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When you reach age 65 in Wisconsin, you become eligible for Medicare, the federal government’s health insurance program for those 65 and older. If you have certain qualifying conditions, like as a qualifying disability, you may be eligible for coverage prior to turning 65.

More than 20% of Wisconsin’s population is enrolled in Medicare as of July 2020. Medicare enrollment becomes a concern for people who reach retirement. However, Medicare also covers Americans under the age of 65 who are incapacitated and receiving disability benefits, as well as those with end-stage renal disease or amyotrophic lateral sclerosis. The percentage of Medicare recipients under the age of 65 is 15% nationwide and 14% in Wisconsin.

With healthcare costs surging every year, you need to make sure you keep your expenses low while getting the care you need. Find out more about different Medicare plans in Wisconsin and learn why you need the services of a licensed Medicare insurance agent.

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Medicare Options in Wisconsin

Original Medicare

Once a person reaches the Medicare eligibility age of 65, they are automatically registered in the original Medicare program. Parts A and B of Original Medicare are the federally funded health insurance program for the elderly and disabled. It takes care of all your fundamental medical expenses.

Part A covers hospital care. All hospitalizations, rehabilitation stays, and certain home healthcare fall under this category. Part B includes preventative care like checkups and immunizations, diagnostic procedures like X-rays and blood tests, long-term care like hospitalizations and oxygen tanks, and emergency services like ambulance rides.

Medicare Supplement (Medigap) Plans in Wisconsin

After Original Medicare (Parts A and B) pays its share for covered services, you will be responsible for paying any remaining costs (such as deductibles, copayments, and coinsurance). This can add up to a significant sum over the course of a year, especially if you have a preexisting condition or often use a variety of medical services.

This is where Medicare Supplement or Medigap plans step in to fill that gap. Medicare Supplement or Medigap plansin Wisconsin help you pay for medical expenses that are not fully covered by Original Medicare. These plans are provided by private companies that contract with Medicare.


A senior couple.

However, it is important to note that Wisconsin’s Medicare Supplement coverage is not standardized the same as the ten plans offered in most states. This state’s program offers a Basic Plan with add-ons called “riders”. Insurance companies offering Medigap policies are obligated by state law to provide certain benefits beyond those provided by the primary (Part A) plans. Here’s more on these plans:

Basic Plan

The Basic Plan includes not only the federally mandated benefits including Medicare Part A coinsurance for skilled nursing facilities, but also covers preventive services. It provides 175 days of psychiatric inpatient coverage beyond what Medicare provides. The Basic Plan includes 40 home health care sessions in addition to what Medicare offers.

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Medicare SELECT or Cost-Sharing Riders

When you enroll in one of these plans, you’ll pay a deductible and then a percentage of the cost of covered benefits, up to an out-of-pocket maximum. The plans cover the Part A deductible, supplemental home health care, the Part B deductible and additional charges, and medical emergencies when traveling overseas.

For 2022, the maximum out-of-pocket expense for a 25% cost-sharing plan in Wisconsin is $3,310, and the maximum for a 50% cost-sharing plan is $6,620. Every year, the CMS publishes updated projections for the out-of-pocket maximums that apply to Medicare Supplement and Medicare SELECT cost-sharing programs.

Medigap in Wisconsin for Beneficiaries Under 65

Wisconsin is one of the many states that mandates Medigap coverage for anyone under the age of 65. However, the costs are significantly more than what seniors pay. These beneficiaries can gain additional protection from Medicare Advantage programs. Special Needs Plans (SNPs) are a type of Medicare Advantage plan designed to meet the needs of those with disabilities and serious health conditions.

Medicare Part D

Medicare recipients who do not qualify for Medicaid or who do not have access to drug coverage through their employers must enroll in Medicare Part D. The Medicare Modernization Act of 2003 established Medicare Part D, which can be purchased either independently or as part of a Medicare Advantage plan that includes Part D coverage.

The “donut hole”, or coverage gap, is a common feature of Medicare Part D PDPs. Once your plan has paid a specific amount for covered medication, you can enter what is called a “coverage gap” during which time you are responsible for paying the full retail price of your medications.

In 2022, the coverage gap threshold becomes applicable after your plan has spent $4,430. When you reach the donut hole, your out-of-pocket costs for prescription pharmaceuticals will be capped at 25% and you may be eligible for a discount on generic medicines. 


Medicare Advantage Plans in Wisconsin

Medicare Advantage plans are provided by private companies that contract with Medicare and offer the same coverage as Original Medicare. The market for Medicare Advantage in Wisconsin is thriving. Private Medicare enrollment in Wisconsin reached 1,236,425 by January 2022.

Medicare Advantage plans varies across states, and in some cases, the deductibles and copayments/coinsurance amounts of your plan may not apply to the Wisconsin Medicare supplement policies. The Wisconsin Office of the Commissioner of Insurance (OCI) does not oversee Medicare Advantage plans. Your plan is not guaranteed permanently renewable like Medicare Supplement policies, and it is not required to include Wisconsin mandated coverage.

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There are four types of Medicare Advantage plans in Wisconsin:

Health Maintenance Organization (HMO)

Most HMOs mandate that you use only in-network providers for all healthcare services:

  • You must have a PCP (primary care physician), specialist referrals, and prior approvals for certain procedures and prescriptions.
  • Plans typically provide drug coverage. You can’t purchase separate drug coverage.
  • Staying within your network keeps costs low.

Preferred Provider Organization (PPO)

Medicare PPO plans have a recommended network of providers, but you can also choose doctors or hospitals outside the network for a higher price.

  • You don’t need to have a PCP or referrals for specialists.
  • Most plans provide drug coverage.
  • Drug coverage cannot be purchased separately.
  • Out-of-network charges and higher premiums.

Private Fee-For-Service (PFFS)

PCPs and specialist referrals aren’t necessary under PFFS programs:

  • You can consult any Medicare-approved doctor or healthcare facility, provided that they agree to the plan’s terms.

  • Drug coverage may be included, or you can purchase a separate drug plan.

  • You’ll pay more if you go with a provider who doesn’t agree with the rules of your insurance plan.

Special Needs Plan (SNP)

SNPs are only available to people with certain medical conditions, and they feature care coordination and benefits that are specifically designed to match their specific needs:

  • You require a PCP and recommendations for specialists.
  • Plans always include prescription coverage.
  • SNPs are open to everyone who meets the eligibility criteria at any point in time.


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Comparing Medicare Advantage Plans in Wisconsin

Every county in Wisconsin offers at least 11 different Medicare Advantage plans, and several offer more than 20. Waukesha and Brown counties have 47 Part C plans available. With all the options on the market, you need to make sure you’re picking a plan that fits your individual requirements and budget.

Here are some factors to consider while weighing your options:

Provider Network

Depending on your Medicare Advantage plan, the network of doctors and hospitals you can visit may be geographically limited. Consider enrolling in Original Medicare with a Medigap plan and Part D coverage if you have concerns about the size of the provider network or if you intend to do a lot of traveling within the country during retirement.

Even if you have a specific insurer in mind, it’s still a good idea to compare your choices before committing to a plan. Some Medicare Advantage programs have contracts with physicians who aren’t in the regular Medicare network.

Perks and Benefits

Do you need a plan that also includes health insurance, a retirement savings account, and a gym membership? These are typically covered under Medicare Advantage plans but are not by Medigap policies. To find the best Medicare plan for your needs, talk to a licensed Medicare insurance agent in Wisconsin.

Plan Ratings

Medicare Part C and Part D plans can be compared on the CMS website, so make sure you check those before enrollment begins.

Out-of-Pocket Expenses

Enrollees are responsible for covering their own “out-of-pocket costs” which include things like deductibles, copayments, and coinsurance. Using a provider network helps keep these costs down. You can use our plan finder tool to compare costs among available options.

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Monthly Premium

Your monthly cash flow will increase by the amount of your Medicare Advantage or Supplement plan premium, so you need to find a way to keep this expense down. Even if you don’t use your benefits, you still have to pay these costs. It is helpful to have access to at least one zero-premium plan that provides reasonable prescription coverage in your area.

Drug Coverage

Look into Medicare Part C programs if you need help paying for your prescriptions. Prescription drug coverage, known as Part D, is typically bundled with Medicare Advantage plans. Medicare Part D is optional, but highly recommended, if you opt for Original Medicare and a Medigap policy.

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Deductibles, Coinsurance & Copays

After you enroll in Medicare and begin receiving benefits, you will start paying these expenses. Therefore, you should be familiar with the hospital and medical coverage provided by your plan. This includes costs associated with doctor visits, prescriptions, and other medical care.

Freedom to Travel

When compared to Original Medicare’s minimal coverage of overseas travel, most Medigap insurance do offer adequate foreign travel coverage. Medicare Advantage insurance, unlike Medigap policies, varies across providers, so it’s important to compare prices and benefits before booking a trip abroad. You should read the plan’s overseas coverage details or discuss them with a Wisconsin Medicare insurance agent before signing up.

Medicare Eligibility in Wisconsin

Medicare enrollment is open to all qualifying Wisconsin residents. Patients of chronic or incurable conditions, such as end-stage renal disease (ESRD) and amyotrophic lateral sclerosis (ALS), can also enroll for Medicare at any point in their lives.


Medicare Enrollment in Wisconsin

You will be automatically enrolled in Medicare if you have received at least four Social Security or Railroad Retirement Board payments before turning 65. Otherwise, you can apply for Social Security at your local office or apply online.

Medicare enrollment is available during the following periods:

Initial Enrollment

The IEP runs from three months before your 65th birthday to three months after it. People who are eligible for Medicare but have never enrolled previously should apply during this period. You can also change or improve your Medicare coverage if you began receiving benefits at an earlier age.

General Enrollment

For those who were not able to enroll during the initial window, a second window opens up on January 1 and closes on March 31. Parts A and B of Original Medicare, Medicare Advantage, a Medigap coverage, and Medicare Part D are all available for enrollment during this time.

Open Enrollment

You can make changes to your Medicare Part C plan over the three months beginning on October 15 and ending on December 7.

Special Enrollment

If you experience a change in your coverage or eligibility due to a life event, such as the loss of your employment or a move to an area not covered by your plan, you may be eligible for a special enrollment period.

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Why Should You Choose Medicare Hope Insurance Agents?

Integrity Now Insurance Brokers ensures that all of their Medicare insurance brokers renew their AHIP certification on annually. Our team is well-versed in Medicare Insurance and can help you with any questions or problems you may have. We serve individuals of all ages, from the elderly to the disabled youth, who are having trouble affording the medical care they need.

Every year, new Medicare health insurance providers and plans enter the market, increasing the variety of choices available to consumers. Plans that are already in place might be updated or revised as well. We are here to help you keep track of these changes and find the right plan for you.

Simply tell us your financial and individual requirements, any goals you want to achieve with your plan, and we’ll find a plan that fits your objectives. Our client-specific offerings are what make us special. We’ll help you compare quotes to find the most affordable plan that carries all the benefits you need.

Get in touch with us today, and we’ll connect you with a Medicare insurance agent in Wisconsin who can help you get started right away.

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