When you turn 65, you can get health insurance through the federal government with Medicare plans in Wisconsin. You may also be able to get coverage before you turn 65 if you meet certain qualifications, such as living with certain disabilities.
Coverage falls into four categories:
Original Medicare covers hospital inpatient care and outpatient services. Everyone who gets a Medicare plan must enroll in Part A and Part B.
Part A (hospital inpatient care)
Part A provides coverage for care in hospitals and hospices. It also provides some coverage for care in critical access hospitals, skilled nursing facilities (SNF), and home health care.
If you or a spouse worked in a job where you paid Medicare taxes for at least 10 years, you won’t need to pay a premium for Part A.
If you don’t qualify for premium-free Part A, you can purchase it.
With Part A, you’ll be responsible for paying a deductible for each hospital stay.
Part B (outpatient and preventive care)
Part B provides coverage for care outside a hospital, including:
- doctor visits
- preventive care
- lab tests
- durable medical equipment
Part B has a monthly premium and an annual deductible. Once the deductible is met, you’ll also be responsible for 20 percent coinsurance toward the cost of your care.
Part D (prescription drugs)
Prescription drug coverage is available through a private insurer. This is referred to as Part D.
You can purchase Part D separately with Medicare, or get a Medicare Advantage plan that includes Part D.
There are three types of Medicare supplemental plans available with original Medicare in Wisconsin:
- Medigap. Helps cover costs for parts A and B. Some plans have higher cost-sharing, higher deductibles, or out-of-pocket maximums. You can use Medigap with in- and out-of-network providers.
- Medicare SELECT. Supplemental insurance that covers Parts A and B costs as long as you go to a provider in the plan’s network.
- Medicare Cost. Basic and enhanced policy options to pay for your costs. Plans include a provider network and are only available if you live in the plan’s area.
Part C (Medicare Advantage)
Medicare Advantage plans are available through private insurers with all your benefits bundled into a single plan.
Medicare Advantage offers plans through private insurance carriers. These plans bundle together the benefits of parts A and B. Most Medicare Advantage plans also include prescription drug coverage (Part D), and some include:
- home meal delivery
- wellness perks
- transportation to appointments
Medicare Advantage plans also often have an out-of-pocket maximum, meaning you pay a deductible and coinsurance up to the maximum, then the plan covers your costs for the rest of the year. Original Medicare does not have an out-of-pocket max.
There are 16 carriers that offer Medicare Advantage plans in Wisconsin:
- Aetna Life Insurance
- Anthem Insurance
- Care Improvement Plus Wisconsin Insurance
- Care Wisconsin Health Plan
- Comp-Care Health Services Insurance
- Dean Health Plan
- Humana Insurance
- Independent Care Health Plan
- Managed Health Services Wisconsin
- Medica Insurance
- Medical Associates Clinic Health Plan
- Network Health Insurance
- Quartz Health Plan
- Security Health Plan of Wisconsin
- Sierra Health and Life Insurance
- UnitedHealthcare of Wisconsin
The available choices for your plan will vary depending on the county where you live.
Types of Medicare Advantage plans
In addition to choosing a carrier, there are also several different types of Medicare Advantage plans available in Wisconsin.
- Health maintenance organization (HMO). A primary care physician (PCP) you choose coordinates care and refers you to specialists within the network. Care outside the network isn’t covered except in an emergency. To avoid unexpected expenses, follow all the plan rules carefully.
- Point of service (POS). Get care from a network of hospitals, doctors, and facilities that the plan covers. POS care outside of the network is available, but costs more. You may also need a referral from your PCP for out-of-network care.
- Preferred provider plan (PPP). Benefits are covered when you use the plan’s network of providers. Some out-of-network care may be covered, but will cost more. Providers within the network are often limited to certain geographic areas.
- Private fee-for-service (PFFS). You can go to any Medicare-approved doctor who accepts the PFFS plan. Coverage and payment terms are negotiated between the provider and plan. Not all doctors and facilities accept PFFS plans.
- Medicare medical savings account (MSA). A high-deductible health insurance policy that covers Parts A and B, and a savings account to pay for approved medical costs. Medicare deposits a certain amount into your MSA each year. Deductibles can be very high and the amount deposited may not cover it all.
- Special needs plan (SNP). Available if you need coordinated care or care management because you have chronic or disabling conditions, such as diabetes or kidney failure (ESRD), or are eligible for Medicare and Medicaid (“dual-eligible”).
You’re eligible for Medicare in Wisconsin when you turn 65 if you are a U.S. citizen or legal resident for five or more years. You may also be eligible if you are under 65 and:
- have ESRD or a kidney transplant
- received Social Security (SSDI) or Railroad Retirement benefits for 24 months
- have Lou Gehrig’s disease (ALS)
Initial enrollment period (IEP)
You can enroll in Medicare for the first time up to three months before you turn 65, and coverage begins the first day of that month. You can also enroll during, or three months after, your birthday month, but there is a delay before coverage begins.
If you decide to enroll in a Medicare Advantage plan, you’ll still need to first enroll in parts A and B when you become eligible for Medicare, and pay the Part B premium.
You can then choose if you want a Part C plan.
Special enrollment period (SEP)
In some special circumstances you can enroll in Medicare outside the normal periods. Examples of circumstances that may allow you to qualify include losing an employer-sponsored plan or moving out of your plan’s service area.
Annual election period
During the annual election period, you can make changes to your current plan or switch between original Medicare and Medicare Advantage.
In 2020, the annual election period is from October 15 to December 7.
General enrollment period
If you didn’t enroll in Medicare during your initial enrollment period, you can enroll in Medicare parts A, B, or D during the general enrollment period. There may be a penalty for late enrollment.
The general enrollment period is from January 1 to March 21.
Medicare Advantage open enrollment
You can switch from original Medicare to a Medicare Advantage plan during Medicare Advantage open enrollment. You can also switch from a Medicare Advantage plan back to original Medicare during this time.
Medicare Advantage open enrollment is from January 1 to March 21.
You can enroll online, by phone (800-772-1213 or TTY 800-325-0778), or in person for Medicare Wisconsin. Carefully review all the available plans to make sure they:
- cover the care you need
- include doctors and facilities in their network that you want to use
- have affordable premiums, deductibles, and out-of-pocket maximums
- are rated highly for patient satisfaction and quality
When you are ready to sign up for Medicare in Wisconsin:
- compare plans to get the right coverage and affordable costs
- identify your enrollment period and mark your calendar to avoid missing a deadline
- contact the Wisconsin SHIP with any questions