Wisconsin Health Insurance Guide
Wisconsin Health Insurance Information, Health Organizations and Resources and access to online health insurance quotes
As a resident of Wisconsin you can choose from a variety of private health insurance plans including plans for individuals and group plans provided by an employer. Depending on your income or employment status, you may also be eligible for Wisconsin State-funded affordable health insurance for individuals and families, and federal programs such as Medicaid and COBRA.
Wisconsin is not a guarantee issue state for individual health insurance policies. Insurance companies are allowed to determine your eligibility by underwriting and you can be turned down for any number of reasons if you don’t meet the insurer’s criteria. In Wisconsin, health insurers are permitted a 24-month exclusionary period and an unlimited look-back period to check for pre-existing conditions. Insurers are not required to give credit for prior coverage and elimination riders are permitted. In Wisconsin, health insurers can base your premium on your health, age, sex, history of claims, where you live, number of people covered on your policy and type of plan you’re applying for among other factors. state does not require insurers to issue standardized policies.
Wisconsin is a guarantee issue state for group health plans issued to small businesses. If your Wisconsin health insurance is provided through your employer, your coverage cannot be denied because of your past or current health. The insurer can impose a 12-month exclusionary period and a six-month look-back period for pre-existing medical conditions, but must give credit for qualifying prior creditable coverage. Your employer may impose a waiting period for eligibility for new hires, but it must be applied equally to all new hires. Premiums for small group health insurance are determined by underwriting that takes into account the overall health of the insured group. Small group insurers can charge a premium not to vary plus or minus 30% of the index rate.
Wisconsin is a guaranteed renewal state. Regardless of your health, your insurer must renew your policy as long as you’ve paid your premiums on time and haven’t defrauded the company, or in the case of some HMOs, as long as you haven’t moved out of the service area. In Wisconsin, your individual health insurance policy premiums cannot be raised because you’ve been sick or now have new risk factors. Your policy can be canceled if your insurer discontinues a plan or no longer sells insurance in the state.
Wisconsin Mandated Health Benefits
Wisconsin laws require private health insurance policies to cover several state-mandated benefits. These currently include:
- Alcoholism and Drug Abuse Treatment
- Ambulatory Surgery
- Anti-Psychotic Drugs
- Blood Lead Poisoning
- Breast Reconstruction
- Cleft Palate
- Clinical Trials
- Dental Anesthesia
- Diabetes Supplies and Self Management
- Emergency Services
- Home Health Care
- Kidney Disease
- Mammograms
- General and Parity Mental Health
- Psychotic Drugs
- TMJ Disorder
- Well-Child Care
- Coverage for newborns under their parent's policy
- Coverage for adopted children under their parent's policy
- Coverage for handicapped children under their parent's policy
- Coverage for continuation/dependents under their guardian’s policy
- Coverage for conversion to non-group
- Coverage for continuation/employees
Types Health Insurance Plans Available in Wisconsin
The following major medical health insurance plans are generally available in Wisconsin. Major medical plans cover illness and injury, hospitalization, prescription drugs and office visits, as well as the mandated services stated above.
Indemnity plans - Typically the most flexible and therefore highest priced choice, an indemnity plan lets you select your health providers and facilities. Depending on your plan, you will have to pay a deductible or co-insurance.
Preferred provider organization plans (PPOs) - You select from a network of preferred health care providers and facilities, and receive services at an agreed-upon discounted rate. You also have the option of going outside the network, but typically at a higher cost. You do not need a referral from a primary care physician to see a specialist. Premiums may be less than an indemnity plan but more than an HMO. You will have to pay a deductible or co-insurance.
Health maintenance organizations (HMOs) - HMOs plans require you to select a primary care physician from a prescribed network of providers, who must issue a referral before you can see a specialist. Services and covered costs are typically more comprehensive than those provided by a PPO. HMOs offer the advantage of affordable premiums and low out-of-pocket costs, with an emphasis on preventive care. Non-emergency services out of network are usually not reimbursed.
Point of Service plans (POS) - Similar to a PPO in that you will receive reimbursement for out-of-network care, but with an HMO’s requirement for a primary care physician who must provide referrals to specialists. Premiums, co-pays and co-insurance are typically higher than what you’d pay with an HMO.
Alternative Health Programs in Wisconsin
Wisconsin Health Insurance Risk Sharing Plan
HIRSP is the state-sponsored high-risk pool that offers health insurance if you are a Wisconsin resident and cannot obtain private health insurance because of a pre-existing condition or have lost your employer-provided coverage. Other eligibility requirements apply. Two plans are offered. One is a PPO plan with three levels of deductible, each with 20% coinsurance for most covered service, but with different out-of-pocket maximums. The second plan is a Medicare supplement with $500 deductible, no coinsurance and maximum out-of-pocket of $500 for individuals and $1,000 for families. Premiums are capped at 200% of the rate charged for similar coverage in Wisconsin. Enrollment is open. There may be a six-month waiting period for pre-existing conditions, but will be waived if you are HIPAA-eligible.
Wisconsin BadgerCare Plus
This program provides comprehensive low-cost health care for resident children up to age 19, whose families meet income requirements and other eligibility requirements. Most children in the program are enrolled in an HMO unless none is available in their area, in which case they can go to any provider who accepts the BadgerCare Plus Forward card. Premiums will be free or no more than 5% of family income. Modest co-pays are charged for most services except preventive care, which is free. There may be a 12-month waiting period under certain circumstances, but it can be waived for good cause. Enrollment is open but is subject to review and renewal every 12 months.
Regulating Agency
The Wisconsin Office of the Commissioner of Insurance is responsible for regulating Wisconsin’s health insurance industry.
Get access to Wisconsin health insurance quotes from http://www.einsurance.com/health-insurance.
State of Wisconsin Office of the Commissioner of Insurance
125 S Webster St
Madison, WI 53703-3474
(608) 266-3585, Madison
(800) 236-8517, statewide
http://oic.wi.gov
Health Insurance Risk Sharing Plan of Wisconsin
1751 W Broadway
PO Box 8961
Madison, WI 53708-8961
(800) 828-4777, statewide
(608) 221-4551, Madison
http://www.hirsp.org
Wisconsin Department of Health Services (Badger Care+)
(800) 362-3002
vedsreipientservices@wisconsin.gov
http://dhs.wi.gov/badgercareplus/
(NAIC) National Association of Insurance Commissioners
The National Association of Insurance Commissioners (NAIC) is the organization of insurance regulators from the 50 states, the District of Columbia and the five U.S. territories. The NAIC provides a forum for the development of uniform policy when uniformity is appropriate. NAIC members are the elected or appointed state government officials who along with their departments and staff regulate the conduct of insurance companies and agents in their respective state or territory.
http://www.naic.org/
Insurance Information Institute (I.I.I)
The mission of the Insurance Information Institute (I.I.I.) is to improve public understanding of insurance -- what it does and how it works.
Contact info:
110 William Street
New York, NY 10038
212-346-5500
http://www.iii.org/