Governor’s budget plan cracks down on insurance companies and prescription price gouging, lowers out-of-pocket healthcare costs, aims to reduce appointment wait times and enable Wisconsinites to get healthcare closer to home, and expands access to affordable healthcare statewide, including in rural communities
Gov. Tony Evers tonight, during his 2025-27 Biennial Budget Message, announced his 2025-27 Executive Budget will make sweeping changes to the healthcare industry in Wisconsin to address the frustrating challenges Wisconsinites face every day simply trying to get the healthcare they need.
Gov. Evers tonight announced several key initiatives to crack down on insurance companies and prescription price gouging; reduce appointment wait times and enable Wisconsinites to get care closer to home; lower out-of-pocket healthcare costs for medication and insulin; require health insurance companies to automatically cover more healthcare services and procedures with no delays and hassles; prevent surprise medical billing and reporting unpaid medical debt to collections and credit bureaus; and provides new hospital investments to improve healthcare access statewide, including in Wisconsin’s rural communities. As part of Gov. Evers’ comprehensive plan to lower costs for working families, he is also proposing to eliminate the sales tax on over-the-counter medications, which would save Wisconsinites a projected $70 million over the next two years.
Gov. Evers hears from Wisconsinites who feel like they are not getting a fair shake from the healthcare industry, especially their health insurers:
Wisconsinites feel like they are not getting straight answers on what is and is not covered by insurance or why their insurance company is refusing to cover their healthcare services, procedures, and treatment.
Wisconsinites get sicker and health problems get worse because healthcare services or treatment are too far away to travel or take time off of work, or it takes too long to get an appointment or be approved for care—if it is ever approved at all.
Wisconsinites get medical bills and see all sorts of charges they did not know about, or, even worse, Wisconsinites suddenly receive calls from collections agencies about unpaid medical bills they did not even know they had not paid.
Health insurance companies often require healthcare professionals to get permission before they prescribe medication or care that Wisconsinites need. This means health insurers—not doctors and healthcare professionals—are deciding whether Wisconsinites’ prescribed treatment is medically necessary. Health insurance companies try to use these so-called “prior authorizations” to help their bottom line and cut costs, banking on being able to avoid covering the services and treatment Wisconsinites need. Wisconsinites also often have to wait to get care until doctors get permission or may end up forgoing treatment altogether because of all the hassles with insurance, which can cause health conditions to get even worse, even dangerous and life-threatening.
Gov. Evers is proposing solutions to address the frustrating challenges Wisconsinites face with sweeping changes to the healthcare industry in Wisconsin:
Gov. Evers is proposing to make Wisconsin the first state in America to start auditing insurance companies over denying Wisconsinites’ healthcare claims. If an insurance company is denying Wisconsinites’ claims too often, we’re going to audit them.
The governor also proposes creating an office that, for the first time in state history, would be devoted to helping Wisconsinites hold health insurers accountable and ensuring folks get the health insurance coverage they pay for.
Gov. Evers is proposing to create new standards to expand the healthcare services and procedures that insurance companies are required to cover. This means more healthcare services and procedures will be covered by Wisconsinites’ health insurance automatically—no delays, no hassle, no questions asked.
Gov. Evers is proposing to require health insurance companies to be more transparent with Wisconsinites up front and before Wisconsinites purchase their health plan. Under Gov. Evers’ plan, health insurance companies would have to tell Wisconsinites from the get-go which services and treatments will require prior approval so Wisconsinites can find a health plan that is right for them.
Wisconsinites should not have to wait weeks and months to get an appointment or have to travel long distances to get the care they need. The governor’s plan also helps to make sure Wisconsinites can get the healthcare they need when and where they need it—quicker and closer to home—by enabling the creation of statewide standards for maximum wait times for scheduling appointments. Gov. Evers also proposes to make sure the services healthcare insurance companies cover are available within a minimum time and distance of the Wisconsinite buying their health plan.
LOWERING OUT-OF-POCKET COSTS FOR HIGH-QUALITY HEALTHCARE COVERAGE, HOLDING INSURANCE COMPANIES ACCOUNTABLE, AND IMPROVING INSURANCE TRANSPARENCY
Gov. Evers believes healthcare should not be a privilege afforded only to the healthy and the wealthy. No one should ever have to choose between life-saving medication and care or putting food on the table and keeping a roof over their head. Wisconsinites should be able to get the healthcare they need when and where they need it, and without breaking the bank. But too many Wisconsinites feel like they are not getting a fair shake when it comes to healthcare. Gov. Evers wants to change that.
The governor’s budget takes bold new steps to hold health insurers accountable, protect consumers, prevent price gouging, and help Wisconsinites afford everyday, out-of-pocket costs.
Cracking Down on Health Insurance Company Claim Denials and So-Called “Prior Authorization” Requirements
According to KFF, 58 percent of insured adults nationwide have experienced problems using their health insurance, including denied claims. Nearly 40 percent of those experiencing problems reported trouble paying medical bills, saying that denied claims contributed to that trouble. For insurance plans offered on the individual health insurance marketplace, in 2023, approximately 73 million, or around 20 percent, of all claims were denied, with some insurers denying as high as 54 percent of in-network claims. These figures do not even include employer-sponsored plans, which make up the largest portion of plans in the state and saw a 21 percent claims denial rate. Meanwhile, public insurance through Medicare and Medicaid sees far lower claims denial rates at 10 percent and 12 percent, respectively.
Cracking Down on Health Insurance Company Claim Denials and So-Called “Prior Authorization” Requirements
According to KFF, 58 percent of insured adults nationwide have experienced problems using their health insurance, including denied claims. Nearly 40 percent of those experiencing problems reported trouble paying medical bills, saying that denied claims contributed to that trouble. For insurance plans offered on the individual health insurance marketplace, in 2023, approximately 73 million, or around 20 percent, of all claims were denied, with some insurers denying as high as 54 percent of in-network claims. These figures do not even include employer-sponsored plans, which make up the largest portion of plans in the state and saw a 21 percent claims denial rate. Meanwhile, public insurance through Medicare and Medicaid sees far lower claims denial rates at 10 percent and 12 percent, respectively.
Gov. Evers’ 2025-27 Executive Budget includes creating a first-of-its-kind process for auditing insurers when their claims denial rates are too high. The state would provide a corrective action plan for the insurer, with enforcement power to determine that the corrective action plan is being followed and ensure claims are not being unjustifiably denied.
The governor’s budget also includes creating a new consumer protection office for the first time in state history that is designed to help Wisconsinites whose insurance claims are denied and make sure Wisconsinites can hold health insurance accountable by getting the coverage they pay for.
