Medicare Advantage (Part C) replaces Original Medicare and must provide at least the same Part A and B benefits as Original Medicare.
Medicare Advantage plans often include additional services like dental, vision, hearing and prescription drug coverage.
There are several types of Medicare Advantage plans in Wisconsin. You can choose from HMOs, PPOs, Fee-for-Service and other types of plans.
Your Medicare Advantage costs will depend on your plan, where you live and other factors.
A key benefit of many Medicare Advantage plans is an out-of-pocket maximum; after you reach this spending limit, your plan will pick up the rest of your medical costs for the year.
As residents of the nation’s top cheese-producing state, Wisconsonites know a thing or two about aging well. And thanks to several top-notch Medicare choices in The Badger State, that isn’t limited to curds and cheddar. If you or a loved one are Medicare-eligible, or nearing eligibility, Medicare Advantage plans in Wisconsin are a choice to consider. Also called Part C, many of these plans offer benefits that the more-traditional Original Medicare doesn’t, and some are even more cost-effective. How do Medicare Advantage plans in Wisconsin work? How are they different from Original Medicare, and how much does Part C cost?
If you live in Wisconsin, here’s your guide to Medicare Advantage.
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One main point to understand about all Medicare Advantage plans in Wisconsin: They must offer at least the same coverage as Original Medicare.
What does that mean?
Original Medicare is made up of Medicare Part A and Medicare Part B. Part A, also called hospital insurance, helps pay for many inpatient services that are received at a hospital or other approved medical facilities. Part B, or medical insurance, helps cover medical services like doctor visits, therapies and lab work. Durable medical equipment like wheelchairs and other devices are also partially covered by Part B. To help limit the number of medical services you need each year, Original Medicare fully covers several approved preventive services. These parts provide the minimum framework for coverage that all Medicare plans must follow, including Medicare Advantage.
Original Medicare does not cover dental, vision or hearing, and you’ll need to purchase these coverages separately. Prescription drugs are also not included, and you’ll need to enroll in a Medicare Prescription Drug Plan (Part D) if you’re on medications. Like dental, vision and hearing, you’ll pay for Part D separately.
Medicare Advantage plans replace Original Medicare (Part A and B) but offer the same Part A and B benefits or coverage as Original Medicare. As we’ve discussed, you’ll have at least the same access to inpatient, outpatient and preventive care. Along with receiving Part A and B benefits, Medicare Advantage plans in Wisconsin also often bundle additional benefits including dental, hearing, vision and prescription drug coverage.
The average monthly premium for a Medicare Advantage plan in Wisconsin is $27.28 in 2023, but all residents eligible for Medicare have access to at least one $0 plan.
How are doctors covered by Medicare Advantage plans in Wisconsin?
The coverage depends on the type of Medicare Advantage plan you have. Medicare Advantage plans use primary care physicians (PCP) and provider networks to manage your care. Provider networks are groups of doctors and other providers that have signed a contract to treat a health insurance company’s customers. The doctors agree to receive fixed rates for their services in return for more patients from the insurers. These networks are based on location. Depending on the type of Medicare Advantage plan you have, seeing a doctor or provider outside your network is often more expensive or reserved for emergencies.
Here are four common types of Medicare Advantage plans in Wisconsin:
- Health Maintenance Organization (HMO): HMO plans rely on a PCP to manage your care. The care includes providing referrals to other in-network doctors when you need specialized services.
- Preferred Provider Organization (PPO): PPO plans use a PCP to manage your care. But unlike HMOs, you have more freedom to see in- and out-of-network doctors without a referral from your PCP.
- Private Fee-for-Services (PFFS): PFFS policies pay your doctors and providers for every service you receive. You don’t need a PCP but may have a provider network. Out-of-network benefits are typically allowed but are more expensive than in-network care.
- Special Needs Plans (SNP): SNPs are condition-specific plans designed for beneficiaries with certain diseases or conditions. D-SNP is for people who are dual-eligible; C-SNP helps beneficiaries with certain chronic illnesses.
Medicare Advantage plans in Wisconsin don’t have to charge standardized rates like Original Medicare. Instead, what you’ll pay for healthcare each year depends on which plan you choose and, of course, your specific medical needs. To give you an idea of what charges will go into your bottom line, here are the standard costs you can expect to see with Medicare Advantage plans in Wisconsin:
Premium: Premiums are what you pay each month for your plan. A premium can vary greatly; some Medicare Advantage plans in Wisconsin have no-cost premiums, while others charge the standard Part B (and Part A, if you have one) premium and more.
Deductible: Your plan’s deductible is the limit you must pay before your coverage kicks in. Deductibles vary by plan; like the premium, insurers have leeway in what they can charge, with some offering no-cost deductibles for medical and prescription drug coverage. Others may charge the standard deductibles from Parts A and B or more.
Copayments and coinsurance: Copayments, or copays, are what Medicare Advantage beneficiaries pay out-of-pocket for most of their care. Copays are flat-rate payments, and you may have different copayment amounts for your doctor and specialists. Some plans may charge coinsurance for some services; this is a percentage-based payment that you share with your plan. For example, some Medicare Advantage plans may pay 80% for various services, while you pay the remaining 20% coinsurance.
Out-of-Pocket Maximum: Medicare Advantage plans in Wisconsin often cover your costs for the year once you surpass the out-of-pocket maximum (OOPM). The out-of-pocket maximum is a crucial difference from Original Medicare, which does not have an OOPM.
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Who is eligible to enroll in Medicare Advantage plans in Wisconsin? To sign up for Part C, you must be a legal U.S. citizen or have been a legal resident for at least five years. One of the following must also be true:
- You’re 65 years old or older.
- You’ve received disability-based benefits from Social Security or the Railroad Retirement Board (RRB) for more than 24 months.
- You’re living with end-stage renal disease.
- You’ve been diagnosed with Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s Disease.
Medicare Advantage plans in Wisconsin: When to enroll
Medicare provides certain times each year when you can make changes to your plan, whether you’re first signing up or want to switch to another Medicare Advantage plan. You can even drop your Part C plan and re-enroll in Original Medicare. Here are the timeframes when you or a loved one can enroll in Medicare Advantage plans in Wisconsin:
Initial Enrollment Period: When you first enroll, it includes the month you turn 65, plus three months before and after. Once you’re enrolled in Parts A and B, you can make the switch and enroll in a Medicare Advantage plan.
Medicare Open Enrollment Period: If you don’t switch to Part C during your IEP, you can choose a plan during the next open enrollment period. Held each year from October 15 to December 7 and also known as the Annual Enrollment Period, it allows you to make changes that go into effect January 1.
Special Enrollment Periods: You may need to make changes to your coverage outside of the enrollment periods above. If so, you may qualify for a Special Enrollment Period — these are enrollment windows that open for certain life events. If you move or lose other coverage, you may be eligible for a special enrollment period.
Yes, there are many Medicare Advantage plans in Wisconsin that include prescription drug coverage. These benefits in your policy mean you won’t have to enroll separately or pay a premium for just prescription drug coverage. To choose a plan that covers the prescriptions you need, you’ll want to make sure your insurance company’s drug formulary includes your medications. A drug formulary is a list of all the drugs covered by your plan. Each drug is placed into one of several tiers; medications placed on the higher tiers are typically name brand or specialty drugs and cost more than generics and common drugs found on the lower tiers.
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