WHO IS COVERED?
All residents and workers in Wisconsin are covered by Healthy Wisconsin, unless they receive health care through Medicare, Medicaid, BadgerCare, or a federal employee health insurance Plan.
Adults who move into Wisconsin but who are not employed must satisfy a twelve month residency requirement. There is no residency requirement for pregnant women or children.
Healthy Wisconsin benefits are based on the comprehensive State Employee Uniform Benefits Plan, to which has been added mental health parity and preventive dental care for children.
This benefits plan basically covers all medically necessary care plus prescription drugs, as well as preventive care, wellness programs, alcohol and chemical dependency programs, etc.
WHAT IS THE HEALTH CARE DELIVERY SYSTEM? CAN I CHOOSE MY OWN DOCTOR?
“Health Care Networks” will submit per-person bids to the Healthy Wisconsin Board of Trustees. A “Health Care Network” is defined as “a provider driven, coordinated group of health care providers comprised of primary care physicians, medical specialists, physician assistants, nurses, clinics, one or more hospitals, and other health care providers and facilities, including providers and facilities that specialize in mental health services and alcohol or other drug abuse treatment.” (Examples would be Marshfield in the northern part of the state, Dean Care in Madison, Group Health in Eau Claire.)
On the basis of their bids, these Networks will be divided into categories: those that are lower cost and higher quality and those that are higher cost and lower quality. There is no additional cost if a person chooses the lower cost network option. If they choose the higher cost network, they must pay, on a monthly basis, the difference in cost between the plans.
There will be a state-wide fee-for-service plan that anyone can choose. If there are no other options in a given area, there will be no additional charge for this plan.
Both in the fee-for-service plan and the Network options, everyone must choose a primary care provider (physician, nurse practitioner, physician’s assistant, etc.) who is responsible for coordinating health care for you or your family.
All employers must pay 9-12 % of wages of their employees (up to the limit of taxable Social Security wages, which is currently $97,500). Employees must pay 2-4% of their Social Security wages. An actuarial analysis estimates that the actual figure in 2007 would be 10.5% for employers and 4% for employees.
THESE PAYMENTS REPLACE THE PAYMENTS FOR PRIVATE HEALTH INSURANCE NOW BEING PAID BY EMPLOYERS AND WISCONSIN RESIDENTS.
The average family income in Wisconsin is about $42,000. So for the average family, the cost would be $140 per month in payroll deductions. On average, the employer would pay about $370 per month.
Unions may bargain, or employers may offer, to pay any part of the employee’s charges, as well as provide additional benefits (including vision, dental, etc.).
Self-employed persons and those with income but no wages pay 10% of income up to the Social Security wage limit.
There is a yearly deductible of $300 for a single person and $600 for a family.
There is a $20 co-pay for office visits and hospital admission, except that there are no co-pays for preventive care, children, or for office visits for those participating in a chronic disease management program. Prescription drug copays are $5 generic, $15 brand name, and $40 for non-formulary drugs. Out-of-pocket expenses are capped at $2000 per adult or $3000 per family.