What's Covered: All approved plans in the state must cover the same package of benefits, called essential health benefits. In Wisconsin, the benefits include:
- Outpatient services, such as doctor visits or tests done outside a hospital
- Emergency services
- Hospital stays
- Pregnancy and baby care; treatment for underlying causes of infertility is covered
- Mental health and substance abuse services, including behavioral health treatment
- Prescription drugs, including generic and certain brand-name drugs.
- Rehab and habilitative services, that help people recover from an illness or injury and those that help people with developmental issues. Wisconsin offers services for children with autism spectrum disorder.
- Lab tests
- Preventive and wellness services, along with those that help people manage chronic conditions
- Services for children, including dental and eye care, along with residential treatment for children with emotional disabilities
Some services not included: Infertility treatment except for that required to treat an underlying cause of fertility, non-emergency medical care outside the U.S., weight loss surgery, long-term care, and cosmetic surgery.
Health Insurance Advisor: Check out Web MD’s Health Insurance Advisor to compare different kinds of plans based on your needs.
Financial Aid and Medicaid
You may be eligible for financial aid to help pay for insurance or for government sponsored insurance. Here’s what’s available:
Premium Subsidies (also known as Tax Credits): You may qualify for a subsidy -- money to help pay your health insurance premium each month. The subsidy may be sent directly to your health insurance company and is available only if you buy your insurance in the Marketplace. In general, you'll be eligible if you're single and make about $45,960 or less a year, or if you have a family of four and make about $94,200 or less a year. Subsidies are based on your estimated household income for 2014.
You also may be eligible for cost-sharing subsidies that will reduce your costs when you get medical care. Cost sharing subsidies are available only if you buy a silver-level plan.
BadgerCare Plus: All children under age 19, regardless of income, are eligible to enroll in BadgerCare Plus. Parents also may be eligible, depending on their income.
Check with Healthcare.gov to see if you are eligible for these programs.
There are several ways you can get help with your insurance decisions:
- Call Center: You can call the federal government's help line, 800-318-2596, 24 hours a day, seven days a week for information, help, and to buy insurance.
- Web Site: Because the U.S. Department of Health and Human Services is operating the marketplace in Wisconsin, the web site HealthCare.gov. is the best place to start. On that site you can create an account, find out information about different plans, and buy insurance, once you have decided which plan you want.
- Apply by Mail: You also can use a paper application to check whether you are eligible for Medicaid, the Children’s Health Insurance Program, or the new subsidies offered through the Marketplace. Download the application from How do I apply for Marketplace coverage. After you send it in, you’ll be notified of your eligibility. You can complete your enrollment online or by calling the Marketplace Call Center at 800-318-2596.
Navigators and assisters: They will teach you about the Marketplace and guide you through your insurance decisions. They are supposed to be fair and impartial helpers and cannot take any money from insurance companies. Here are the organizations approved to operate Navigator programs:
- Partners for Community Development, Inc.
- Northwest Wisconsin Concentrated Employment Program, Inc.
- Legal Action of Wisconsin, Inc./SeniorLAW
- National Council of Urban Indian Health
- National Healthy Start Association
- R&B Receivables Management Corporation DBA R&B Solutions
- Local, state, and federal organizations: Many health and community organizations, public libraries, and hospitals are offering help. Some organizations will have volunteers who can answer questions for you. Other groups will have trained and certified helpers who can take you through the whole process by computer or by using a paper application. Certified helpers must complete required training. They also are supposed to protect your personal information.
You can find a list of organizations that are helping with enrollment at LocalHelp.HealthCare.gov.
- Insurance brokers and agents: People in the insurance business who take special training also can help you buy insurance through the Marketplace. They also may have policies that are not offered on the Marketplace. You can only get tax credits or subsidies if you buy through the Marketplace.