Health Insurance Marketplace in Wisconsin
If you live in Wisconsin, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Specific plans and prices are available now and coverage can start as soon as January 1, 2014.
Spanish language speakers can contact cuidadodesalud.gov.
Choosing the Right Health Insurance Plan
There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.
Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:
NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.
Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.
Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.
Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.
Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.
Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.
Wisconsin has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under Wisconsin’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.
Consumer Operated and Oriented Plan Program
Consumer Operated and Oriented Plan (CO-OP) Program are qualified nonprofit health insurance issuers that offer competitive health plans in the individual and small group markets. CO-OP in Wisconsin:
Who can help you (the Navigators)
Partners for Community Development will facilitate the enrollment of the uninsured with emphasis on reaching out to Hispanic and Hmong families and other hard-to-reach eligible consumers in Door, Kewaunee, Manitowoc, Ozaukee, and Sheboygan Counties in Wisconsin. It will focus outreach and enrollment efforts in its service area on hard-to-reach consumers and families with limited English proficiency.
The Northwest Wisconsin Concentrated Employment Program will help lead a Navigator project in their region to promote accessibility to health insurance Marketplace and the health care system in Wisconsin. The cooperative agreement will be used to provide Marketplace Navigator services at 21 Wisconsin Job Centers without reach provided at libraries, Senior Centers and college campuses by existing staff that have experience working with diverse populations.
SeniorLAW is a community and consumer-focused nonprofit located in Milwaukee that provides a variety of services to individuals age 60 or over, mostly related to health insurance and public benefits. This group will conduct outreach to the 60-64 population in Wisconsin, using community education, client contacts and agency relationships that SeniorLAW has established throughout Southeastern Wisconsin.
National Council of Urban Indian Health is the only national, membership-based organization dedicated to outreach and education on behalf of Urban Indian Health. It provides training, technical assistance, outreach, and education to Urban Indian Health Programs.
The National Healthy Start Association is a non-profit organization that works to improve birth outcomes and health disparities across the country through the federal Healthy Start programs. They will reach out to the uninsured population and provide education and assistance services for Marketplace enrollment.
R&B Receivables Management Corporation DBA R&B Solutions
Anticipated grant amount: $104,520
R&B Receivables Management Corporation currently works to connect uninsured and underinsured individuals with coverage options to help them afford health care. They will expand their services to connect with a broader range of underserved populations, and leverage their experience screening people for eligibility for medical assistance programs to connect people with coverage.
Who you can contact for more help
If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.
Accountable Care Organizations in Wisconsin
ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.
- Pharmacy Society Of Wisconsin WI – Health Care Innovation Award
- TransforMED WI – Health Care Innovation Award
- Children’s Hospital And Health System, Inc. WI – Health Care Innovation Award
- Institute For Clinical Systems Improvement WI – Health Care Innovation Award
- University Of North Texas Health Science Center WI – Health Care Innovation Award
- State of Wisconsin WI – Incentives for the Prevention of Chronic Disease in Medicaid Demonstration
Health care facilities where Innovation Models are being tested
- Meriter Health Services, Inc. Madison, WI – BPCI Initiative: Model 2
- Golden LivingCenter Heritage Square Greendale, WI – BCPI Initiative: Model 3
- 16th Street Community Health Center Milwaukee, WI – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Visiting Physicians Association, P.C West Allis, WI – Independence at Home Demonstration
- Cristin Sullivan BSN, MBA Green Bay, WI – Innovation Advisors Program
- Kathy Scott PhD, MPA, RN, FACHE Waukesha, WI – Innovation Advisors Program
- Christine Baker PhD, RN, MBA, FACHE Madison, WI – Innovation Advisors Program
- Maureen Murphy MD, FAAFP, ABMA Lake Delton, WI – Innovation Advisors Program
- Jonathan Jaffery MD, MS Madison, WI – Innovation Advisors Program
- Bellin-ThedaCare Healthcare Partners Appleton, WI – Pioneer ACO
- Footprints in Midwifery Black River Falls, WI – Strong Start for Mothers and Newborns Initiative
The Insurance Exchange/Marketplace
What has been done, not been done, or left up to the federal government to do.
Establishing the Exchange in Wisconsin
On November 16, 2012, Governor Scott Walker (R) notified federal officials that Wisconsin would default to a federally-facilitated health insurance exchange.1 After initial efforts to develop a state-based health insurance exchange, Governor Walker announced in July 2012, he would not take any action to implement federal health reform until after the November elections.2
In 2011, Walker had issued an executive order to create the Office of Free Market Health Care to develop a plan for a Wisconsin health benefit exchange; however, almost a year later he closed the Office.3,4 Exchange establishment legislation failed to pass at the end of the 2012 legislative session. Prior to closing, the Office of Free Market Health Care had been seeking subcontractor assistance with the state’s marketing and outreach strategy and had completed actuarial and economic analyses to determine next steps in designing an exchange.5
Under former-Governor Jim Doyle (D), Wisconsin’s Department of Health Services had investigated the information technology necessary for a state-run exchange and based on insight from over 40 healthcare stakeholders, created an exchange prototype to simulate eligibility determinations and the consumer enrollment process. The prototype was launched in December 2010, with much of the functionality required of an exchange website.
On April 5, 2012, Governor Walker signed into law SB 92, a bill prohibiting plans in a state exchange from offering abortion coverage, except in cases of rape, incest, or to avert severe physical impairment or death of the pregnant woman.6
Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Since Wisconsin has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, United- Choice Plus, POS.
The Wisconsin Department of Health Services received a federal Exchange Planning grant of $1 million in September 2010 and a federal Early Innovator grant of $37.7 million in February. Wisconsin planned to use the Early Innovator grant to refine their exchange prototype into a single portal through which residents could access subsidized and non-subsidized health care and other state-based programs.7 In January 2012, the Governor announced the state would be returning the Early Innovator grant funding.8
Expansion of Medicaid
From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.
As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.
However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.
Wisconsin will not participate in Medicaid expansion.
The federal government will assume full responsibility for running a health insurance exchange in Wisconsin beginning in 2014.
1. Scott Walker Office of the Governor. Letter to Secretary Sebelius. November 16, 2012.http://www.walker.wi.gov/Documents/11.16.12%20Letter%20to%20Secretary%20Sebelius.pdf
2. Governor Scott Walker. Governor Walker’s Reaction to the US Supreme Court Ruling on ObamaCare, June 28, 2012. http://www.wisgov.state.wi.us/Default.aspx?Page=8533b724-db36-4bce-9b24-3b408bfe3206.
3. Wisconsin Executive Order #10. January 27, 2011. http://www.wisgov.state.wi.us/journal_media_detail.asp?locid=177&prid=5649
4. Wisconsin Executive Order #57:http://docs.legis.wisconsin.gov/code/executive_orders/2011_scott_walker/2012-57
5. Office of Free Market Health Care. Office of Free Market Health Care Releases Report on Impacts of Patient Protection and Affordable Care Act (PPACA), August, 24,2011.http://www.iiaw.com/index.php?module=cms&folder=16&cmd=cmsproxy&filename=files/0824freemarket.pdf
6. SB 92. 2012 Legislative session. Enacted April 5, 2012.http://docs.legis.wisconsin.gov/2011/related/acts/218
7. Early Innovator Grant Awards. HHS announcement. February 16, 2011.http://www.healthcare.gov/news/factsheets/exchanges02162011a.html (Accessed August 23, 2011)
8. Office of the Governor Press Release. “Governor Walker Turns Down Obamacare Funding.” January 18, 2012. http://18.104.22.168/Default.aspx?Page=84c6be7e-6bf7-47bb-949a-7330dd644579
Also of interest
Provided by the Henry J. Kaiser Family Foundation