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Fact Sheet on Health Care Reform in Wisconsin

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Fact Sheet on Health Care Reform in Wisconsin

The Affordable Care Act (ACA) provides new important consumer protections described below. The provisions generally go into effect for health care coverage that is issued or renewed after September 23, 2010, and applies to self-funded and fully-insured health care coverage plans.

Individual and Families

  • Health plans cannot deny or exclude coverage for your children (under age 19) based on a preexisting condition including a disability.
  • Parents can choose to keep their adult children on their health insurance policies until age 26 if the policy allows for dependent coverage. This allows parents to continue to provide coverage for their children who face a variety of circumstances, e.g., they are in school, seeking employment, or have access to coverage that is not as comprehensive as their parents' coverage.
    Prior to ACA, Wisconsin enacted a similar version of this law that covers adult dependents up to age 27; however, the federal changes in the ACA will apply to all health care coverage plans in Wisconsin. It is important to note that those seeking adult dependent coverage from age 26 to 27 cannot be married and cannot have access to less expensive coverage available through their employer. Those attending school full-time but who get called away for active duty also have the ability to access adult dependent coverage beyond the age of 26 if called away while under 27.
  • Insurance companies cannot drop coverage when you get sick if you make a mistake on your coverage application.
  • All new group health plans and all new plans in the individual insurance market are required to cover recommended preventive services without charging copayments, coinsurance, or deductibles.


Health care reform strengthens Medicare, reduces fraud, and closes the gap in prescription drug coverage known as the "donut hole." Wisconsin seniors in the donut hole have already begun to receive rebates and next year all covered brand-name drugs inside the donut hole will be half-off until the gap is completely closed in 2020. The Affordable Care Act also takes a number of steps that improve health care for those enrolled in Medicare.

  • Your existing guaranteed Medicare-covered benefits will not be reduced or taken away. Neither will affect your ability to choose your own doctor.
  • If you have Medicare prescription drug coverage and have to pay for your drugs in the donut hole, in 2010 you will get a one-time, tax-free $250 rebate from Medicare to help pay for your prescriptions.
  • Starting in 2011, if you have high prescription drug costs that put you in the donut hole, you will get a 50% discount on covered brand-name drugs while you're in the donut hole.
  • Starting in 2011, Medicare will cover certain preventive services without charging you the Part B coinsurance or deductible. You will also be offered a free annual wellness exam.

Badgercare/Medicare enrollees

If you are currently eligible and enrolled in BadgerCare Plus, you can stay enrolled in BadgerCare Plus. Your benefits under the program will remain the same. If you are on the BadgerCare Plus Core Plan waiting list and you have a preexisting condition, you may be eligible for the preexisting condition insurance plan administered by the Health Insurance Risk-Sharing Plan (HIRSP). Eligible residents can visit the HIRSP Web site for more information on how to enroll in the HIRSP program: or call toll free (888) 253-2698.

Additionally, for those on the BadgerCare Plus Core Plan waiting list, Wisconsin developed the BadgerCare Plus Basic program. For more information and eligibility requirements for this program, please visit the Wisconsin Department of Health Services Web site or call toll-free (800) 291-2002.

Additional Information

If you have employer-sponsored health care coverage and have questions about how health care reform may affect that coverage, your employer human resources department can help. If you would like additional information, feel free to contact the Office of the Commissioner of Insurance, toll-free at (800) 236-8517 or visit our Web site at