- In 2019, there were 97 Medicare Advantage Plans available in Wisconsin.
- 40% of the total Medicare population in Wisconsin is enrolled in Medicare Advantage Plans as of 2018.
- In 2018, Original Medicare spent an average of $8,763 per beneficiary in Wisconsin, which is 13% lower than the national average.
- Available Medicare Advantage Plans range from 11 to 47 across Wisconsin’s 72 counties.
You can only select a Medicare Advantage Plan available in your county in Wisconsin, even if you prefer a plan from the county next door. The Medicare Advantage Plan you choose will impact your out-of-pocket costs for premiums, copays and deductibles. It helps to draw up a current list of your medical expenses, including medications, to help you narrow down your choices.
Medicare Advantage Plans in Wisconsin
Types of Medicare Advantage Plans
You can select from one of four different Medicare Advantage Plans in Wisconsin. Each plan offers different benefits, restrictions, and coverage. Select the one that best suits your health care needs and your financial situation. Keep in mind, when browsing through Wisconsin’s Medicare Advantage program, that you can only select an option available in your county.
Health Maintenance Organizations (HMO)
If you’ve ever had employer-covered healthcare, you probably understand how an HMO works — Medicare Advantage HMOs are very similar. You must use the plan’s in-network providers, select a primary care physician, and obtain referrals to see specialists. Many HMO plans are among the least expensive Medicare Advantage Plans available. Many Medicare Advantage HMO plans include prescription drug coverage, but not all do.
Preferred Provider Organizations (PPO)
Medicare Advantage PPOs offer more flexibility but are also more expensive. Medicare Advantage PPOs allow you to see out-of-network providers. You won’t need to choose a primary care physician nor obtain referrals. You can use the PPO in-network providers if you want to reduce your health care costs but keep open the option of seeing an out-of-network provider. Many PPO plans offer prescription drug plans and benefits like vision, dental care, and access to fitness and hearing programs.
Private Fee-For-Service Plans (PFFS)
A Medicare Advantage PFFS offers the most flexibility of any Medicare Advantage Plan but with some restrictions. With a PFFS, the health care company decides how much it, and you, will pay for your coverage. You are free to use any health care provider who is willing to accept your plan. However, not every provider will accept it. (All providers must take a PFFS plan in an emergency.) Most PFFS plans offer prescription drug coverage.
Special Needs Plans (SNP)
SNPs are designed to best suit the needs of a specific group or those suffering from a particular illness, such as cancer, AIDS, or End Stage Renal Disease (ESRD). These SNPs are also limited to people who are eligible for Medicare and Medicaid or who live in an adult care facility or a nursing home. SNPs require you to select a primary care physician and obtain a referral to see a specialist. All SNPs offer some type of prescription drug coverage.
Enrollment and eligibility For Medicare Advantage Plans in Wisconsin
To qualify for Medicare Advantage in Wisconsin, you must be at least 65 years of age or suffer from a disability. You need to be a U.S. citizen or a permanent resident for the past five years. You must be enrolled in Original Medicare’s Part A and Part B but not in Medicare Supplemental Insurance (Medigap).
- Initial Enrollment begins three months before you turn 65 and continues for the month you turn 65 and three months after your 65th birthday.
- The Open Enrollment period takes place annually between October 15-December 7. You can move from Original Medicare to a Medicare Advantage Plan or return from a Medicare Advantage Plan to Original Medicare. You can switch to a new Medicare Advantage Plan if you are unhappy with your current one.
- The Medicare Advantage Open Enrollment period is from January 1 to March 31. You can change Medicare Advantage Plans. You can also return to Original Medicare, but you can’t select a Medicare Advantage Plan if you’re currently on Original Medicare. If you have not signed up for Medicare Part B in the past, you can during this period and then select a Medicare Advantage Plan between April 1 and June 30 with coverage starting on July 1.
- You are eligible for Special Enrollment if you change or lose your job or move your coverage area.
If you’re covered by your employer’s or spouse’s health care insurance when you turn 65, you do not need to select Original Medicare or a Medicare Advantage Plan. You have eight months after that insurance ends to select Medicare or a Medicare Advantage Plan.
Prescription drug coverage
The cost of prescription medication can make a huge dent in your retirement income. It’s important you understand if your Medicare Advantage Plan pays for prescription drugs.
- Many HMO and PPO plans include prescription drug coverage (Medicare Part D). Some plans add this cost to monthly fees, or you may be required to pay a separate premium.
- HMO and PPO plans that don’t include prescription drug coverage forbid members from purchasing a separate prescription drug plan. HMOs and PPOs will expel you if you do this and return you to Original Medicare.
- Most PFFS plans include prescription drug coverage, but if your plan doesn’t, you can purchase a separate prescription drug plan.
- Legally, SNP’s must provide prescription drug coverage.
Medicare Advantage Resources in Wisconsin
When you select a Medicare Advantage Plan, it should be both affordable and appropriate for your health care needs. For seniors, their families, or caregivers trying to choose the proper Medicare Advantage Plan from all the options available, it can be confusing and frustrating. Fortunately, Wisconsin has numerous state and community organizations willing to provide free counseling on selecting the appropriate plan.
Wisconsin Regional Area Agencies on Aging (AAA)
Established by the federal government in 1973, the Area Agencies on Aging exist to help seniors across the country and Wisconsin. The AAA develops plans to help plug service gaps for seniors, advocate for their needs, and provide numerous resources and counseling on issues like health care, access to resources in the community, and helping seniors live independent lives.
Contact Information: Website | 608-266-1865
Wisconsin Office of the Commissioner of Insurance
The Office of the Commissioner of Insurance provides free expert advice on healthcare. This includes providing information about Original Medicare, Medicare Advantage, prescription drug plans, and Supplemental Medicare Insurance plans available in Wisconsin. Counseling is provided free of charge to seniors, their families, or their caregivers.
Contact Information: Website | 608-266-3585
Wisconsin State Health Insurance Assistance Program (SHIP)
The Wisconsin SHIP program provides counseling and education about health care choices in Wisconsin. The program’s trained, experienced counselors also provide enrollment assistance to Medicare eligible seniors in the state. All counseling is provided free of charge to seniors, their families, or their caregivers.
Contact Information: Website | 800-242-1060
Wisconsin Aging and Disability Resource Centers (ADRC)
The Wisconsin ADRC connects seniors, their families, or caregivers to important resources in their communities such as in-home personal care and nursing, transportation options, home-delivered meals, and advice on Medicare, Medicaid and Social Security.
Contact Information: Website | 608-266-1865
Learn More from Our Sources
- Medicare | What Part A covers | Last accessed June 2021
- Medicare | What Part B covers | Last accessed June 2021
- Medicare Advantage | Health Maintenance Organizations (HMO) | Last accessed June 2021
- Medicare Advantage | Preferred Provider Organizations (PPO) | Last accessed June 2021
- Medicare Advantage | Private Fee-for-Service Plans (PFFS) | Last accessed June 2021
- Medicare Advantage |Special Needs Plans (SNP) | Last accessed June 2021
- Medicare Advantage |Who can join a Medicare Advantage Plan | Last accessed June 2021
- Medicare | Joining a health or drug plan\ | Last accessed June 2021
- Medicare | What’s Medicare Supplement Insurance (Medigap)? | Last accessed June 2021
- Medicare | Part D | Last accessed June 2021
- Medicare Advantage | Special Circumstances (Special Enrollment Periods) | Last accessed June 2021
- Medicare Advantage |Are prescription drugs covered in Medicare Advantage Plans? | Last accessed June 2021