With most of the Affordable Care Act’s major provisions now in effect, the nation’s health insurance marketplace has undergone a significant transformation. Obamacare impacts individuals, families and small business owners alike. Most Americans are required to have minimum essential coverage unless they qualify for an exemption; however, the law is designed to make health insurance more accessible and affordable with income-based financial assistance and one-stop shopping via state-based and federally facilitated exchanges. Meanwhile, the private marketplace remains a place to shop for quality, affordable health insurance plans that meet ACA requirements.
The following guide offers a glimpse at the various types of ACA-compliant health insurance in Wisconsin, including individual and family health plans, small group health plans, coverage for high-risk applicants, mini-COBRA continuation coverage, Medicaid, and CHIP.
Health and healthcare in Wisconsin
Wisconsin placed 23rd in United Health Foundation’s 2014 America’s Health Rankings.1 The state’s strengths included a high rate of high school graduation, high immunization coverage among children, and a low percentage of uninsured population. Wisconsin’s biggest health challenges, according to the rankings, include a high prevalence of binge drinking, a high incidence of infectious diseases, and low per capita public health funding.
Wisconsin individual and family health insurance
Wisconsin is one of many U.S. states that defaulted to a federally facilitated health insurance exchange under the Affordable Care Act. Individuals and families in Wisconsin can use the federal Health Insurance Marketplace to shop and apply for Obamacare qualified health plans. When doing so, they may be eligible for income-based premium tax credits and cost-sharing subsidies. Those who go without health insurance may face a tax penalty known as the shared responsibility payment.
Wisconsinites can also buy ACA-compliant health plans in the private marketplace on websites such as HealthCare.com. Check out HealthCare.com’s tax subsidy calculator to see if you qualify for a tax credit. If you do, visit Wisconsin’s Health Insurance Marketplace to apply for health insurance coverage.
The U.S. Department of Health and Human Services reported that 139,815 individuals in Wisconsin selected a marketplace plan through the exchange from Oct. 1, 2013, through April 19, 2014.2 In 2015, the number of individuals in Wisconsin enrolled in a marketplace plan increased to 207,349 during the open enrollment period.3
|Wisconsin’s health insurance exchange:||healthcare.gov|
|Wisconsin department of insurance:||oci.wi.gov|
Wisconsin small group health insurance plans
Wisconsin small business owners with 50 or fewer employees may use the federal Health Insurance Marketplace’s Small Business Health Options Program (SHOP) portal to offer group health insurance coverage to workers. Those who use SHOP and have 25 or fewer employees may qualify for a Small Business Healthcare Tax Credit.
Small businesses may also enroll in ACA-compliant small group health insurance plans sold through the private marketplace. Self-employed individuals with no employees must apply for an individual health insurance plan on or away from Wisconsin’s federally facilitated exchange.
Wisconsin state COBRA variations for small groups
The Consolidated Omnibus Reconciliation Act (COBRA) allows those employed by businesses with 20 or more employees to continue their group health insurance plan for a limited time should they lose coverage due to qualifying events such as termination of employment due to reasons other than gross misconduct, a reduction in work hours, divorce or legal separation, and loss of dependency status. To learn more about the federal COBRA program, visit dol.gov/ebsa/cobra.html.
In some states, those who work for a small business and lose health insurance coverage due to a qualifying event may be eligible for health insurance continuation through mini-COBRA or a similar state continuation program. In a few states, these programs may also be extended to those who work for larger companies and exhaust their federal COBRA continuation coverage limit. Mini-COBRA generally works like the federal COBRA continuation coverage, but its terms may vary.
Wisconsin’s small group COBRA continuation variations are as follows4 5:
|Eligible group sizes||All sizes|
|Maximum continuation period – standard||18 months|
|Maximum premium Increase||100 percent|
|State legislation reference||s. 632.897, Wis. Stat.|
|More information||800-236-8517 — Office of the Commissioner of Insurance|
|Additional notes||Does not apply to employer self-funded health plans or policies that cover only specified diseases or accidental injuries; employees have 30 days from notification of their continuation rights to elect coverage and pay their premium; individuals must be continuously covered under the group policy for at least three months prior|
Wisconsin high-risk pools
It used to be that health insurance companies could deny applicants or charge them more based on health history and preexisting conditions. When the Affordable Care Act was passed in 2010, many states created federally funded preexisting condition insurance programs or accepted federal funding to assist with similar high-risk pool programs they already operated.6
The Affordable Care Act prohibits this practice for health insurance plans considered minimum essential coverage with effective dates beginning Jan. 1, 2014, and later. As such, the PCIPs and state high-risk pools created to provide health insurance for those once considered uninsurable are being phased out.
Medicaid is a state health insurance program for low-income individuals under age 65, pregnant women, children, disabled individuals, and seniors over age 65; it is partially funded by the federal government. In 2014, states were given the option to accept additional federal funding and expand their Medicaid program eligibility to those who make up to 133 percent of the federal poverty level (effectively 138 percent due to how it is calculated, according to HealthCare.gov).7
Wisconsin did not expand its Medicaid program in 2014.8 However, among the states that did not expand Medicaid, Wisconsin is the only one that provides full Medicaid coverage to adults without dependent children.9
In 2014, a coverage gap was created in states where Medicaid was not expanded. This coverage gap includes about 5 million Americans whose incomes are too high for Medicaid but too low to receive federal premium and cost-sharing assistance when shopping the state’s federally facilitated health insurance exchange. Because Wisconsin already extends full Medicaid to adults without dependents up to the poverty level, no uninsured Wisconsin adults fall into the coverage gap.10
The information below is specific to Wisconsin Medicaid, BadgerCare Plus for low-income Wisconsinites, and other Wisconsin ForwardHealth programs:
|Governing agency||Centers for Medicare & Medicaid|
|Administrator||Wisconsin Department of Health Services|
|Where to apply||access.wisconsin.gov|
|More information||dhs.wisconsin.gov/medicaid/index.htm / dhs.wisconsin.gov/ForwardHealth/index.htm|
|Open-enrollment period||Year-round in all states|
The Children’s Health Insurance Program is a partnership between the states and federal government. CHIP provides health insurance to uninsured children who meet certain eligibility guidelines.
The information below is specific to BadgerCare Plus, Wisconsin’s health insurance program for low-income children:
|Program name||BadgerCare Plus|
|Where to apply||access.wisconsin.gov / dhs.wisconsin.gov/forwardhealth/imagency/index.htm|
|Eligibility11||Low-income Wisconsin residents; apply to determine eligibility|
1 United Health Foundation. 2014 America’s Health Rankings Annual Edition. “Annual State Health Rankings.” http://www.americashealthrankings.org
2 Kaiser Family Foundation http://kff.org/other/state-indicator/state-marketplace-statistics-2014/.
3 Kaiser Family Foundation http://kff.org/other/state-indicator/state-marketplace-statistics-2015/.
4 State of Wisconsin. Office of the Commissioner of Insurance. “Health Insurance for Small Employers and Their Employees 2014.” http://oci.wi.gov/pub_list/pi-206.pdf.
5 State of Wisconsin. Office of the Commissioner of Insurance. “Fact Sheet on Continuation and Conversion Rights in Health Insurance Policies.” March 2011. http://oci.wi.gov/pub_list/pi-023.pdf.
6 National Conference of State Legislators. Coverage of Uninsurable Pre-Existing Conditions: State and Federal High-Risk Pools. Updated April 2014. http://www.ncsl.org/research/health/high-risk-pools-for-health-coverage.aspx.
7 Centers for Medicare & Medicaid Services. “Medicaid Expansion & What It Means for You.” HealthCare.gov. N.D. https://www.healthcare.gov/what-if-my-state-is-not-expanding-medicaid/.
8 Centers for Medicare & Medicaid Services. “Wisconsin.”http://www.medicaid.gov/medicaid-chip-program-information/by-state/wisconsin.html.
9 The Henry J. Kaiser Family Foundation. “The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid.” April 2, 2014. http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/.
11 Wisconsin Department of Health Services. “BadgerCare+: Wisconsin’s Connection to Health Care Coverage.” http://www.dhs.wisconsin.gov/publications/p1/p10179.pdf.