Wisconsin is one of the few states left that offer health insurance through a CO-OP. Residents can also access affordable coverage through the Marketplace and publicly-funded programs.
Wisconsin Health Insurance Overview
Wisconsin has more than a dozen private insurance companies that offer health insurance plans for individuals and families. More people have coverage through Medicaid and Medicare than through private health insurance. The majority of people with private Obamacare insurance qualify for financial assistance. If you have low income, Wisconsin offers several public health insurance options through its Medicaid program.
Below is a summary of Wisconsin’s health insurance market.
Wisconsin and the Affordable Care Act (ACA)
The Affordable Care Act (Obamacare) gave individuals and families access to buy coverage through the Health Insurance Marketplace, starting in 2013. Since then, Wisconsin’s uninsured rate has remained in the single digits.
Six percent of Wisconsin’s population has no health insurance compared to 9% across the rest of the country. Even before the Marketplace was implemented, Wisconsin’s uninsured rate has been lower than the national average.
The ACA implemented Medicaid expansion in 2014. This gave states access to federal funds to expand Medicaid to able-bodied, childless adults under 65 who earn up to $17,609 in 2020 (138% of the federal poverty level [FPL]).1
Wisconsin is among 14 states that have not expanded Medicaid. Many states that refuse to expand Medicaid have thousands of uninsured residents in the coverage gap. Wisconsin has none. Why? Wisconsin partially expanded Medicaid to childless adults who earn up to 100% of the federal poverty level.2 This was already in place before the ACA expanded Medicaid.
Consumer Oriented and Operated Plans (CO-OPs)
Wisconsin’s Common Ground Healthcare Cooperative is one of only four Consumer Oriented and Operated Plans (CO-OPs) that still exist in five states. Originally, there were 23. The Affordable Care Act (ACA) allowed states to set up CO-OPs as an alternative to buying coverage through the ACA health insurance exchange.
CO-OPs serve as a way for certain groups, such as trade workers, self-employed individuals, and nonprofits, to access to quality coverage that would otherwise be unaffordable through the individual and group insurance markets. Wisconsin’s CO-OP offers health insurance to residents of 20 counties in the state’s eastern region.
Buying Wisconsin Health Insurance for Individuals, Families, and Self-Employed Entrepreneurs
Wisconsinites have access to individual and family plans under the ACA. This also applies if you’re a self-employed entrepreneur or freelancer with no employees.
ACA plans come in bronze, silver, gold, and platinum. Each plan covers a percentage of your costs. Plans are required to offer 10 essential health benefits, including emergency services and prescription drug coverage. Dental and vision benefits must also be offered to children. Plans cannot deny you coverage because of your health or a preexisting condition.
You can buy ACA health insurance in Wisconsin through the federal Marketplace at Healthcare.gov. Open enrollment typically takes place from November 1 to December 15. You can still get 2021 coverage in Wisconsin if you qualify for a Special Enrollment Period.
Another Chance to Enroll
Wisconsin residents who missed open enrollment have another chance to buy health insurance. Due to the coronavirus, the federal government reopened the Marketplace in a Special Enrollment Period from February 15, 2021 to August 15, 2021.
Wisconsin Marketplace Enrollment and Health Insurance Companies
About 192,000 Wisconsinites enrolled in 2021 Marketplace plans at the end of open enrollment on December 15, 2020.3
Wisconsin has had challenges with carriers leaving the Marketplace. For example, Molina Healthcare had the highest number of enrollees in 2017.4 But it stopped offering plans in Wisconsin the following year. However, Molina returned in the 2019 plan year and has expanded coverage to more than 20 Wisconsin counties for 2020.5
These 14 Wisconsin health insurance companies offer individual and family plans for 2021:
- Aspirus Arise Health Plan of Wisconsin
- Children’s Community Health Plan
- Common Ground Healthcare Cooperative
- Dean Health Plan, Inc.
- Group Health Cooperative of South Central Wisconsin
- HealthPartners Insurance Company
- Medica Community Health Plan
- MercyCare HMO, Inc.
- Molina Healthcare of Wisconsin, Inc.
- Network Health Plan
- Quartz Health Benefit Plans Corporation
- Security Health Plan of Wisconsin, Inc.
- Wisconsin Physicians Service Insurance Corporation
- WPS Health Plan, Inc. (Arise)
Wisconsin Health Insurance Costs and Subsidies
Here are the monthly premiums for Wisconsin Marketplace plans:
- Average Lowest Cost Bronze Premium: $338 in 2021; $345 in 2020
- Average Lowest Cost Silver Premium: $443 in 2021; $470 in 2020
- Average Lowest Cost Gold Premium: $491 in 2021; $484 in 2020
Among Wisconsin enrollees, 88% received federal subsidies in 2019. Subsidies help reduce your monthly premium and can be applied to any metal plan.6 The average subsidy (known as premium tax credits) was $623 in 2019 .7
Medicaid for Low-Income Wisconsinites
Wisconsin’s Medicaid program includes several options for low-income adults and children. Wisconsin’s children’s health insurance program is provided under Medicaid. This includes BadgerCare Plus and Care4Kids.
Children under 19 account for 1 in 3 Medicaid enrollees in Wisconsin. About 17% of the state’s 5.6 million residents have coverage through Medicaid.8
Medicaid in Wisconsin is available to:
- Adults ages 19 to 64 (includes parents and those without children who earn up to 100% of the federal poverty level)9
- Pregnant women
- Individuals with disabilities
- Seniors age 65 or older
- Children 18 and younger
- Youths under 21 who need behavior, emotional, or mental healthcare
Medicare Enrollment and Plan Options in Wisconsin
Medicare is generally for people 65 and older. But younger Wisconsinites with disabilities can also get Medicare. About one fifth of Wisconsinites have Medicare. This amounts to roughly 1.2 million people. Just over 3 in 5 beneficiaries are enrolled in Original Medicare from the federal government. The rest get coverage through private Medicare Advantage plans.10
Medicare Drug Coverage in Wisconsin
About 2 in 5 Wisconsin residents on Medicare are enrolled in a separate Part D prescription drug plan.11 Part D is often included in Medicare Advantage plans, unlike Original Medicare which doesn’t cover most prescription drugs. If you have Original Medicare and don’t have access to drug coverage, you can choose to enroll in Part D. Wisconsin offers a Prescription Drug Helpline if you have any questions.
Medicare Supplement in Wisconsin
Wisconsin is one of three states where Medicare Supplement (also called Medigap) plans are different than what’s commonly available. Most states have plans lettered A through N that offer the same standard benefits. Wisconsin offers the basic plan and a few other options that have slightly different coverage.12
If you have Original Medicare, you can add a Wisconsin Medicare Supplement plan to help cover your out-of-pocket costs, including copayments, coinsurance, and deductibles. Wisconsin’s Department of Health Services offers a Medigap helpline for residents.
When Do You Need Short-Term Health Coverage in Wisconsin?
Many situations can leave you in a coverage gap. For example:
- You may have left a job and need health insurance until your new job starts;
- Aged off your parent’s health insurance when you turned 26; or
- Missed the open enrollment period for Obamacare.
Short-term health insurance offers temporary coverage to fill these gaps.
Wisconsin allows you to have short-term health insurance for up to 364 days. But unlike many states that allow renewals for up to 36 months, Wisconsin limits them to 18 months.13
Short-term health plans offer basic benefits that can help you pay for care, such as doctor’s visits. However, these plans are not the same as ACA health insurance that offers comprehensive coverage. This means short-term plans aren’t required to cover pre-existing conditions or include essential health benefits.
Short-term health insurance may not work for everyone. Getting comprehensive coverage may have a higher monthly premium but could save you more money out of pocket in the long run. This summary about Wisconsin health insurance can help you decide what’s best.