Medicare Advantage Plans in Wisconsin

Written by:

Aaron Garcia

Reviewed by:

Kai Martinez

Key Takeaways

Medicare AdvantageMedicare Advantage (Medicare Part C) is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D). (Part C) substitutes for Original MedicareOriginal Medicare is a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance). 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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Wisconsin Medicare Advantage Plan Coverage

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 not included, and you’ll need to enroll in a Medicare Part D prescription drug plan (Part D) for medications. Like dental, vision, and hearing, you’ll pay for Part D separately.

Medicare Advantage plans substitute for Original Medicare (Part A and B), offering the same Part A and B benefits. Medicare Advantage plans often bundle additional benefits including dental, hearing, vision, and prescription drug coverage.

The average monthly premium for a Medicare Advantage plan in Wisconsin is $26.15 in 2024, 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.

WI Medicare Advantage Plan Costs

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 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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Medicare Advantage Plan Eligibility and Enrollment in Wisconsin

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.

Are There Wisconsin Medicare Advantage Plans With Prescription Drug Coverage?

Most Medicare Advantage plans 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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Sources

FACT SHEET. CMS.gov.

This website is operated by GoHealth, LLC., a licensed health insurance company. The website and its contents are for informational and educational purposes; helping people understand Medicare in a simple way. The purpose of this website is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our mission is to help every American get better health insurance and save money.

Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

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