the HIRSP Plan and the HIRSP Medicare Supplement Plan.  HIRSP offers four yearly options for deductibles and the higher the deductible amount, the lower the cost of monthly premiums.  The HIRSP Medicare Supplement Plan wraps around the available Medicare benefits and offers subsidies to help with health care costs for those earning low incomes.

The HIRSP program has ended as of May 2013, but the federal benefits marketplace has begun to accept applications since.

Health Insurance Portability and Accountability Act (HIPAA)
Under HIPAA, your patient records and medical data is protected from use by unauthorized parties.  It was also designed to make health insurance portable and accountable.  This coverage extends to health insurance plans that are both group and individual policies.  Health care providers that send and receive information related to your medical care using electronic means.  It also covers healthcare clearinghouses that translate information between forms.

In addition, HIPAA offers the following protections for consumers:

  • Guarantees employers or individuals can get their insurance renewed without regard for health status
  • Guarantee that continuation coverage is available in the event of insurance loss
  • Exclusion periods are limited for people suffering from pre-existing medical conditions
  • Prohibits group plans from denying coverage to people with pre-existing conditions

For more information on HIPAA protections, see this website.