Gov. Evers: “I Want Wisconsin to Become the First State in America to Start Auditing Insurance Companies over Denying Healthcare Claims”

MADISON — 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.
• Gov. Evers also proposes cracking down on surprise medical bills and the healthcare industry sending unpaid medical bills to collections or reporting to credit bureaus. Gov. Evers’ plan would require health providers to give Wisconsinites notice of unpaid medical bills and would give Wisconsinites a six-month grace period by banning healthcare providers from reporting unpaid medical debt to collections or credit bureaus during that time.
• No one should be in a mental health crisis wondering whether insurance will cover an in-patient stay to get help. Gov. Evers also proposes banning health insurance companies from requiring pre-approval for in-patient mental health services so Wisconsinites in crisis can be safe and get life-saving care.

As part of Gov. Evers’ plan to lower out-of-pocket costs for working families, make healthcare more affordable, and crack down on price gouging, Gov. Evers last month announced his “Less for Rx” plan to lower prescription drug prices, improve oversight of drug companies, and protect consumers from price gouging on their medications, including removing the sales tax on over-the-counter medications, which will result in a projected total of $70 million in annual savings, setting price ceilings for prescriptions, capping the cost of insulin copays to $35, and protecting Wisconsinites from price gouging on prescriptions.

Relevant excerpts from Gov. Evers’ 2025-27 Biennial Budget Message are available below:

“… A key part of my plan to lower costs for working families includes making it easier for folks to get the healthcare they need without breaking the bank. Healthcare should not be a privilege afforded only to the healthy and the wealthy. It’s why I’m again proposing to expand BadgerCare, which would save Wisconsin taxpayers nearly $2 billion over the next two years and expand quality, affordable healthcare coverage for about 100,000 Wisconsinites. And I’m also providing new hospital investments to improve access to healthcare across Wisconsin, including in our rural communities.

“As part of my comprehensive plan to lower costs for working families, I’m also proposing sweeping plans to lower costs for prescriptions and medication and crack down on price gouging and health insurers. My “Less for Rx” plan will lower costs for life-saving prescription drugs and insulin. We’d create a Prescription Drug Affordability Review Board to crack down on prescription price gouging. We’d cap the cost of insulin copays at $35. We’d set price ceilings for prescription medication. And we’d save Wisconsinites a projected $70 million over the next two years alone by eliminating the sales tax on over-the-counter medications. Let’s finally make lowering everyday, out-of-pocket costs for medication a bipartisan priority this session.

“Here’s something else we can do with bipartisan support. In the Year of the Kid, let’s finally do what’s best for moms and babies. Let’s extend postpartum coverage for pregnant women on BadgerCare to up to one year after giving birth. Wisconsin and Arkansas are the only two states in America that haven’t done this. I mean, nothing against Arkansas, but come on, folks. I’ve proposed this in every budget I’ve introduced as governor. There’s also a bipartisan bill to get it done that almost 90 legislators support. One legislator should not be able to single-handedly obstruct a bill that’s supported by a supermajority of the Legislature. Let’s just get it done.

“Wisconsinites should be able to get the healthcare they need when they need it. But I hear from folks all the time who feel like they’re getting ripped off by the healthcare industry and insurers. Folks can’t get a straight answer on what’s covered by insurance and what’s not. People get sicker and health problems get worse because it takes too long to get an appointment or be approved for care—if it’s ever approved at all. People try to get their care paid for but insurance companies refuse to cover it. Families get a medical bill and see all sorts of charges they didn’t know about. Or, even worse, suddenly, collections agencies are calling about unpaid medical bills they didn’t even know they hadn’t paid.

“Wisconsinites aren’t getting a fair shake when it comes to healthcare, and I want to change that. So, first things first: I want to make Wisconsin the first state in America to start auditing insurance companies over denying healthcare claims.

“If an insurance company is going to deny your healthcare claim, they should have a darn good reason for it. It’s frustrating when your claim gets denied and it doesn’t seem like anyone can give you a good reason why. So, here’s how I propose we fix that: under my plan, if an insurance company is denying Wisconsinites’ claims too often, we’re going to audit them. Pretty simple.

“And here’s what else my plan would do: we’d create a new office to help Wisconsinites whose health insurance claims are denied. For the first time in state history, we’d have an office in state government devoted to helping Wisconsinites hold health insurers accountable and ensuring folks get the health insurance coverage they pay for. That’s a big deal, folks.

“Another thing that gets me wound up is how health insurance companies require healthcare professionals to get permission before they prescribe medication or care that you need. Basically, that means health insurers—not your doctor—are deciding whether your prescribed treatment is medically necessary. Health insurance companies try to use these so-called “prior authorizations” to help their bottom line and cut costs. They’re banking on being able to avoid covering the services and treatment you need.

“And Wisconsinites, you pay the price. Folks have to wait to get care until doctors get permission or may end up forgoing treatment altogether because of all the hassles with insurance. That can cause health conditions to get even worse—even dangerous and life-threatening.

“So, my plan would create new standards to expand the healthcare services and procedures that insurance companies are required to cover. That means more healthcare services and procedures will be covered by your insurance automatically—no delays, no hassle, no questions asked.

“Wisconsinites should know what you’re getting when you buy your health insurance plan. You should know which services and treatments will need prior authorization. So, we want to require health insurance companies to be transparent from the get-go—they’d have to tell you right up front which services and treatments will require prior approval so you can find a health plan that’s right for you.

“And here’s one thing we have to make sure of: no one should be in a mental health crisis wondering whether insurance will cover an in-patient stay to get help. So, we’re going to ban health insurance companies from requiring pre-approval for in-patient mental health services so Wisconsinites in crisis can be safe and get life-saving care.

“Wisconsinites, you should be able to get healthcare when and where you need it—and you should be able to get it quickly and close to home. Folks can’t afford to travel hours away to get basic services. And you shouldn’t have to wait weeks and months to get an appointment. So, my plan would enable creating statewide standards for maximum wait times for scheduling appointments. And I’m proposing to require health insurance companies to make sure the services they cover are available within a minimum time and distance of where you live.

“Even if folks can get care, far too often, unpaid medical bills are sent to collections agencies because Wisconsinites can’t afford to pay them. Other times, Wisconsinites might not even know about unpaid medical bills before they’re sent to collections or reported to credit bureaus. My plan would require health providers to give Wisconsinites notice of unpaid medical bills. And we’d give Wisconsinites a six-month grace period, banning healthcare providers from reporting unpaid medical debt to consumer reporting agencies during that time. …”

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.

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.

Gov. Evers’ new Public Intervenor Office would assist Wisconsinites whose insurance claims were denied by helping them understand their rights, get the most out of their insurance policies, and provide legal assistance to pursue coverage for medical procedures, prescription medication, and other healthcare services that were unreasonably denied. A new position would also be created to assist in the investigation of fraudulent insurance acts by insurers.

Additionally, insurance companies requiring prior authorization for medical procedures is one of the most blatant inefficiencies in the healthcare industry today. Prior authorization allows insurers who do not have any direct knowledge about a patient’s medical needs or life circumstances to decide whether a procedure recommended by a doctor is medically necessary. Prior authorizations have been proven to result in delayed care, wasted time, increased healthcare costs, and reduced health outcomes. Requirements resulting from prior authorization denials, such as step therapy or requiring patients to try a less expensive or preferred drug before insurers cover “stepping up” to a similar but more expensive option, mandate ineffective initial treatments, requiring additional office visits and delays in immediate care needs that can result in emergency department visits and hospitalizations. This can drastically increase the cost of care, impede on the judgment of healthcare providers, and waste valuable time in getting folks the care they need to be well and live their best and fullest lives.

According to a nationwide survey conducted by the American Medical Association, more than 90 percent of physicians reported that prior authorizations cause unnecessary delays for necessary care. Nearly 80 percent reported that prior authorizations led to their patients forgoing the recommended treatment. About one in four physicians reported that prior authorizations have led to a serious adverse health event for one of their patients.

The governor’s budget provides a number of prior authorization requirement reforms to improve efficiency, expedite the process, and get individuals the care they need. Procedures and services that already receive approval rates above a certain percentage from providers would be automatically approved. If a procedure is recommended by a doctor who already receives a 95 percent approval rate from the insurer in the year prior, there is no need to delay treatment. To further expedite services, insurers would be prohibited from requiring prior authorization for inpatient mental health services for kids and adults, ensuring that individuals get that critical care without delay. Insurers would also be required to list all covered services under each plan that require prior authorization so that the information is clearly disclosed to individuals before purchasing a plan.

Gov. Evers also recommends prohibiting health insurance providers from establishing annual or lifetime limits on health insurance plan benefits and requiring all health insurance plans to provide coverage for essential health benefits as determined by the commissioner of the Wisconsin Office of the Commissioner of Insurance (OCI), including the ten essential health benefits categories covered under the federal Affordable Care Act (ACA), and to provide coverage for certain preventive services at no cost to the plan holder. All of these provisions would also apply to short-term, limited- duration plans, also known as “junk plans,” to improve their coverage quality.

Just because a service is covered does not guarantee that it is available within a reasonable distance. Gov. Evers proposes establishing network adequacy standards to improve access to services by requiring in-network services to be within set travel times and distances from the plan holder. The governor also proposes exploring standards for appointment wait times, making sure that individuals get access to services within a reasonable number of business days.

Another crucial barrier to overcome before receiving care is affordability. In emergency situations, there is a high likelihood that individuals don’t have the ability to choose what type of care they receive or where they receive it. Even if fully insured, receiving care in an out-of-network facility can result in astronomical, unreasonable medical bills. This lack of cost transparency has individuals less willing to utilize healthcare services that they may desperately need. This budget would not only codify federal law to curb surprise billing for emergency services and reduce medical costs, but it would further expand upon them to protect against receiving unreasonably high medical bills for ground ambulance services and certain behavioral health services received during a crisis to help ensure folks can focus on getting the care they need when they need it to stay safe and be well rather than worrying about the bill coming in the mail.

Additionally, as telehealth services have become more available, Gov. Evers recommends expanding coverage protections and providing parity for those telehealth services to further expand their availability. This includes requiring insurance plans to cover telehealth services if an equivalent in-person service is covered, prohibiting insurers from charging a higher cost-sharing amount for the telehealth version of an equivalent in-person service, prohibiting annual or lifetime limits on telehealth services, and eliminating the need for prior authorization to receive telehealth services under an insurance plan, among others. Increasing access to telehealth visits is especially critical for reaching Wisconsinites who may live far away from the nearest healthcare facility.

Building upon his work to support maternal and infant health, Gov. Evers’ budget also includes adding pregnancy to the list of qualifying life events for individuals to enroll in healthcare coverage during health insurance special enrollment periods.

LOWERING OUT-OF-POCKET COSTS FOR MEDICATION, IMPROVING OVERSIGHT OF DRUG COMPANIES, AND CRACKING DOWN ON PRESCRIPTION PRICE GOUGING
As previewed in his 2025 State of the State address, Gov. Evers also announced in his 2025-27 Biennial Budget Message tonight that his 2025-27 Executive Budget will include over 10 policies aimed at reducing prescription drug prices, setting price ceilings for prescriptions, and improving oversight of drug companies to protect Wisconsinites from price gouging on medications. Among the governor’s proposals include removing the sales tax on over-the-counter prescriptions, through which Wisconsinites will see a projected total of $70 million in annual savings. Additionally, Gov. Evers is proposing to establish a $35 copay cap on insulin.

According to a 2023 national survey by KFF, more than a quarter of adults in America reported that it is somewhat or very difficult to afford the cost of their prescription drugs, with about 30 percent of adults reporting that they did not take their medications as prescribed in the past year due to cost. Additionally, a 2024 Public Policy Polling survey found that 89 percent of Wisconsin voters, including 84 percent of Republicans, believe that lowering costs for prescription drugs would help people afford the cost of living.

Gov. Evers announced tonight that his 2025-27 Executive Budget will:

• Establish the Office of Prescription Drug Affordability to oversee prescription drug regulations and further analyze and develop policies aimed at reducing prescription drug costs for Wisconsinites statewide. Provide 16 positions, $2 million in fiscal year 2025-26, and $1.9 million PR in fiscal year 2026-27 to create the Office of Prescription Drug Affordability and support this critical work;
• Lower everyday, out-of-pocket costs for Wisconsinites, including working families, seniors, and expecting parents by:
  • Making essential healthcare products more affordable and accessible by exempting over the-counter medications from sales tax. This will reduce sales taxes on consumers by $29.8 million in fiscal year 2025-26 and $40.8 million in fiscal year 2026-27. Making basic family needs including diapers, incontinence products, menstrual products, and breast pumps exempt from sales tax. This will reduce sales taxes on families by $14.9 million in fiscal year 2025-26 and $20.4 million in fiscal year 2026-27.
• Ensure insulin is affordable for Wisconsinites by establishing a $35 maximum copay cap for a month’s supply of insulin;
• Establish an Insulin Safety Net Program to ensure those with an urgent need for insulin, as well as those with lower incomes and limited-to-no insurance coverage, have access to affordable insulin;
• Establish a value-based diabetes medication pilot program to develop a value-based formulary, focus on medications that work, and reduce spending waste;
• Require prescription drug cost reductions received from prescription drug manufacturer coupons and other discounts to count towards a plan holder’s deductible or out-of-pocket maximum. Only discounts for brand name drugs that have no generic equivalent and brand name drugs that have undergone prior authorization by a prescriber or the insurer are eligible in order to avoid incentivizing the purchasing of more expensive brand name drugs over their generic equivalents;
• Require health insurance plans offered in the state to cover over-the-counter oral contraception to increase the accessibility and affordability of an essential component of women’s health. Health insurance plans would be prohibited from requiring an individual to have a prescription for the oral contraceptive in order to be provided coverage;
• Improve oversight of drug companies by creating a Prescription Drug Affordability Review Board to oversee the pharmaceutical industry and drug market, analyze other state and national drug policies and practices, establish spending limits for public sector entities, and set price ceilings on price-gouging prescription drugs;
• License and regulate entities involved in the prescription drug supply chain, including pharmacy benefit management brokers and consultants, pharmacy services administration organizations, and pharmaceutical sales representatives;
• Require pharmacy benefit managers and other third-party payers to reimburse certain 340B drug discount program participants, specifically federally qualified health centers, critical access hospitals and Ryan White HIV/AIDS programs, at the same rate that non-340B program participants are reimbursed to end discriminatory reimbursement practices;
• Require pharmacy benefit managers to owe a fiduciary duty to insurers and other payers with whom they contract;
• Fully fund the Wisconsin Healthcare Stability Plan to stabilize the individual healthcare market and lower premiums for Wisconsinites;
• Increase total funding for the Wisconsin Healthcare Stability Plan to $250 million in each fiscal year to reinsure high-cost individuals for all health insurers who offer individual plans. Allow the spending cap for the plan to be adjusted by the governor;
• Create a Prescription Drug Importation Program that would allow the state to import drugs that would create substantial savings for Wisconsin consumers and taxpayers; and
• Direct OCI to study the creation of a state prescription drug purchasing entity.

This proposal builds upon Gov. Evers’ efforts over the past six years, including creating the Governor’s Task Force on Reducing Prescription Drug Prices and previously introducing his “Less for Rx” plan. Additional information on Gov. Evers’ efforts to make prescription medications more affordable is available here.

EXPANDING ACCESS TO QUALITY, AFFORDABLE HEALTHCARE
Finally, as he has in his last three executive budgets, Gov. Evers is once again proposing to expand BadgerCare to provide quality, affordable healthcare coverage to more than 95,000 low-income Wisconsinites, while saving the state $1.9 billion and drawing down an additional $2.5 billion in federal funding over the biennium.

According to data from KFF, more than 1.2 million Wisconsinites, or roughly 20 percent of the state’s total population, were enrolled in Medicaid as of August 2024, with Medicaid covering one in seven adults between the ages of 19 and 64, one in three kids, four in seven nursing home residents, one in six Medicare beneficiaries, and one in three people with disabilities.

Studies have shown that in states that have expanded Medicaid, more people have access to healthcare, more people are able to use preventive health care services, and patients see improved health outcomes, more people are able to access treatment for mental health or substance use disorder challenges, and states with Medicaid expansion have seen a significant decrease in their mortality rates.

Further, analysis from KFF indicates that rural hospitals in states that have not expanded their Medicaid programs under the ACA fared worse financially than those in states that have expanded Medicaid, with median operating margins for rural hospitals being consistently higher in states that have expanded Medicaid programs than in non-expansion states from July 2017 to June 2022.

According to a Marquette Law School Poll, more than 70 percent of Wisconsinites think the state should accept federal funds to expand Medicaid, but despite this fact, currently, Wisconsin is only one of 10 states in the country and the only state of its Midwest neighbors that has not yet expanded Medicaid.

NOTE: This press release was submitted to Urban Milwaukee and was not written by an Urban Milwaukee writer. While it is believed to be reliable, Urban Milwaukee does not guarantee its accuracy or completeness.