Medicare in Wisconsin

In most cases, enrollment in Medicare 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, about 12% percent of Medicare beneficiaries are under age 65, and it’s roughly the same percentage in Wisconsin.

Medicare options

Medicare beneficiaries can choose from among several options to access Medicare coverage. The first choice is between 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 Medicaid

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, because it helps to pay for inpatient stays in a hospital, skilled nursing facility, or hospice center) and Part B (also called medical insurance, which helps pay for outpatient and physician 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 nearly every county have access to at least 30 Medicare Advantage plans. In some counties, there are more than 60 Medicare Advantage plans for sale.

Forty percent of beneficiaries of Medicare in Wisconsin had Medicare Advantage policies as of 2018, versus about 34% nationwide. As of early 2023, there were 690,770 Wisconsin Medicare beneficiaries enrolled in private Medicare coverage (not counting private supplemental coverage like Part D and Medigap).

That’s nearly 55% 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). In Wisconsin, the other 573,071 Medicare beneficiaries had coverage under Original Medicare as of early 2023.

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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 24 insurers that offer traditional Medigap plans in Wisconsin, in addition to three insurers that offer Medicare Select plans, and three that offer Medicare Cost 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).

299,925 Wisconsin Medicare beneficiaries had Medigap coverage as of 2021, according to an AHIP analysis.

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 SB1021/AB1086 in 2022 (similar to SB615, which was considered in 2020, and legislation that had also been introduced in 2018). The legislation, which did not pass, would have created a “birthday rule,” allowing people to switch to equal or lesser Medigap plans without underwriting during a window linked to their birthday each year. Such provisions are fairly rare – only 12 states have guaranteed-issue rules for Medigap outside of the initial enrollment window. And although Wisconsin lawmakers have considered changing that rule several times, they have not yet done so.

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, 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 $8,300 in 2023 for in-network care, plus the out-of-pocket cost of prescription drugs.

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 23 stand-alone Medicare Part D plans for sale in Wisconsin in 2023, with premiums that range from about $7 to $113/month.

About 34% of Wisconsin’s Medicare beneficiaries (403,265 people) had stand-alone Medicare Part D plans as of early 2023. Another 572,721 Wisconsin Medicare beneficiaries had Medicare Part D prescription coverage integrated with their Medicare Advantage plans. Because more than half of Wisconsin’s Medicare beneficiaries have Medicare Advantage plans, the number of people covered by Part D integrated with Medicare Advantage is higher than the number of people with stand-alone Part D coverage.

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.

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.

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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.