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Numerous state and federal laws make it easier for people with pre-existing conditions to get or keep health insurance, or to change from one health plan to another. A federal law, known as the Health Insurance Portability and Accountability Act (HIPAA) sets national standards for all health plans. In addition, states can pass different reforms for the health plans they regulate (fully insured group health plans and individual health plans), so your protections may vary if you leave Wisconsin. Neither federal nor state laws protect your access to health insurance in all circumstances. So please read this guide carefully.

The following information summarizes how federal and state laws do – or do not – protect you as a Wisconsin resident.

How am I protected?
In Wisconsin, as in many other states, your health insurance options are somewhat dependent on your health status. Even if you are sick, however the laws protect you in the following ways.

• Coverage under your group health plan (if your employer offers one) cannot be denied or limited, nor can you be required to pay more, because of your health status. This is called nondiscrimination.

• All group health plans in Wisconsin must limit exclusion of pre-existing conditions. There are rules about what counts as a pre-existing condition and how long you must wait before a new group health plan will begin to pay for care for that condition. Generally, if you join a new group health plan, your old coverage will be credited toward the pre-existing condition exclusion period, provided you did not have a long break in coverage.

• Your health insurance cannot be canceled because you get sick. Most health insurance is guaranteed renewable.

• If you leave your job, you may be able to remain in your old group health plan for a certain length of time. This is called COBRA continuation coverage or state continuation coverage. It can help when you are between jobs or waiting for a new health plan to cover your pre-existing condition. There are limits on what you can be charged for this coverage.

• If you lose your employer sponsored group health insurance and meet other qualifications, you will be federally eligible. If so, you can buy an individual health plan from the Health Insurance Risk Sharing Plan (HIRSP). You will not face a new pre-existing condition exclusion period. There are limits on what you can be charged for a HIRSP policy.

• If you are unable to obtain individual health insurance because of your health condition, you may also be eligible for HIRSP coverage. In this case you may face a new pre-existing condition exclusion period. There are limits on what you can be charged for a HIRSP policy.

• If you are a small employer buying a group health plan, you cannot be turned down because of the health status, age, or any factor that might predict the use of health services of those in your group. All health plans for small employers must be sold on a guaranteed issue basis.

• If you are a small employer buying a group health plan then your premiums can vary due to health status, age, industry, or other characteristics. There are limits on what you can be charged based on health status. Even within, these limits, however, premiums can be significantly higher if someone in your group has a serious health condition.

• If you have low or modest household income, you may be eligible for free or subsidized health coverage for yourself or members of your family. The Wisconsin Medicaid program offers free or subsidized health coverage for pregnant women, families with children, elderly and disabled individuals with very low incomes.

• If your children are under the age of 19, do not have health insurance and meet other qualifications, you may be able to buy insurance for them through Wisconsin’s BadgerCare Program.