Medicare is a popular health insurance plan introduced by federal government for U.S. citizens, as well as permanent legal residents of at least five continuous years of age 65 years or older. This plan is also available to individuals under 65 years of age with qualifying disabilities. Around 1.15 million residents of Wisconsin are enrolled in Medicare and fifteen percent Medicare enrollees are under 65 years of age and qualify for Medicare due to disability. The total Medicare enrollees in the state is nearly 20% of the state’s population enrolled in Medicare plans. Nearly 44% of the state’s Medicare population are enrolled in private Medicare coverage. Medicare beneficiaries in Wisconsin get automatically enrolled at the age of 65, if they have been receiving retirement benefits either through the Social Security Administration (SSA) or the Railroad Retirement Board (RRB). Differently abled people under the age of 65 receiving disability benefits or certain RRB disability benefits for 24 months continuously also get automatically enrolled. Medicare beneficiaries receive their Medicare card three months prior their coverage begins. Wisconsin residents can either register manually for Medicare or can apply by visiting their local SSA office or can even register over the phone. Wisconsin should familiarize themselves with all the available Medicare plan option before picking the best Medicare option that ideally suits their healthcare requirements and budget.
Medicare Plan Options in Wisconsin
Original Medicare or traditional Medicare is the fee-for-service program administered by federal government that works on a fee-for-service basis. This means that enrollees of the Original Medicare plan can visit any doctor or hospital of their choice that accepts Medicare, anywhere in the United States. The Medicare is responsible to pay its share of the healthcare bill for any healthcare services covered under Medicare. Original Medicare plan is managed and handled by the federal agency, the Centers for Medicare & Medicaid Services. Beneficiaries must keep in mind that Original Medicare covers many healthcare services and supplies but it doesn’t pay for all the medical expenses of the insured. Original Medicare comprises of two parts, Medicare Part A, hospital insurance and Medicare Part B, medical insurance.
Medicare Part A, which is hospital insurance provides coverage of inpatient expenses such as hospital visits, healthcare received in skilled nursing facilities, hospice care and home health services. Medicare beneficiaries enrolled in original Medicare usually do not have to pay any premium if they or their spouse have paid their Medicare taxes during their working years.
Medicare Part B, which is medical insurance provides coverage for medically necessary services as well as preventive services. Medically necessary services are required to diagnose or treat medical condition meeting accepted standard of medical practice and preventive services include health care offered to prevent illness like flu along with other medically necessary services such as physician and nursing fees, x-rays cost, blood transfusions, diagnostic tests, renal dialysis, chemotherapy along with some vaccinations and preventive services.
Original Medicare Enrollment
Individuals who do not get automatically enrolled in Medicare Part A can enroll during the Initial Enrollment Period, which is a seven month duration starting three months prior to the month when they turn 65 years of age. Individuals enrolling during this period are eligible for premium-free Part A enrollment and if they do not enroll during this period then they will be subject to additional premium for Part A. Individuals who qualify for Original Medicare based on their age have an opportunity to enroll in Medicare Part B during the seven month Initial Enrollment Period, which include three months before they turn 65, the month on which they turn 65 and three months after it. If the individuals enroll three months prior to the month they turn 65 then their coverage become effective from the month they turn 65. Individuals receiving the Social Security or Railroad Retirement benefits are notified three months before their 65th birthday about the Original Medicare enrollment. Medicare Part A is mandatory and is generally available free of cost whereas Part B is optional and enrollees have to pay a premium for Part B coverage.
Medicare Advantage Plan in Wisconsin
Medicare Advantage plan is an alternative way of receiving Original Medicare coverage. These plans are offered by private insurance companies having contract with CMS to provide same coverage as original Medicare except the hospice care that is covered only be Medicare Part A. Medicare Part C or Advantage plan also include some additional benefits such as routine dental and vision care along with prescription drug coverage. In 2019 around 41% of medicare beneficiaries were enrolled in a Medicare Advantage plan. In Wisconsin there are 1,502 different types of Advantage plans available, though not every plan is available in each and every county. Individuals looking out for Advantage plan must find out the plan that are available in their area. The average premium paid by the beneficiaries of Medicare Advantage plan in Wisconsin in 2019 was $92 per month. Medicare Advantage plan premiums, deductibles and out-of-pocket costs vary greatly depending on where individuals live and the plan in which they enroll.
Medicare Advantage Eligibility
Individuals looking to enroll in Medicare Advantage plan in Wisconsin first need to be enrolled in Medicare Part A and Part B plan. In addition to this individuals should also be living in the plan’s service area and they should not have end-stage renal disease in order to qualify for the Medicare Part C plan. In order to be covered under Part C plan, enrollees of Advantage plan need should continue paying their Part B premium along with the premium amount of Advantage plan.
Medicare Part C or Advantage plan is administered by private private health insurance companies having contract with Medicare. These plans cover everything that is covered under Original Medicare like inpatient hospital care, skilled nursing facility care and home health care along with outpatient care like doctor visits, lab tests, x-rays, inpatient and outpatient mental health services, durable medical equipment like wheelchairs, preventive tests and vaccines, occupational therapy, speech and language pathology. Besides these, Medicare Part C also offer coverage for prescription drugs which insured take at home and also include additional benefits like routine dental care, vision care, hearing care along with fitness benefits.
Individuals in Wisconsin are first eligible to enroll in a Medicare Part C plan during their Medicare Initial Enrollment Period (IEP), which starts three months before their 65th birthday, includes their birth month and then continues for another three months after their birthday.
Types of Medicare Advantage Plans
Different types of Medicare Advantage plans are available in Wisconsin, though not each and every Advantage plan is available in all the county. Individuals looking to enroll in Medicare Advantage plan must first check the Part C plan that are available in their area. The major types of Medicare Advantage plans include:
- Health Maintenance Organization (HMO)
- Preferred Provider Organization (PPO)
- Private Fee-For-Service (PFFS)
- Special Needs Plan (SNP)
Medicare Advantage Prescription Drug Plan
Medicare Advantage Prescription Drug plan is a comprehensive package that comes with the combined health and prescription drugs coverage into a single plan. This plan is offered by Medicare-contracted private health insurance companies and is considered as an alternative way to obtain Medicare coverage. Medicare Advantage Prescription Drug plans just like all Medicare Advantage plans have to cover everything that are covered under Original Medicare with the only exception of hospice care.
Medicare Advantage Prescription Drug plan has its own formulary, which is a documented list of prescription medications that it covers. Each Medicare Advantage Prescription Drug plan must offer two or more medications within each popular category of drugs. Individuals enrolling in this plan are advised to ensure that their current medications are included in the plan’s formulary, since the medications covered under each plan varies.
Medicare Advantage Prescription Drug plans combine both health insurance benefits and prescription drug benefits into one comprehensive package. This plan like all Medicare Advantage plans cover everything that is covered under Original Medicare, with the only exception of hospice care. This is the only Medicare plan that include coverage of Medicare Part A, Part B, Part C and Part D in a single plan.
Medicare Advantage Prescription Drug plans are offered by Medicare-approved private insurance companies, so that cost of the plan varies from one insurance carrier to other. This plan comes with a monthly premium, though some insurance carriers may offer plan with premiums as low as $0 a month. However, members of this plan are still responsible for paying Medicare Part B premium. In addition to this, members are also liable to to pay additional costs like co-payments, coinsurance, and deductibles.
Medicare Part D or Prescription Drug Plan
Medicare beneficiaries in Wisconsin receiving health coverage through Original Medicare get health benefits only, as neither Medicare Part A nor Part B provides prescription drug coverage except in cases during inpatient hospital stay or when drugs are administered by a professional healthcare provider in a clinic setting. Therefore, Medicare beneficiaries who wish to stay with Original Medicare can enroll in a stand-alone Medicare Part D prescription drug plan offered by private insurance companies contracted with Medicare.
Each Medicare Part D plan has its own formulary, which is simply a list of prescription drugs and vaccines that are covered under the plan. Medicare Part D plan formularies vary form plan to plan, but there are certain medications that should be covered by every Part D plan, as per Medicare dictates. Medicare Part D plan formularies generally cover all commercially available vaccines, which are efficient in preventing illness and are not covered under Medicare Part B. The plan’s formulary might change any time, though members of the plan are notified by the insurance companies. The plan’s formulary must include at-least two drugs from the following popular categories:
Individuals are eligible to enroll in Medicare Part D plan if they are already enrolled in Medicare Part A and Part B plan. Besides, they should also live in the service area of a Medicare plan that includes prescription drug coverage. Individuals eligible for Medicare Part D can either enroll in a stand-alone Medicare Prescription Drug plan or in Medicare Advantage prescription Drug plan during their initial enrollment period.
Medicare Supplement Plans in Wisconsin
Medicare Supplement plan is not a comprehensive health insurance plan but it is only meant to supplement Original Medicare so it is named as Medicare Supplement plan. Medicare Supplement plans helps beneficiaries cover the out-of-pocket costs associated with Original Medicare coverage. original Medicare comprising of Part A and Part B have certain out-of-pocket expenses that quickly add up to the Original Medicare cost. Thus, beneficiaries opt for Medicare Supplement plans to offset those costs.
Individuals are eligible to enroll in a Medicare Supplement plan during their Medigap Open Enrollment Period, which automatically starts when they attain the age 65 and are enrolled in medicare Part B. Open Enrollment Period is a good time to enroll in the Medicare Supplement plan because individuals have guaranteed-issue rights during this time and they will not be denied coverage or charge higher premium because of any health issues. However, individuals can enroll in these plans at any time of the year but if they enroll outside the Medigap Open Enrollment Period, then they may may be denied coverage or charged higher premiums depending upon their health.
There are ten standardized Medicare Supplement plans available in most of the U.S. states but in Wisconsin all types of Medicare Supplement plans are standardized, which means that these plans offer the same coverage and benefits. Medigap plans in Wisconsin cover the following basic benefits:
- First three pints of blood every year
- Coinsurance or ca-payments of Part A hospice care
- Part A co-insurance for inpatient hospital care
- Part B coinsurance
Medigap basic plan includes the following benefits in Wisconsin:
- All basic benefits
- Part A skilled nursing facility coinsurance
- Part A inpatient mental health coverage
- Part A home health coverage
- State-mandated benefits like services related to kidney disease and diabetes