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Insurance and Healthcare Consultant

Tammy Burns is an experienced health insurance advisor. She is ACA-certified for health insurance and other ancillary, life, and annuity product.

Most Wisconsin residents receive coverage through an employer, but you also have access to Medicare, Medicaid, and individual insurance policies.

Read this guide to understand your coverage options and how to apply for health insurance in Wisconsin.

What to know about insurance in Wisconsin

  • Low uninsured rate: Wisconsin has one of the lowest uninsured rates in the United States. In 2020, only 5.8% of residents in the state were not covered by a private insurance plan, Medicare, or Medicaid.
  • Coverage types: Roughly 5% of Wisconsinites are covered under employer health insurance. An additional 15.5% are covered under Medicare, and 16% are enrolled in Medicaid. 5.3% of Wisconsin residents have private health plans.
  • Direct coverage and secondary plans: In the state of Wisconsin, you may purchase health insurance from whatever provider you choose. You may also have a secondary plan if your current coverage isn’t adequate to suit your needs.
  • Open Enrollment: The open enrollment for the ACA Health Insurance Marketplace occurs each year from November 1 until December 15. Not enrolling during this period means you need to wait for a special enrollment period or the next year’s open enrollment to purchase coverage from the marketplace.
  • Tax credits: If you want to take advantage of the Advanced Premium Tax credit, you need to enroll through the federal Health Insurance Exchange. If you don’t enroll in a place through the exchange, you’ll miss your opportunity to get this credit.

How do I enroll in Wisconsin’s health insurance marketplace?

There is no state exchange available for Wisconsinites to use for ACA enrollment. You need to use the federal Health Insurance Marketplace by visiting Healthcare.gov. You’re required to create an account before you begin shopping for the right plan for you or your family. Ensure you provide correct contact information and store your password and the answers to your security questions somewhere safe.

After you set up your account, you’ll be able to compare up to three plans at a time. Based on the information you provide, Healthcare.gov will also check to see if you’re eligible for programs such as Medicaid, plus let you know if you qualify for the Advanced Premium Tax credit. There is some information you’ll need to collect and have ready before you apply for insurance.

Here is what you need for your application:

  • Your marital status
  • The number of people you claim on your taxes as dependents
  • Whether you’re looking to apply for financial aid
  • The full name, birth date, and social security number for each member of your household you’re looking to place under your plan
  • Your household’s income

The list of plans will include things such as annual deductibles, your monthly premium, and what your copayment will be when you receive medical care. Choose your plan wisely based on your household’s needs, and the website will guide you through enrollment.

How do I enroll in Wisconsin individual and family insurance?

Enrolling for coverage as an individual requires the same process as enrolling for family coverage. Before you decide on a plan, carefully consider your health conditions and the needs of every person in your household. Policies that have low monthly premiums might not provide enough coverage if family members suffer from chronic conditions. You also shouldn’t seek more coverage than you need or can afford.

Insurance for individuals in Wisconsin

An individual health insurance policy can lower your financial responsibility in an emergency. You can save money if you choose a plan with a higher annual deductible and lower coinsurance, but pay more when you require care.

There are three primary types of plans. Each plan has its benefits and disadvantages.

  • Health Maintenance Organization (HMO) plans offer lower premiums but restrict access to care by requiring you to see in-network doctors and get referrals if you need to see a specialist.
  • Preferred Provider Organization (PPO) plans let you see the doctors you choose. But, you can expect higher monthly premiums than HMOs offer.
  • Point-of-Service (POS) plans are somewhere in the middle, allowing you to see out-of-network doctors if you agree to a higher copayment.

The following health insurance companies offer individual coverage in Wisconsin, depending on what part of the state you reside:

  • Aspirus Arise
  • Children’s Community Health Plan
  • Common Ground Healthcare Cooperative
  • Dean Health Plan
  • HealthPartners Insurance
  • Medica Health Plans of Wisconsin
  • MercyCare HMO Inc
  • Molina
  • Network Health
  • Security Health Plan of Wisconsin
  • Quartz Health Benefits
  • Unity Health Insurance

Insurance for families in Wisconsin

Shopping for a family health insurance plan can be more complicated than shopping just for yourself. While you might be in perfect health, one of the other members of your household might have a preexisting condition that requires ongoing medical treatment. It’s possible to save more money by paying a higher monthly premium than you would on a discount policy.

Consider whether the monthly premium is worth the amount of coverage you and your family will receive. Plans with a high deductible may force you to pay a lot of money upfront when someone in your family needs care. Thus, paying more for that low deductible and higher coinsurance might make more sense. Choosing a plan type is crucial because you must decide if you’re willing to be confined to only seeing doctors within an approved network or seeking approval for specialist care.

How much does health insurance cost in Wisconsin?

The ACA offers four tiers of coverage, including bronze, silver, gold, and platinum. The tiers have differing deductibles, monthly premiums, and copayment requirements. Consider the total yearly cost of your plan before enrolling because higher copayments and deductibles could increase your total cost for care. Here is what the most affordable plans in each tier cost:

Average premiums in Wisconsin 2018 2019 2020 2021
Most affordable bronze Plan $389 $373 $345 $338
Most affordable silver Plan $532 $492 $470 $443
Most affordable gold Plan $576 $527 $484 $480

  • Bronze plans have the highest deductibles and a 40% coinsurance requirement, meaning you’re responsible for 40% of your medical expenses. Most purchase a bronze plan for emergency medical care.
  • A silver plan offers a copayment of 30% and a lower annual deductible in exchange for higher monthly premiums. Some residents may qualify for cost-sharing plans if their income is below a certain threshold and purchase a silver plan for less than a bronze plan.
  • Gold and platinum plans offer the most coverage but at a higher cost point. Gold plans usually require a 20% copayment on medical services, while platinum plans only require a 10% copayment. These are the most cost-effective plans if someone in your household has a medical condition that requires ongoing treatment or state-of-the-art care.

What kind of low-income health insurance is available in Wisconsin?

The state of Wisconsin offers several Medicaid plans, including its BadgerCare Plus program. Low-income residents can enroll in one of these programs as long as they meet certain criteria. Your eligibility will depend on your income, marital status, and the number of people in your household. BadgerCare offers health care to children through its CHIP program.

Medicaid in Wisconsin

Medicaid is a program that is run jointly between state governments and the federal government. Wisconsin offers Medicaid to seniors who are dually eligible for Medicare and state assistance. The Medicaid program also covers residents with disabilities, those who must care for a family member with a disability, families with minor children, and pregnant women.

To qualify for Medicaid, you need to have an income below the state poverty level. The income threshold for a single person applying for Medicaid is $17,131 per year and increases depending on the number of people you support in your household. A household of five, for example, qualifies for Medicaid as long as the total household income doesn’t exceed $41,284 per year.

If you’d like to apply for Wisconsin’s Medicaid or BadgerCare Plus program, you can do so through the state’s online portal.

Wisconsin CHIP Program

Wisconsin residents can receive health care coverage for children through the BadgerCare CHIP program. Eligible children benefit from access to routine physical examinations, diagnostic testing, immunizations, emergency room treatment, vision care, and dental. Children must be under 19, and the household must be under similar income thresholds as the Medicaid program.

The BadgerCare program for children assists low-income households by helping them find qualifying doctors and treatment centers for common pediatric conditions. The addition of vision and dental care makes Wisconsin’s child health care program more comprehensive than most states in the U.S.

What are Wisconsin’s Medicare options for seniors and people with disabilities?

The Medicare program is a federally funded program for retirees and those with qualifying disabilities. Wisconsinites can choose from the original Medicare program and Medicare Advantage plans through health insurance companies.

  • Original Medicare is Medicare Part A, which covers inpatient care, and Part B, which provides coverage for preventive care, medical transportation, testing, medical equipment, and supplies. You can enroll in Medicare Part D, which covers prescription medications.
  • Medicare Advantage Plans provide Wisconsin residents with the option to customize their coverage. Some Medicare Advantage Plans offer a prescription drug plan, plus vision and dental coverage not provided through Medicare Part A or B.

You can enroll in a Medicare Supplement Insurance (Medigap) plan to offset your out-of-pocket expenses. Wisconsin requires more coverage for Medigap policies than other states, such as copayments for nursing care and limited home health care. These plans usually cover 25% or 50% of your out-of-pocket expenses. You can choose a deductible that suits your needs.

Eligibility and Enrollment
Eligibility
  • To enroll in Original Medicare or Medicare Advantage, you must meet certain eligibility requirements. First, you must be a U.S. citizen or permanent resident. You must also be at least 65 years old or have a disability that causes you to receive SSDI benefits for at least 24 months. You may also qualify for Medicare at a younger age if you have end-stage renal disease or ALS.
Enrollment
  • Three months before you turn 65, you’ll become eligible for an initial enrollment period. During the IEP, you’ll have an opportunity to sign up for Medicare. If you started receiving Medicare before the age of 65, you could make changes to your coverage at this time.
  • Medicare has an open enrollment period from October 15 to December 7 each year. You can switch your Medicare Advantage or Medicare Part D plan to meet your needs better during open enrollment.

Medicare Resources

For further assistance or if you’ve got more questions about Medicare enrollment, you can contact the Wisconsin Department of Health Services by calling 608-266-1865.

Are there short-term health insurance plan options in Wisconsin?

Wisconsin lets insurers offer short-term health insurance policies. However, the state has some of the strictest rules for these policies in the nation.

A short-term health insurance plan fills the gap in coverage that might result from losing your job, moving, or waiting for your Medicare benefits to come into effect. The maximum term that a short-term plan can have is one year. While most states allow short-term insurance policy renewal several times, Wisconsin won’t allow you to be covered by a short-term policy for longer than 18 months.

With a short-term plan, you’re not protected by the Affordable Care Act that protect people with preexisting conditions. You can be denied coverage or pay higher rates due to your medical history. You might not receive coverage for routine care, medical treatments for chronic conditions, or prenatal care.

Wisconsin Insurance FAQs

Does Wisconsin require health insurance?

The state of Wisconsin follows the federal mandate for health insurance prescribed by the Affordable Care Act. You’re required to have health insurance but won’t face a penalty if you don’t because Congress passed a measure that removed the tax penalty for not having coverage.

Do I have to use the Health Insurance Marketplace in Wisconsin?

There are several benefits to using the Healthcare Marketplace, such as the Advanced Premium Tax credit. It isn’t a requirement, though, and you’re free to enroll in any health insurance policy you choose. Just know that you’re forfeiting the tax credit and other benefits that come along with enrolling in a policy through the marketplace.

What types of alternative health insurance plans (like cost-sharing plans) are available in Wisconsin?

Wisconsin residents can enroll in cost-sharing programs. These programs can help save you money because all members pool their resources to pay for medical costs, but the plans aren’t insurance and typically have extensive limitations. Wisconsin also has the Consumer Operated and Oriented Plan (CO-OP) program.

What type of marketplace does Wisconsin have?

Wisconsin doesn’t have a marketplace and uses the federal Health Insurance Marketplace, which you can access by visiting Healthcare.gov.

How many health insurance carriers offer insurance through the marketplace in Wisconsin?

There are 13 health insurance companies that provide plans to Wisconsinites through the Health Insurance Marketplace. Many residents have access to multiple insurance companies. There are some places where they can only access a single company.

Do I need health insurance if I have HSA/FSA?

You can choose whether you’d like to purchase a health insurance policy along with a health care savings program or a flexible spending program. These programs benefit you if you’re required to cover significant out-of-pocket expenses. It’s not a replacement for health insurance coverage.

Do I need short-term disability coverage in Wisconsin if I have health insurance?

Short-term disability coverage has a different purpose than health insurance. It is a supplement that allows you to continue paying your household bills during recovery and unable to return to work. Most people benefit the most from having short-term disability coverage in addition to a health care plan.

Do I need long-term disability coverage in Wisconsin if I have health insurance?

Health insurance allows you to receive the best possible medical care if you’re disabled due to an injury. This is often not enough to pay the rent or cover the mortgage, buy food, and pay your monthly bills, but long-term disability coverage can pay for those essentials. Long-term disability insurance will rarely meet your financial needs on its own, so don’t consider it a replacement for health insurance.

What does CHIP cover?

The CHIP program covers preventive care, emergency treatment, dental care, and vision to those who qualify for the program. Enrollees need to be under the age of 19.

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