- About 1.15 million residents are enrolled in Medicare in Wisconsin. Fifteen percent are under 65 and enrolled due to a disability.
- More than 40 percent of beneficiaries of Medicare in Wisconsin are enrolled in Medicare Advantage plans.
- The market for Medicare Advantage in Wisconsin is robust, with between 11 and 47 plans available, depending on the county.
- At least 32 insurers offer Medigap plans in Wisconsin; the state does its own Medigap plan standardization, so Medigap plans in Wisconsin are different from Medigap plans sold in most states.
- In 2020, Wisconsin lawmakers considered, but did not pass, legislation that would have allowed Wisconsin Medigap enrollees to switch, without medical underwriting, to a plan with equal or lesser benefits.
- Wisconsin regulations guarantee access to Medigap Basic plans for disabled enrollees under age 65, but premiums can be considerably higher for under-65 enrollees.
- There are 30 stand-alone Medicare Part D prescription drug plans available in Wisconsin in 2020, with monthly premiums ranging from about $13 to $124. About 38% of Wisconsin Medicare beneficiaries have stand-alone Part D prescription drug plans.
- Per-enrollee spending for Original Medicare in Wisconsin is 13% lower than the national average.
How many people are enrolled in Medicare in Wisconsin?
Medicare enrollment in Wisconsin stood at 1,198,428 people as of July 2020, amounting to more than 20 percent of the state’s population.
In most cases, filing for Medicare benefits goes along with turning 65. But Medicare also provides coverage for disabled Americans under age 65, once they have been receiving disability benefits for 24 months, and for people with ALS or end-stage renal disease. Nationwide, 15 percent of Medicare beneficiaries are under age 65; in Wisconsin, it’s 14 percent. In Alabama, Arkansas, Kentucky, and Mississippi, 22 percent of Medicare beneficiaries are under 65, while just 9 percent of Hawaii’s Medicare beneficiaries are eligible due to disability.
Medicare beneficiaries can chose among several options to access Medicare coverage. The first choice is between Medicare Advantage plans, where coverage is through private Medicare Advantage plans or Original Medicare, where coverage is paid for directly by the federal government. There are pros and cons to either option, and the right solution is different for each person.
Medicare beneficiaries also have options around Medigap policies and Medicare Part D (prescription drug) coverage.
Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries the chance to switch between Medicare Advantage and Original Medicare (and add, drop, or change to a different Medicare Part D prescription plan). And people who are already enrolled in Medicare Advantage also have the option to change to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31.
Original Medicare coverage is provided directly by the federal government, and enrollees have access to a nationwide network of providers. But people with Original Medicare need supplemental coverage (from an employer-sponsored plan, Medicaid, or privately purchased plans) for things like prescription drugs and out-of-pocket costs (i.e., premiums, deductibles, copayments, and coinsurance), which are not capped under Original Medicare.
Original Medicare includes Part A (also called hospital insurance, which helps pay for inpatient stays, like at a hospital, skilled nursing facility, or hospice center) and Part B (also called medical insurance, which helps pay for outpatient care like a doctor appointment or preventive healthcare services).
Medicare Advantage in Wisconsin
Medicare Advantage includes all of the coverage provided by Medicare Parts A and B, and the plans often include additional benefits, usually including integrated Medicare Part D prescription drug coverage and often including coverage for things like dental and vision care. But Medicare Advantage insurers establish their own provider networks, which are generally localized and more limited than the nationwide network for Original Medicare. Out-of-pocket costs for Medicare Advantage are often higher than they would be if a beneficiary had Original Medicare plus a Medigap plan.
Wisconsin’s Medicare Advantage market is robust: Medicare Advantage plans are available state-wide, and residents in every county have access to at least 11 Medicare Advantage plans, and in most cases, more than 20. In Waukesha and Brown counties, there are 47 Medicare Advantage plans for sale.
Forty percent of beneficiaries of Medicare in Wisconsin had Medicare Advantage polices as of 2018, versus about 34 percent nationwide. As of July 2020, there were 556,643 Wisconsin Medicare beneficiaries enrolled in private Medicare coverage (not counting private supplemental coverage like Part D and Medigap). That’s more than 46 percent of the state’s Medicare population, but some Wisconsin Medicare beneficiaries are enrolled in Medicare Cost plans, which are an earlier form of private Medicare coverage that predates Medicare Advantage plans (three insurers in Wisconsin offer Medicare Cost plans). The other 661,785 Medicare beneficiaries in Wisconsin had coverage under Original Medicare as of mid-2020.
The popularity of Medicare Advantage enrollment varies from one state to another. In Minnesota, nearly half of the state’s Medicare population is enrolled in Advantage plans, whereas only 1 percent of Alaska Medicare beneficiaries have Medicare Advantage plans (via employer-sponsored coverage, as there are no Medicare Advantage plans available for individuals to purchase in Alaska).
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Medigap in Wisconsin
Original Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental coverage. Nationwide, more than half of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement plans, or MedSupp) will pay some or all of the out-of-pocket costs they would otherwise have to pay if they had only Original Medicare.
Although Medigap plans are sold by private insurers, the plans in nearly every state are standardized under federal rules. But Wisconsin is one of just three states that have waivers from the federal government allowing the state to conduct its own Medigap standardization. So Medigap plans in Wisconsin are not the same as they are in most of the rest of the country.
Instead of having ten different plan designs available (as is the case in most states), Wisconsin Medigap is structured so that there’s a basic plan, and then enrollees can choose to add riders that make the coverage more comprehensive. So instead of buying “Plan G” (as newly-eligible enrollees in most states would do if they wanted the most comprehensive Medigap plan), Wisconsin Medigap enrollees would buy the basic plan and then add on the optional riders.
Wisconsin Medigap insurers have to offer “basic benefits” that include coverage for Part A coinsurance (including the Part A hospice coinsurance and hospital coinsurance), Part B coinsurance, and up to three pints of blood each year. Each Medigap insurer has to offer a “Basic Plan,” which includes the basic benefits in addition to Part A skilled nursing facility coinsurance, additional coverage for home health care and inpatient mental health care (both have limits on the number of days that are covered), outpatient mental health care, and Wisconsin state-mandated benefits.
In addition, Wisconsin Medigap insurers can offer up to seven optional riders that beneficiaries can purchase, with coverage for things like the Part A deductible, additional home health care, the Part B deductible and excess charges, and foreign travel coverage for emergencies abroad (people who are newly eligible for Medicare in 2020 or later are not be able to purchase Medigap coverage for the Part B deductible; those who already had this coverage can keep it, and people who became eligible for Medicare prior to 2020 can still purchase it, assuming they can meet the medical underwriting requirements; this applies nationwide, under the terms of the Medicare Access and CHIP Reauthorization Act of 2015).
So if a person in Wisconsin wants a Medigap plan that’s comparable to Medigap Plan G sold in other states, they would need to buy the Basic Plan plus riders for the Part A deductible, Part B excess charges, additional home health care benefits, and foreign travel emergency coverage. Medigap coverage similar to the various lettered plans sold in other states can thus be obtained in Wisconsin by layering various riders on top of the Basic Plan.
Medigap insurers in Wisconsin can also offer cost-sharing plans that require the member to pay a portion of the out-of-pocket costs until they reach a specified out-of-pocket limit (similar to Medigap plans K and L that are sold in other states), and high-deductible plans that require the member the pay all costs until they meet the deductible for the year (similar to the high-deductible versions of Medigap plans F and G that are sold in other states).
There are at least 32 insurers that offer traditional Medigap plans in Wisconsin as of 2020, in addition to four insurers that offer Medicare Select plans. (Wisconsin’s Medigap guide notes that there may be other insurers in the state that have chosen not to have their pricing and sales information detailed in the publication). 299,988 Wisconsin Medicare beneficiaries had Medigap coverage as of 2018, according to an AHIP analysis. That was about 45 percent of the state’s Original Medicare enrollees (Medigap coverage cannot be used with Medicare Advantage plans).
Medigap insurers in Wisconsin can choose to use attained-age rating (rates increase as an enrollee gets older) or issue-age rating (rates are based on the age the person was when they enrolled).
Unlike other private Medicare coverage (Medicare Advantage and Medicare Part D plans), there is no annual open enrollment window for Medigap plans. Instead, federal rules provide a one-time six-month window when Medigap coverage is guaranteed-issue. This window starts when a person is at least 65 and enrolled in Medicare Part B (you must be enrolled in both Part A and Part B to buy a Medigap plan).
Lawmakers in Wisconsin considered SB615 in 2020 (a 2018 bill that was brought back up for consideration in the 2020 session). The legislation, which did not pass, would have allowed people to switch to equal or lesser Medigap plans without underwriting. That’s fairly rare – very few states have guaranteed-issue rules for Medigap outside of the initial enrollment window. And although Wisconsin lawmakers considered changing that rule, they did not do so during the 2020 legislative session.
People who aren’t yet 65 can enroll in Medicare if they’re disabled and have been receiving disability benefits for at least two years About 15 percent of Medicare beneficiaries in Wisconsin are under age 65. Federal rules do not guarantee access to Medigap plans for people who are under 65, but the majority of the states — including Wisconsin — have implemented rules to ensure that disabled Medicare beneficiaries have at least some access to Medigap plans.
Medigap insurers in Wisconsin are required to offer coverage to disabled enrollees under age 65, with the same six-month open enrollment period that begins when the person is enrolled in Medicare Part B. But premiums for people under the age of 65 are considerably higher than premiums for people who are 65 and over. And insurers are only required to offer the Medigap Basic Plan to applicants under the age of 65. There are only a handful of insurers that offer any other plans (the high-deductible option, and the 25 percent and 50 percent cost-sharing options): Humana, Wisconsin Physicians Service Insurance Corporation, Garden State, Physicians Life Insurance Company, United American, and United World.
Disabled Medicare beneficiaries also have access to the normal Medigap open enrollment period when they turn 65. At that point, they can select from among any of the available Medigap plans, with lower premiums that apply to people who are aging onto Medicare when they turn 65.
Disabled Medicare beneficiaries have the option to enroll in a Medicare Advantage plan instead of Original Medicare, as long as they don’t have kidney failure (as of 2021, Medicare beneficiaries who have kidney failure will be able to enroll in Medicare Advantage plans). Medicare Advantage plans are otherwise available to anyone who is eligible for Medicare, and the premiums are not higher for those under 65. But as noted above, Advantage plans have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $6,700 per year for in-network care, plus the out-of-pocket cost of prescription drugs (the upper limit for out-of-pocket costs, not counting prescription costs, will increase to $7,550 as of 2021).
Although the Affordable Care Act eliminated pre-existing condition exclusions in most of the private health insurance market, those rules don’t apply to Medigap plans. Medigap insurers can impose a pre-existing condition waiting period of up to six months if you didn’t have at least six months of continuous coverage prior to your enrollment (although many of them choose not to do so). And if you apply for a Medigap plan after your initial enrollment window closes (assuming you aren’t eligible for one of the limited guaranteed-issue rights), the Medigap insurer can consider your medical history in determining whether to accept your application, and at what premium.
Wisconsin Medicare Part D
Original Medicare does not provide coverage for outpatient prescription drugs. More than half of Original Medicare beneficiaries nationwide have supplemental coverage either through an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage.
Medicare beneficiaries who do not have Medicaid or employer-sponsored drug coverage need Medicare Part D enrollment in order to have coverage for prescriptions. Medicare Part D was created under the Medicare Modernization Act of 2003, and can be purchased as a stand-alone plan, or obtained as part of a Medicare Advantage with built-in Part D benefits.
There are 30 stand-alone Medicare Part D plans for sale in Wisconsin in 2020, with premiums that range from about $13 to $124/month.
About 38 percent of Wisconsin’s Medicare beneficiaries (452,969 people) had stand-alone Medicare Part D plans as of mid-2020. Another 441,044 Wisconsin Medicare beneficiaries had Medicare Part D prescription coverage integrated with their Medicare Advantage plans.
Medicare Part D enrollment is available during a beneficiary’s initial enrollment period (when they turn 65 or become eligible for Medicare due to a disability), and there is also an annual open enrollment period each fall. During this window, beneficiaries can switch to a different Medicare Part D plan or enroll for the first time (with a late enrollment penalty, depending on the circumstances), with coverage effective the following January.
Per-beneficiary spending for Medicare in Wisconsin
Per-beneficiary spending for Original Medicare in Wisconsin was 13 percent lower than the national average in 2018, at $8,763; only ten states had lower average per-beneficiary Original Medicare spending. The spending amounts are based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for Medicare Advantage. Nationwide, average per-beneficiary Original Medicare spending stood at $10,096.
How does Medicaid provide financial assistance to Medicare beneficiaries in Wisconsin?
Many Medicare beneficiaries receive financial assistance through Medicaid with the cost of Medicare premiums and services Medicare doesn’t cover – such as long-term care.
Our guide to financial assistance for Medicare enrollees in Wisconsin includes overviews of these benefits, including Medicare Savings Programs, long-term care coverage, and eligibility guidelines for assistance.
Medicare in Wisconsin: Resources for beneficiaries and their caregivers
Need help with your Medicare application in Wisconsin, or have questions about Medicare eligibility in Wisconsin? These resources provide free assistance and information.
- The website for the Wisconsin Department of Health Services has a comprehensive list of resources related to Medicare coverage in Wisconsin.
- Visit the Medicare Rights Center. This website provides helpful information geared to Medicare beneficiaries, caregivers, and professionals.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.