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Rights – Laws

As a current or prospective health insurance policyholder, it is always necessary to understand your state’s regulations regarding coverage, underwriting, and benefits. What you are unaware of before applying may surprise you if expecting a seamless entry into a health plan. For healthy individuals, this is typically possible, though even the slightest mark in your medical history may be cause for an elevated premium. Not always the case, but Wisconsin insurers have laws that allow them to underwrite pretty fiercely in contrast to it’s neighbor Minnesota, at least. Wisconsin also abides by federal health care policies, necessarily adopting parts of the Affordable Care Act that greatly affect the present and future state of private insurance.

Learning how to navigate through the system is important to anyone buying or continuing a health plan, as well as knowing what’s to come. In this section we’ll explore Wisconsin health insurance laws from now until 2014, and the health insurance reforms to expect in the state afterwards. A few of the key legal elements of the Wisconsin private insurance market are explained below, though the laws applying to health conditions only affect those applying for coverage in the next year. Guaranteed renewability will continue, and benefits will continue to expand under the ACA, as the more recently passed laws have been in place to protect plan members.


Guaranteed Renewability

As with all states, Wisconsin insurers are required to follow the guidelines of guaranteed renewability. This law states that insurers must offer to renew a member’s plan for another year before the end of their coverage year. Guaranteed renewability also prevents any policyholder from getting their benefits canceled on the account of health status, or anything other than a person missing premium payments, committing fraud, or lying on their application. This helps individuals keep their coverage continuously, and not leave someone sick and uninsured if they suddenly acquire a condition.


Pre-Existing Conditions

Wisconsin adults with pre-existing conditions have some tough times ahead of them when applying for individual coverage, at least judging by the state laws. Anyone over age 19 is evaluated for health conditions based on the prudent person standard, which includes any conditions a person has had even if they did not get diagnosed or receive care. The maximum look-back period is unlimited in Wisconsin, so they can search your entire medical history if they choose. Once an insurer defines an applicant as having a pre-existing condition, they can either reject or accept the individual under certain terms. Premiums will undoubtedly increase, and insurers in Wisconsin can give elimination riders and exclusion periods of up to 24 months.


Mandatory Benefits

The state requires health plans on the private market to offer certain benefits in some of their plans for groups and individuals. Not every plan issued by every insurer will include these services, though they are required if seen medically necessary by many comprehensive plans offered throughout Wisconsin. Some of these services meet the requirements for essential health benefits as outlined by the health reform law, and others go beyond the requirements.

  • Ambulatory surgery
  • Anti-psychotic medications
  • Blood lead poisoning
  • Breast reconstruction
  • Cleft palate surgery
  • Clinical trials
  • Colorectal cancer screening
  • Coverage for adopted and newborn children through parent’s plan
  • Dental anesthesia
  • Diabetes supplies and self-management
  • Emergency care
  • End Stage Renal Disease (ESRD) services
  • Home health care
  • Mammograms
  • Mastectomy and hospitalization
  • Maternity care
  • Mental health and substance abuse
  • Preventive care (well-child and well-woman visits)
  • TMJ disorder treatment