TABLE OF CONTENTS
When you turn 65, you become eligible to apply for Medicare, which is health insurance backed by the federal government. People with disabilities or certain medical conditions may also be eligible regardless of age. There are two choices when selecting Medicare coverage: Original Medicare, which is facilitated by the government, and Medicare Advantage, which is offered via health insurance companies but must follow federal guidelines. Medicare Advantage is also known as Medicare Part C or commonly referred to as MA.
Wisconsin has Medicare Advantage plans available. MA plans sometimes offer additional benefits that aren’t found with Original Medicare, so they are worth considering. Wisconsin residents can choose from several Medicare Advantage plans, though the number varies by county.
This article guides you through everything you need to know about Medicare Advantage Plans in Wisconsin.
Compare ratings of insurance companies offering Medicare Advantage Plans in Wisconsin:
You have choices in Medicare coverage. While you can opt to stick with Original Medicare, a Medicare Advantage Plan – also known as Part C – may be a better alternative for you.
|Original Medicare||Medicare Advantage Plans|
|Original Medicare covers your Part A hospital insurance and Part B medical insurance.||Medicare Advantage Plans combine Part A, Part B, and additional benefits.|
|You can add Part D prescription drug coverage.||Prescription drug coverage is usually included.|
|You’re able to use any medical provider in the U.S. that accepts Medicare.||You’ll usually need to use doctors in your plan’s network.|
|You can buy supplemental coverage to manage out-of-pocket costs, including your coinsurance.||Your Medicare Advantage Plan may have lower out-of-pocket costs than Original Medicare.|
|Vision, hearing, dental, and other benefits aren’t covered.||Your plan may offer additional benefits, including vision, hearing, and dental.|
Medicare Advantage Plans cover benefits from Original Medicare Part A (hospital insurance), Part B (medical insurance), usually Part D (prescription drug coverage), and sometimes additional benefits that Original Medicare doesn’t cover. Each Medicare Advantage Plan insurer sets the rules about how you receive and pay for these benefits.
|Hospital and skilled nursing facility inpatient care||Home health care||Prescription drug coverage (if included in your plan)|
|Medically necessary outpatient services, such as:
||Preventive services, such as:
||Additional benefits (depending on your plan), such as:
With 126 Medicare Advantage Plans available in Wisconsin, you likely have several options in your area. To help you choose the best plan for you, consider what is most important to you before selecting a plan. There are several factors to keep in mind:
With nearly half of eligible Wisconsin residents choosing a Medicare Advantage Plan, it’s a very popular choice as compared to most other states in the nation.
|Number of Medicare Advantage Plans available||Medicare Advantage Plan types available||Medicare Advantage Plans rated 3.5 or higher by NCQA|
In Wisconsin, the most common Medicare Advantage plans available are HMOs or PPOs, although there are also a few SNPs and regional PFFS plans available. Seniors eligible for Medicare may choose from plans provided by multiple private insurers, although the choices available vary by county.
|HMOs||HMOs typically require that you receive all services from in network providers:
|PPOs||PPOs include a preferred network of providers, but you have the option of choosing doctors or hospitals from outside of the network for a higher cost.
|PFFS Plans||PFFS plans don’t require a primary care physician or referrals for specialists:
|SNPs||SNPs are only for people with specific conditions and characteristics, and include care coordination and targeted benefits tailored to meet your specific needs:
You’re eligible for Medicare when you turn 65 or if you’re younger and have a qualifying disability. A qualifying disability means at least one of the following applies:
When you become eligible for Medicare, you are also eligible for Medicare Advantage Plans. There are specific times of the year when you can enroll for the first time in a Medicare Advantage Plan: during your Initial Enrollment Period and the Open Enrollment Period.
Medicare Advantage Open Enrollment occurs between January 1 and March 31 of each year. This period is only for beneficiaries already in a Medicare Advantage Plan, and you can change plans or switch to Original Medicare. You cannot switch from Original Medicare to Medicare Advantage during Medicare Advantage Open Enrollment.
There are exceptions to these enrollment periods called Special Enrollment Periods. Certain events or circumstances may make you eligible to change your Medicare Advantage Plan outside of the open enrollment periods, such as if you move outside of your existing plan’s service area or to a location with new plan options you didn’t have before. If you think you may qualify for a Special Enrollment Period, call 1-800-MEDICARE and explain your situation.
|Enrollment period||When it happens||Medicare plans you can choose||What you can do|
|Initial Enrollment Period||Three months before you turn 65, the month you turn 65, and three months after||Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan||Sign up for Medicare Part A and Part B. Complete your Part B enrollment to avoid a late enrollment penalty.|
|General Enrollment Period||January 1 – March 31||Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan. If you enroll in Medicare during this period, your MAP enrollment is April through June.||Sign up for Medicare if you missed your IEP|
|Open Enrollment Period||October 15 – December 7||Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan||Join, switch, or drop a plan|
|Medicare Advantage Open Enrollment Period||January 1 – March 31||Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan||If you’re enrolled in a Medicare Advantage Plan, you can change your plan or switch to Original Medicare|
|Special Enrollment Period||When you have a qualifying event||Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan||Make changes to your plan|
Most Medicare Advantage HMO and PPO plans and all SNP plans provide prescription drug coverage like you would get from Medicare Part D. Some PFFS plans may provide prescription drug coverage, but not all do. Evaluate a plan’s prescription drug coverage when deciding which Wisconsin Medicare Advantage Plan to use.
Prescription drug coverage may vary by cost, coverage, and convenience among Medicare Advantage Plans. Your monthly premium may include a premium for the drug coverage in the plan. There is usually a copayment or coinsurance amount that you have to pay for each prescription after you reach your annual deductible.
Some plans use different cost tiers with different costs for different drugs. For instance, you may pay less for generic drugs than brand-name drugs or less for brand-name drugs within different tiers. If your plan uses tiers, the formulary will list all covered drugs and their tiers. Verify your preferred or local pharmacies are included in the plan’s network.
|Resource||Contact||How they help|
|Wisconsin Department of Health Services – Medicare||(608) 266-1865||DHS is committed to protecting and promoting the health and safety of the people of Wisconsin, making sure everyone can live their best life|
|Wisconsin Office of the Commissioner of Insurance – Consumer’s Guide to Medicare Advantage in Wisconsin||(608) 266-3585
|This guide explains the options under Medicare Advantage, provides important questions to consider, and lists some of the advantages and disadvantages of Medicare Advantage Plans|
|Resource||Contact||How they help|
|Milwaukee County Department on Aging – Medicare 101||(414) 289-6874||The Milwaukee County DHHS Division on Aging provides a single point of access to services for people aged 60 and over|
|Resource||Contact||How they help|
|American Hospital Association – Medicare Advantage||(800) 424-4301||The AHA provides education for health care leaders and is a source of information on health care issues and trends.|
|CMS.gov – Medicare Advantage Applications||N/A||This page provides important information on the application process for Part C Medicare Advantage plans.|
|Medicare.gov – Medicare Advantage Plans||(800) 633-4227||This government website provides information on the Medicare Advantage program.|