Medicare Advantage (Part C) provides an alternative way to receive your Medicare benefits. Medicare Advantage plans are offered by private insurance companies contracted with Medicare. If you enroll in a Medicare Advantage plan, you still have Part A (hospital insurance) and Part B (medical insurance) coverage, but you receive your benefits from the insurance company’s Medicare Advantage plan.
How Medicare Advantage works in Wisconsin
All Medicare Advantage plans are required to offer at least the same level of coverage as Original Medicare, Part A and Part B, with the exception of hospice care, which continues to be covered under Part A. Many Medicare Advantage plans offer additional benefits. Depending on the specific plan, you may have coverage for routine vision, dental, health wellness programs, and/or prescription medications. Although specific benefits vary by plan, Medicare Advantage generally works the same way in Wisconsin as in all states.
All Medicare Advantage members must continue to pay the Part B premium, in addition to the Medicare Advantage plan’s premium, if any.
Eligibility rules for Medicare Advantage in Wisconsin are the same as in other states. To enroll in Medicare Advantage, you must:
- Have Original Medicare, both Part A and Part B.
- Live in the service area of the plan you’re considering.
In most cases, Medicare Advantage plans are not available to individuals who have end stage renal disease (ESRD).
You can enroll in a Medicare Advantage plan during the following periods:
- Initial Coverage Election Period: This is the period when you’re first eligible to enroll. In most cases, this time period occurs at the same time as your Medicare Initial Enrollment Period (IEP), which generally begins three months before the month you turn 65, includes your birthday month, and ends three months after your birth month.
- Annual Election Period: During the Medicare Advantage and Prescription Drug Annual Election Period (October 15 to December 7 each year) you can switch from Original Medicare to a Medicare Advantage plan, add prescription drug coverage, or disenroll from a Medicare Advantage plan.
- Medicare Advantage Open Enrollment Period: During this period (January 1 to March 31 each year), you can disenroll from a Medicare Advantage plan and return to Original Medicare. You also can switch Medicare Advantage plans at this time.
- Special Election Period: Outside of the annual election period, you can make changes to your Medicare Advantage coverage only if you qualify for a Special Election Period. Certain situations, such as moving out of your Medicare Advantage plan’s service area, will allow you a Special Election Period.
Types of Medicare Advantage plans in Wisconsin
Wisconsin beneficiaries may have several choices when it comes to Medicare Advantage plans, depending on what’s available in their area and whether they meet certain eligibility requirements:
More prevalent types of Medicare Advantage plans include:
- A Health Maintenance Organization (HMO) plan is a type of Medicare Advantage plan that generally requires you to visit doctors, health-care providers, and hospitals included in your plan’s network to receive benefits from the plan except in the instances of emergency care or medically necessary care that is authorized by the plan but not available within the plan’s network. Note that you may have to get a referral from your primary doctor or health provider to receive coverage for certain health services.
- An HMO Point-of-Service plan (HMO-POS) is more flexible than a standard HMO plan, allowing you to go out of network in certain circumstances for covered services but generally at a higher out-of-pocket cost.
- A Preferred Provider Organization (PPO)* plan offers even greater flexibility, allowing you to select doctors, health care providers, and hospitals outside of your plan’s network, but again at a higher out-of-pocket cost.
- A Private Fee-for-Service (PFFS) plan may or may not offer a partial or full network of participating providers. The insurance company, and not Medicare, sets payment terms. If the plan does not have a network of participating providers, it is important to verify if the provider accepts the plan.
- A Medical Savings Account (MSA) plan combines a high deductible plan with a savings account that you can use to pay for your health-care expenses.
- A Medicare Special Needs Plan (SNP) is for people with certain health needs, offering coverage tailored to suit their specific situations. There are Medicare SNPs for people with chronic medical conditions, those living in nursing homes, and people who qualify for both Medicare and Medicaid.
- A Medicare Advantage Prescription Drug (MAPD) plan combines health and prescription drug coverage into a single Medicare plan offered by a private insurer.
Comparing Medicare Advantage plans available in Wisconsin
As a Medicare beneficiary in Wisconsin, you may find it useful to compare all Medicare Advantage plans available in your area.
The availability and costs of Medicare Advantage plans vary depending on where you live, the insurance company offering the plan, and specific plan details. You may find that some Medicare Advantage plans in Wisconsin offer premiums as low as $0. Be sure you consider other costs as well, such as copayments and deductibles, and that you continue paying your Medicare Part B premium no matter which Medicare Advantage plan you choose.
The Medicare Advantage plans available where you live in Wisconsin may include networks of participating providers. If so, your use of the doctors, hospitals and other health-care providers who participate in the plan’s network has a significant impact on your ability to receive the full benefits of the Medicare Advantage plan. If you currently have doctors and other health-care providers you want to retain, check to see if they participate in the Medicare Advantage plan before you make a final decision to enroll in it.
Some Medicare Advantage plans may offer additional benefits beyond those included in Original Medicare, Part A and Part B. Consider whether a Medicare Advantage Prescription Drug plan would be a good choice to meet your medical and prescription drug coverage needs. If a Medicare Advantage plan offers other extra benefits, such as preventive vision or dental care, consider whether these are important to your coverage needs.
To start comparing Medicare Advantage plans in Wisconsin, enter your zip code above for a customized list of plans available in your area. You can also enter your prescription drug needs to further refine your search and cost estimates.
You can learn more about your Medicare options in Wisconsin by referring to the following pages:
* Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether the plan will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.