Medicare Advantage (MA) plans are offered by private insurance companies and usually provide more well-rounded coverage than Original Medicare. Thanks to increased benefits and plan offerings, the program has grown significantly over the past decade. Over 30 million people had an Advantage plan in 2023, accounting for over one-half of all eligible Medicare beneficiaries. Keep reading to learn more about Medicare Advantage plans in Wisconsin and how to compare your options.
What is Medicare Advantage in Wisconsin?
Also known as Medicare Part C, every Advantage plan provides – at a minimum – the same benefits you get with Original Medicare. This includes:
- Medicare Part A: Inpatient services received in a hospital or skilled nursing facility (SNF) and hospice care
- Medicare Part B: Outpatient services such as doctor visits, lab work, urgent care, and durable medical equipment (DME)
Original Medicare does not include prescription drug coverage. Those benefits are part of Medicare Part D.
One reason for Medicare Advantage's growing popularity is the fact that over 90% of plans cover services beyond what you get with Parts A and B.
Wisconsin Medicare Advantage plans with prescription drug coverage
Medicare Advantage Prescription Drug plans (MA-PD) combine your Medicare Parts A, B, and D benefits. In addition to prescriptions, most MA plans cover at least one of the following:
- Fitness programs like SilverSneakers
- Hearing aids
- Routine dental care, such as cleanings and x-rays
- Routine vision care, including eye exams and prescription lenses
Even if you join an Advantage plan, you're still responsible for the Medicare Part B premium.
Who is eligible for Medicare Advantage in Wisconsin?
Medicare Advantage plans are available to Wisconsinites who have Medicare Parts A and B.
If you are an American citizen or permanent legal resident who has lived here for at least 5 years, you qualify for Medicare on your 65th birthday. Enrollment in Parts A and B is only automatic for those who began collecting Social Security benefits at least 4 months before turning 65. Everyone else must apply for Medicare online.
You also qualify for Medicare if you collect Railroad Retirement Board (RRB) or Social Security disability benefits for 24 months. Enrollment occurs automatically during your 25th month of disability.
When can you sign up for a Medicare Advantage plan in Wisconsin?
Medicare restricts plan enrollment to certain times.
The first is your Initial Enrollment Period (IEP), which begins 3 months before you become eligible for Medicare and lasts for 7 months. So, if your 65th birthday or 25th month of collecting RRB or Social Security disability occurs in June, then your IEP runs from March 1 to September 30. If your birthday is on the first of the month, though, you need to move those dates ahead by one month (February 1 through August 31 if your birthday is June 1).
If you don't sign up for Medicare Part A and/or Part B during your IEP, you may do so during the General Enrollment Period between January 1 and March 31. Then, from April 1 through June 30, you can join a Medicare Advantage plan.
Current beneficiaries can take part in the Medicare Annual Enrollment Period (AEP) from October 15 through December 7. You may join an Advantage plan or make any other coverage change you want during AEP.
If you're already enrolled in Medicare Part C, you can change your plan during the Medicare Advantage Open Enrollment Period. Your second option is returning to Original Medicare. You can also sign up for a standalone Medicare Part D plan if you lose your coverage after making one of those changes.
Finally, Special Enrollment Periods allow people who experience certain life changes to join an Advantage plan. There are dozens of ways to qualify for an SEP. Find the full list here.
Types of Medicare Advantages plans in Wisconsin
There are four main types of Medicare Advantage plans in Wisconsin. Health maintenance organizations (HMOs) are the most common, accounting for more than half of all MA plans. HMOs have provider networks that may include pretty much any entity you rely on for healthcare services:
- Durable medical equipment
- Medical clinics
- Nurse practitioners
- Nursing homes
- Urgent care centers
Unless it's an emergency, HMO plans rarely cover out-of-network care. HMO plan members also need to choose a primary care physician and get a referral to see a specialist.
Like HMOs, preferred provider organizations (PPOs) also have networks. However, enrollees may go to an out-of-network provider for a higher copay. PPO plans do not require members to choose a primary doctor. They also don't need a referral to see a specialist.
Private fee-for service plans (PFFS) determine how much the plan and its members will pay for covered services. Like PPOs, if your PFFS plan has a provider network, you can go out-of-network for a higher copay.
Special needs plans (SNPs) limit membership to people in certain populations. To join an SNP, one of the following must apply to you:
- Are eligible for both Medicare and Medicaid
- Have a chronic condition, such as diabetes, ESRD, or HIV/AIDS
- Live in an institution, such as a nursing home, or require in-home care
SNP services are tailored to meet the needs of the plan's members. This includes specialists and covered prescriptions if it's an MA-PD plan.
How to choose a Medicare Advantage plan in Wisconsin
To get the best Advantage plan for your unique needs, consider the following:
- Costs: May include a yearly deductible, monthly premiums, and copays or coinsurance that you pay at the time of service.
- Coverage: Covered services help put the plan's costs into perspective. They also vary widely, so look carefully at what each plan offers to be sure you're comparing apples to apples. If it's an MA-PD plan, don't forget to review the drug formulary. This is the list of covered medications. If it doesn't include yours, keep looking until you find a plan that does.
- Network: Some people prefer an Advantage plan that covers their providers, particularly if they have preexisting conditions.
- Ratings: Medicare rates plans on a 5-point scale and releases their findings every year before Annual Enrollment.
Our Find a Plan tool makes comparing Medicare Advantage plans in Wisconsin easy. Just enter your location information to review the Medicare plan options in your area.
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