Key Takeaways
- Wisconsin uses the federal HealthCare.gov marketplace
- Office of the Commissioner of Insurance (OCI) regulates health insurance
- Pre-existing condition exclusions are prohibited in ACA-compliant plans
- Wisconsin has unique insurance regulations under Chapter 632
- Essential health benefits are required in all qualified plans
Last updated: January 2026
Wisconsin Health Insurance Policy Requirements
Wisconsin has comprehensive health insurance regulations under Chapter 632 of the Wisconsin Statutes.
Regulatory Structure
Wisconsin health coverage is regulated by:
| Agency | Responsibility |
|---|---|
| Office of the Commissioner of Insurance (OCI) | Primary insurance regulator |
| Department of Health Services (DHS) | Medicaid and BadgerCare Plus |
| Federal HealthCare.gov | Individual marketplace enrollment |
Office of the Commissioner of Insurance
The OCI:
- Reviews and approves policy forms and rates
- Licenses insurance producers and companies
- Handles consumer complaints
- Enforces insurance laws and regulations
Health Insurance Marketplace
Wisconsin uses the federal HealthCare.gov marketplace:
Key Features
- Federal marketplace platform
- Premium tax credits available based on income
- Qualified Health Plans (QHPs) certified by federal standards
- Wisconsin-specific plan options
Enrollment Periods
- Annual open enrollment each fall
- Special enrollment for qualifying life events
- Financial assistance based on income
BadgerCare Plus
Wisconsin's Medicaid program is called BadgerCare Plus:
Eligibility
- Adults with income up to 100% of federal poverty level (FPL)
- Children covered up to higher income levels
- Pregnant women have expanded eligibility
Required Coverage
Wisconsin ACA-compliant plans must cover Essential Health Benefits:
Essential Health Benefits
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
Pre-Existing Condition Protections
Wisconsin follows ACA rules on pre-existing conditions:
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual | Prohibited |
| Small Group | Prohibited |
| Large Group | Prohibited |
Exam Tip: Wisconsin prohibits pre-existing condition exclusions in all ACA-compliant plans.
Guaranteed Issue and Renewal
Wisconsin requires:
Guaranteed Issue
- Insurers must accept all applicants during open enrollment
- Cannot deny coverage based on health status
Guaranteed Renewal
- Cannot cancel coverage except for non-payment or fraud
- Plan discontinuation requires advance notice
Mental Health Parity
Wisconsin requires mental health parity:
- Mental health benefits must equal medical benefits
- Same copays, deductibles, and limits
- Coverage for substance use disorders required
Test Your Knowledge
Which marketplace does Wisconsin use for individual health insurance enrollment?
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D
Test Your Knowledge
What is the name of Wisconsin's Medicaid program?
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D