Last Updated: May 3, 2019
Health Care Reform
Per federal regulation all health insurance plans in the individual market are "guaranteed available" to consumers during an annual open enrollment period. You and your family may or may not be eligible for health insurance coverage from all companies listed in your county depending on your address. For more information, you should contact:
The health insurance companies listed for your county in the
Health Insurer Map.
Your licensed insurance agent.
Federally Facilitated Market Place (FFM).
Please note that if you are eligible for subsidies from the federal government, these can only be accessed by applying for coverage through the FFM. The Advance Premium Tax Credit Examples explain how premium subsidies are calculated, including a list of second-lowest cost silver plan rates by county. Consumers should note that premium subsidies are based on the cost of the second-lowest cost silver plan in their county.
Navigators/Non-navigator Assisters/Certified Application Counselors
Information on the licensing and registration of navigators and non-navigator assisters is available on the Navigator Overview page at https://oci.wi.gov/Pages/Agents/NavigatorLicense.aspx.
Comprehensive Individual and Small Group Policy Form Filings
Federal law requires that all comprehensive individual and small group health insurance policies issued on or after January 1, 2014, comply with all requirements of the Affordable Care Act (ACA) including, but not limited to, essential health benefits (EHB), actuarial value (AV) requirements (also referred to as Metal Levels), and guaranteed availability requirements. All existing Wisconsin insurance laws continue to apply. Therefore, insurers operating in the individual and/or small group markets must ensure that policy language in full compliance with both state and federal statutes and regulations is on file with the Office of the Commissioner of Insurance (OCI) for use in Wisconsin.
Section 631.20, Wis. Stat., provides that Wisconsin is a file and use state and that insurers file their forms with OCI 30 days before use. The file and use requirement applies to individual and small group product filings whether the product is being offered on the FFM, off the FFM or both. Please refer to the
Comprehensive Health Form Filing Requirements page for more information on policy form filing requirements.
Essential Health Benefit Benchmark Plan
Federal law requires that all comprehensive individual and small group health insurance policies issued on or after January 1, 2014, provide coverage of the essential health benefits (EHB) package as defined in the Affordable Care Act (ACA). The ACA provides that each state may select a benchmark plan to serve as the standard for plans required to offer EHB in the state. If a state does not exercise the option to select a benchmark plan, the default is the largest plan by enrollment in the largest product by enrollment in the state's small group market.
Wisconsin's benchmark plan is the largest plan by enrollment in the largest product by enrollment in the small group market. For Wisconsin's current EHB benchmark plan, please refer to the federal
2017 EHB Benchmark Plan Summary document for detailed information on benefits included in the plan. Please note that the summary document may not capture all of the benefits included in the benchmark plan. Refer to the
Comprehensive Health Form Filing Requirements page for links to actual benchmark plan language. All benefits in the Wisconsin benchmark plan are EHB in this state and all plans in the individual and small group markets must offer, at a minimum, benefits that are substantially equal to the EHB benchmark plan, including: covered benefits, limitations on coverage and prescription drug benefits. Plan offerings are not restricted to EHB so plans may offer additional benefits.
Stand-Alone Dental Plans and other Dental Insurance Plans
Insurers wishing to offer in Wisconsin a marketplace-certified stand-alone dental plan (SADP) that meets the standards related to the pediatric dental essential health benefits must comply with all Wisconsin policy form and rate filing requirements. In order to be eligible for marketplace certification as an SADP for plan year 2020, all relevant policy forms and rates must be received at OCI or have a submission date in SERFF of no later than July 1, 2019. In addition, insurers must include with the form filing the following federal documents completed and signed by a qualified actuary: (1)
Stand-Alone Dental Plan Actuarial Value Supporting Documentation and Justification and (2)
Stand-Alone Dental Plans – Description of EHB Allocation. Insurers that want to offer in Wisconsin SADPs off the FFM that are marketplace-certified should also include documents (1) and (2) with their policy form filing. Off-Exchange certified dental plans for plan year 2020 must be submitted to OCI by October 1, 2019 (30 days prior to the individual open enrollment period).
For detailed form filing requirements, see
Policy Form and Rate Filing Requirements Table - Stand-Alone Dental Plans and other Dental Insurance Plans.
Comprehensive Health Rate Filings
For non-grandfathered individual and small group comprehensive health products issued on or after January 1, 2014, companies are required under federal law to develop rates based on a single, market-level index rate (single risk pool) adjusted pursuant to the rating rules prescribed in federal regulation, on and off the federal health insurance exchange. Federal rate review market rules provide that single risk pool premium rates for a particular plan may vary only based on (1) whether the plan covers an individual or family, (2) rating area, as established by the state or federal government, (3) age, consistent with the federal uniform age rating curve, and (4) tobacco status, consistent with the federal 1.5:1 restriction.
OCI established 16 geographic rating areas, the maximum number allowable for Wisconsin based on the criteria provided in federal regulation. Refer to the
Geographic Rating Areas document for the Geographic Rating Areas map and Rating Area IDs assigned to each area by the federal government for use in federal systems.
Please refer to the
Comprehensive Health Rate Filings page for additional guidance and rate filing requirements.
Wisconsin Navigator Grant Recipients
Navigators serve as an in-person resource for eligible individuals who want additional assistance in shopping for and enrolling in plans in the health insurance marketplace this fall.
Additional information regarding Wisconsin navigator grant recipients is available at
Town Hall Meeting PPACA Presentation
In an effort to provide a forum for citizens to gather unbiased information about the Patient Protection and Affordable Care Act (PPACA), the Office of the Commissioner of Insurance and the Department of Health Services held informational sessions across the state in the form of town hall meetings. These 90-minute meetings were open to anyone who has an interest in learning more about PPACA.
Affordable Care Act Tax Provisions and Topics
National Federation of Independent Business Healthcare Playbook
U.S. Department of Labor Patient Protection and Affordable Care Act Information
Federal Health Care Page