New Health Insurance Laws - 2025 Wisconsin Acts 103 and 122
Summary
The Wisconsin Office of the Commissioner of Insurance issued a bulletin summarizing two recently enacted laws affecting health insurers. 2025 Wisconsin Act 103 modifies mammogram coverage by requiring insurers to cover diagnostic breast examinations without cost-sharing and supplemental breast screening examinations for individuals with increased breast cancer risk or dense breast tissue. 2025 Wisconsin Act 122 makes technical changes including removing a deadline for OCI to reapply for the federal 1332 waiver and clarifying navigator licensure requirements.
“The Act requires insurers to provide coverage of diagnostic breast examinations without cost-sharing.”
Health insurers offering policies in Wisconsin should audit current mammogram and breast screening benefit designs against the new definitions in Act 103 before January 1, 2027. The definition of 'supplemental breast screening examination' ties coverage eligibility to National Comprehensive Cancer Network guidelines and dense breast tissue classifications — insurers should review medical management criteria to ensure coverage determinations align with these external standards.
What changed
2025 Wisconsin Act 103 creates new coverage mandates for diagnostic and supplemental breast examinations. Insurers must cover diagnostic breast examinations without cost-sharing and supplemental breast screening examinations for individuals meeting National Comprehensive Cancer Network guidelines or with dense breast tissue as defined by the Breast Imaging-Reporting and Data System. Insurers may impose cost-sharing for subsequent supplemental breast screening examinations in a policy year after the first. 2025 Wisconsin Act 122 removes a statutory deadline that had limited OCI's ability to reapply for the federal 1332 waiver after December 31, 2023, and clarifies that federal background check requirements apply only to individual navigator applicants who are natural persons rather than the entities they work for.
Health insurers, agents, and navigators in Wisconsin should prepare for the January 1, 2027 effective date. Insurers should update plan documents and cost-sharing policies to reflect the new diagnostic and supplemental breast examination coverage requirements. Navigator entities should ensure individual navigators complete required background checks and fingerprinting while confirming that these requirements do not apply to the entity itself.
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Apr 21, 2026GovPing captured this document from the original source. If the source has since changed or been removed, this is the text as it existed at that time.
OCI > Bulletin, April 20, 2026, New Health Insurance Laws
Bulletin, April 20, 2026, New Health Insurance Laws
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Last Updated: April 20, 2026
Date: April 20, 2026
To: Insurers, Agents, Navigators, and Interested Parties
From: Nathan Houdek, Commissioner of Insurance
Subject: New Health Insurance Laws
Bulletin20260420NewHealthInsuranceLaws.pdf
This bulletin summarizes recently enacted laws that impact the insurance industry. The Wisconsin Office of the Commissioner of Insurance (OCI) is providing this summary to make insurers, agents, and interested parties aware of the changes.
2025 Wisconsin Act 103
Wis. Stat. § 632.895 (8) was created by 1989 Wisconsin Act 129 to mandate insurance coverage of mammograms to detect the presence of breast cancer. On March 19, 2026, 2025 Wisconsin Act 103, was enacted which modifies the coverage of mammograms benefit as outlined in Wis. Stat. § 632.895 (8).
2025 Wisconsin Act 103 defines “supplemental breast screening examination" as a medically necessary examination of the breast using breast magnetic imaging or breast ultrasound to screen for breast cancer, even without suspected abnormality, based on personal or family medical history or additional factors that may increase an individual's risk of developing breast cancer. The Act defines “diagnostic breast examination" as a medically necessary examination of the breast using breast magnetic resonance imaging, breast ultrasound, breast tomosynthesis, or diagnostic mammography to evaluate a seen, suspected, or detected abnormality.
The Act requires insurers to provide coverage of diagnostic breast examinations without cost-sharing. It also requires insurers to provide coverage of supplemental breast screening examinations to individuals with an increased risk of breast cancer as determined by guidelines from the National Comprehensive Cancer Network or has dense breast tissue as defined by the Breast Imaging-Reporting and Data System. Health insurers may not impose cost-sharing for the first supplemental breast screening examination in a policy year. Insurers may impose cost-sharing for subsequent supplemental breast screening examinations in a policy year.
Governmental self-insured health plans, small group health plans, and individual market health insurers are expected to continue to comply with the mandated benefit outlined in Wis. Stat. § 632.895 (8). The provisions of 2025 Wisconsin Act 103 apply to policy or plan years beginning on January 1, 2027.
2025 Wisconsin Act 122
On March 27, 2026, an insurance omnibus law, 2025 Wisconsin Act 122, was enacted that makes various technical changes to the insurance statutes.
Allow Future Applications for 1332 Waiver Extension
The Wisconsin Healthcare Stability Plan operates under a 1332 waiver granted by the Centers for Medicare and Medicaid Services (CMS) since 2018. Wisconsin's waiver lasts through the end of 2028 but a deadline defined in statute limited OCI's ability to reapply for the federal waiver after December 31, 2023. Act 122 removed this deadline allowing OCI to continue to reapply for the federal waiver from CMS in the future.
Wis. Stat. § 601.83 (1) (a)
Clarify Statutory Definitions Delineating Navigators from Navigator Entities
Navigators are individuals who help consumers determine their eligibility for health insurance and public assistance programs. Navigators are individually licensed with OCI and work for our state's federally designated Navigator entity, Covering Wisconsin. Act 122 clarifies that the federal background check (including fingerprinting) requirement for licensure applies only to individual applicants who are natural persons, rather than the entity they work for. The bill updates statutory definition for an “individual navigator" to refer to natural persons and “navigator entity" to refer to entities.
Wis. Stats. § 628,095 (3) and (5); § 628.10 (2), (3), (5) (a) and (5) (b); § 628.90 (3) (intro.); § 628.90 (3) (am) and (bm), 628.90 (3m); § 628.91, § 628.92 (1) (intro.) and (d) (2) (intro.), (a) and (b), (6) and (7); § 628.95 (title), (1) and (2) (intro.), and (c).
Any questions concerning this bulletin may be directed to Lauren.VanBuren@Wisconsin.gov.
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