Medicare Advantage Plans in Wisconsin
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Updated: Oct 23, 2021
Medicare Advantage in Wisconsin, also known as Part C, offers seniors enhanced Medicare options. Its plans often bundle prescription drug coverage (Part D) with the hospital and medical coverage of Original Medicare Parts A and B. Medicare Advantage plans may also offer other coverage selections, including dental, hearing, and vision, as well as medical appointment transportation and gym memberships. Medicare-approved private insurance companies manage Medicare Advantage plans, rather than the federal government. They are required, however, to adhere to Medicare's guidelines. Costs may vary depending on specific benefits.
- 1 In 2019, there were 97 Medicare Advantage plans available in Wisconsin.
- 2 40% of the total Medicare population in Wisconsin is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $8,763 per beneficiary in Wisconsin, which is 13% lower than the national average.
- 4 Available Medicare Advantage plans range from 11 to 47 across Wisconsin’s 72 counties.
Seniors can compare cost and coverage options to determine which Medicare Advantage plans in Wisconsin best meet their unique circumstances. Each plan’s specific availability depends on the enrollee’s geographic location and the health insurance provider. Selections may include HMOs, PPOs, PFFSs, and SNPs. The insurance carrier and Medicare agree on a monthly payment schedule to cover the beneficiary’s care. While each plan has its own rules, individuals are protected by Medicare’s guidelines regarding eligibility and enrollment.
Medicare Advantage Plans in Wisconsin
Types of Medicare Advantage Plans
Wisconsin seniors may choose from Medicare Advantage’s HMOs, PPOs, PFFSs, and SNPs. The private insurers that manage the plans can stipulate specific rules, such as requiring beneficiaries to choose a primary care physician. However, those enrolled in Wisconsin’s Medicare Advantage program enjoy the same safeguards as those enrolled in Original Medicare.
Health Maintenance Organizations (HMO)
HMO plans offer beneficiaries a network of physicians, hospitals, and other healthcare options. Members are required to select a primary care physician to manage general medical care and write referrals for necessary specialist visits. To receive full coverage, beneficiaries must receive healthcare within the network. However, there are a few exceptions, including some emergency services and out-of-area dialysis. While many HMOs include prescription drug coverage, not all of them do. Enrollees who require prescription coverage are advised to select an HMO that offers it. Participants are not permitted to enroll in both a Medicare Advantage HMO and Medicare Part D. Although HMOs are among the most restrictive plans, they’re also the most affordable.
Preferred Provider Organizations (PPO)
Wisconsin residents seeking more flexibility than what an HMO offers may want to consider a PPO. Participants don’t need to choose a primary care physician, and they have the freedom to see a specialist without needing a referral. PPO plans offer in-network care, and members may also receive out-of-network services. The coinsurance and co-pay rates are generally lower, however, when remaining in-network. PPOs, like HMOs, usually include prescription drug coverage. Just as with HMOs, participants who require it must choose a plan with prescription coverage. Selecting a Medicare Advantage PPO plan and Part D coverage is not an option.
Private Fee-For-Service Plans (PFFS)
Offering the most flexibility of any of the Medicare Advantage plans, PFFSs set prearranged rates with providers and participants. As long as the physician or facility accepts the plan, beneficiaries are free to choose the healthcare provider of their choice. Some PFFSs work as part of a network. While members are not required to seek treatment within the network, their rates are lower when they do. Many plans offer prescription drug coverage, but individuals can also enroll in Part D if the PFFS doesn’t include it. Enrollees interested in a PFFS plan should expect to pay more for these plans than they would for HMO or PPO coverage.
Special Needs Plans (SNP)
While SNPs represent the most limiting and costly plans available through Medicare Advantage, they also provide coverage for people with specific needs. SNPs offer options for enrollees experiencing chronic conditions, such as HIV/AIDS, dementia, and heart failure. These plans are also available for beneficiaries who qualify for both Medicaid and Medicare and nursing home residents. Members are required to seek care through their established network to receive full coverage. All SNPs include prescription drug coverage.
Enrollment & Eligibility for Medicare Advantage Plans in Wisconsin
Seniors at least 65 years of age and younger individuals with a qualifying disability who are eligible to enroll in Medicare Parts A and B are also eligible to enroll in Wisconsin’s Medicare Advantage program. They must also meet the following requirements.
- They must be U.S. citizens or permanent residents.
- They must live within the geographic area.
- They cannot be enrolled in a Medigap plan.
Medicare Advantage enrollment periods vary depending on the current status of the enrollee and the desired plan changes. Adhering to the specified dates ensures the most beneficial coverage and avoids penalties.
- Initial enrollment occurs three months before the beneficiary’s 65th birthday, the month of their birthday, and the three months following their birthday.
- The annual election period occurs from October 15th through December 7th. It’s available for current Medicare members initially switching to a Medicare Advantage plan. Medicare Advantage participants are also permitted to change plans.
- During the open enrollment period, from January 1st through March 31st, current Medicare Advantage members may switch plans or return to Original Medicare.
- The general enrollment period, occurring from April 1st through June 30th, is only open to participants who had Medicare Part A and completed Part B registration during the open enrollment period. It’s also available for individuals who want to move into a Medicare Advantage plan.
Prescription Drug Coverage
Wisconsin’s Medicare Advantage prescription drug plans are operated by private Medicare-approved insurance providers. Each Medicare Advantage prescription drug program (MA-PD) has specific coverage criteria. Medicare Advantage members enrolled in an HMO or PPO that does not include a prescription plan are not permitted to purchase separate Part D coverage. Individuals attempting to sign up for both are dropped from Medicare Advantage and reenrolled in Original Medicare. PFFS plans may include prescription drug coverage; however, enrollees can purchase a Part D policy if they don’t. SNPs are legally required to have prescription drug coverage.
Medicare Advantage Resources in Wisconsin
With so many variables, navigating the Medicare system can feel overwhelming, particularly for new enrollees. There are a number of free resources available to help Wisconsin seniors find the best plan for their specific circumstances.
Wisconsin Department of Health Services
The Wisconsin Department of Health Services offers assistance with understanding and completing benefit enrollment applications. Its resources are federally funded through a grant with the State Health Insurance Assistance Program (SHIP). The program’s trained and certified counselors are available to provide objective advice regarding how Medicare’s specific benefits align with individual needs. Staff and volunteers also assist individuals with completing forms and ensuring deadlines are met.
SHIP’s staff and volunteers are committed to empowering individuals through education to make informed decisions about their own care. They provide a variety of resources, formats, and availability options to satisfy individual schedules and preferences. The department’s educational outreach programs include workshops and seminars to help participants understand their options. Additionally, Wisconsin’s DHS offers departments dedicated to assisting with specific concerns, such as Medicare Advantage and Medigap.
Contact Information: Website | 608-266-2536
Kenosha County Aging & Disability Resource Center
Kenosha County’s Medicare benefit specialists are available to evaluate individual benefit questions, offer unbiased counseling, and assist with completing required paperwork on time. The department’s counselors work with seniors and younger individuals with qualifying disabilities who have questions about Medicare coverage, including Medicare Advantage and Part D benefits. In addition to one-on-one assistance, the Medicare specialists provide workshops that help individuals understand terminology, deadlines, regulations, and the appeals process. Kenosha County ADRC also offers online resources, such as the self-guided Medicare series.
Contact Information: Website | 262-653-2600
N.E.W. Community Clinic
The Green Bay-based N.E.W. Community Clinic delivers a wide range of services to area residents. The clinic’s health benefit coordinators and benefits specialists are available by appointment and can answer questions, help organize records, and identify the appropriate Medicare program for eligible enrollees. In addition to providing Medicare and Medicaid benefits coordination, the clinic’s professionals can help residents understand each of the plan’s requirements and complete the appropriate application forms for other types of benefits. As a community clinic, N.E.W. also provides healthcare benefits, including mental health care, medical and dental treatments. Additionally, N.E.W. is part of Wisconsin’s Well Woman Program.
Contact Information: Website | 920-437-9773
- Sources [-]
https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans | Last accessed June 2021
https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b | Last accessed June 2021
https://www.medicare.gov/Pubs/pdf/11135-prescription-drug-coverage-with-ma-mcp.pdf | Last accessed June 2021
https://www.dhs.wisconsin.gov/benefit-specialists/medicare-counseling.htm | Last accessed June 2021
https://www.dhs.wisconsin.gov/publications/p0/p00166.pdf | Last accessed June 2021
https://www.kenoshacounty.org/209/Medicare | Last accessed June 2021
https://www.newcommunityclinic.org/programs/health-benefit-access | Last accessed June 2021
Roseann Birch, Medicare Consultant
With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.
Leron Moore, Medicare Consultant
With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.