Rules Qualified Wisconsin Health Insurance Companies Must Follow

  • September 13, 2016
  • |Quartz
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Get answers to 5 FAQ's about major medical health insurance in Madison, WI.

The Affordable Care Act (ACA) has created some new rules for health insurance companies* in Wisconsin. These new rules help provide consumers with more opportunities to obtain the coverage they need. Knowing these can help you make a more informed choice about your health insurance.

  • The Health Insurance Marketplace ( was created so people can get information and purchase health insurance online. All plans offered by health insurance companies on must cover essential health benefits, pre-existing conditions and preventive care
  • Summary of Benefits and Coverage – Insurance companies must provide you with –
    • A short, plain-language Summary of Benefits and Coverage (SBC). All health insurance companies must use the same standard form to help you compare plans
    • A list of terms used in health coverage and care
  • Pre-existing conditions – Health insurance companies can't refuse to cover you or charge you more just because you have a pre-existing condition. They also can’t charge women more than men
  • Limited rate increases – Health insurance companies now must publicly justify any rate increase of 10 percent or more before raising your premium
  • The 80 / 20 Rule – Health insurers are required to spend at least 80 percent of the money they receive in premiums on health care and quality improvements. If they don’t meet this ratio, members will receive a rebate from the health insurance company
  • Canceling coverage – Health insurance companies can’t cancel your coverage just because you made a mistake on your insurance application. Your insurance can still be canceled if you put false information on the application on purpose or if you don’t pay your premiums on time. Your insurance company must give you at least 30 days notice before cancellation
  • Doctor choice – You have the right to choose the doctor you want from your health plan’s provider network
  • Children may be able to stay on their parent’s plans longer – Children in Wisconsin up to age 26 may be able join a parent’s plan. They can join, remain or return to it even if they are married. This applies even if the child is not living with a parent, is attending school, is financially independent or is eligible to be on their own employer’s plan
  • Free preventive care – Medical insurance companies must offer plans that cover certain preventive services at no out-of-pocket cost to you
  • No lifetime and yearly dollar limits – Insurance companies cannot set yearly or lifetime coverage maximums for essential health benefits. They can still limit what they pay for non-essential health benefits, such as care received from an out-of-network provider

Unity offers plans that fit a variety of unique needs. Learn more about our health plans or get a health insurance quote today!

*These rules don’t apply to extension plans or grandfathered plans that were in existence on March 23, 2010 and haven’t been changed substantially since. Health insurance companies must notify members if they are part of a grandfathered plan.


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