All the states are faced with bringing their insurance regulations in line with the requirements of the 2010 Patient Protection and Affordable Care Act, the legislation that is implementing progressive stages of health care reform in the United States. Children are now protected against coverage exclusions and refusals for pre-existing conditions and may remain on their parents’ health policies to age 26 regardless of educational or marital status. Adults with pre-existing conditions may seek temporary coverage through high-risk insurance pools that will be replaced on January 1, 2014 by health care exchanges.
General Insurance Regulations
Health policies in Wisconsin must carry a guarantee of renewability, but currently exclusions for pre-existing conditions can be permanent with an indefinite look-back period. Rates may be raised on the basis of health status, and applicants may be denied for the same reason. A policy may not, however, be canceled due to illness. Newborns and adopted children must be covered for a minimum of 60 days if the policy already covers dependents.
Health Care Exchanges
Wisconsin is continuing to study its options for the creation of a health care exchange, but progress has been limited to investigating the necessary information technology and taking feedback. Currently any further action is on hold pending the Supreme Court decision on the constitutionality of the individual insurance mandate contained in the 2010 Patient Protection and Affordable Care Act. If no further action is taken, the federal government will assume responsibility for the creation of the Wisconsin exchange.
Pre-Existing Condition Insurance
The Wisconsin Pre-Existing Condition Insurance Plan program is run by the Health Insurance Risk-Sharing Plan (HIRSP) Authority, and offers benefits for primary and specialty care, as well as hospital stays and prescription medication. Premiums fall in the range of $94 to $754 with deductibles of $500 to $3500. Out-of-pocket limits are set at $1000 for medical costs and $2000 for pharmacy expenses.
Recipients qualify for Medicaid based on income as a percentage of the Federal Poverty Level, the same formula applied for benefits through Children’s Medicaid and Children’s CHIP-funded Medicaid Expansions. Infants under the age of one year qualify for Medicaid at 300% FPL, and for CHIP at 133%. Those ages 1-5 receive Medicaid benefits at 185% FPL, while the 6-19 age group is at 100%.
Pregnant women qualify for Medicaid at 250% FPL, parents at 200%, and non-elderly disabled Social Security recipients at 93%.
Approximately 15 percent of the residents of Wisconsin draw Medicare benefits, with more than 877,000 accessing prescription drug coverage.