Medicare Advantage is a type of Medicare plan for seniors and qualified adults with disabilities. Also known as Medicare Part C or simply MA, Medicare Advantage plans are provided by private, government-approved insurance companies. By law, all Medicare Advantage plans must include the same benefits as Medicare Parts A and B, or Original Medicare. However, MA cannot be combined with Medicare Supplemental Insurance or Medigap. Some MA plans include enhanced coverage for vision, dental and hearing care.
In Wisconsin, 42% of eligible seniors are enrolled in a Medicare Advantage plan, although participation varies widely between counties and is higher in urban areas throughout the state. Fond du Lac, Brown and Waupaca counties have enrollment rates over 50%, while enrollment rates are below 25% in Menominee and Richland. Nationwide, 36% of Medicare beneficiaries have MA coverage as of 2020, up from 24% in 2010 and 17% in 2000.
Seniors in Wisconsin have over 1,500 Medicare Advantage plans to choose from; however, plan availability varies between counties. PPO, SNP and HMO plans are available, as well as MA plans with prescription drug coverage. In this guide, we describe the different types of Medicare Advantage plans offered in Wisconsin and the enrolment and eligibility criteria. We’ve also included a list of statewide and local agencies, nonprofit organizations and services that can give seniors unbiased assistance with MA plan selection and management.
Special Needs Plans (SNPs)
Designed to meet the unique health care needs of adults and seniors who have complex medical issues such as permanent disabilities or chronic, life-altering diseases, Special Needs Plans provide coordinated services that include prescription drug coverage. Also known as Dual-Eligible plans, SNPs extend Medicare Advantage benefits to people who qualify for Medicare and Medicaid, such as those who reside in long-term care facilities. SNPs provide benefits beyond what is offered through Original Medicare, and coverage may be customized to each member to include vision, hearing and dental benefits.
Health Maintenance Organizations (HMOs)
A Health Maintenance Organization is a collection of medical providers and facilities that are under contract with the HMO to deliver in-network care to members. Contracted HMO costs are less than the standard fees for services. When compared to a PPO, premiums for HMO Medicare Advantage plans are usually lower; however, there are tight restrictions on coverage and care options. HMO beneficiaries can only seek care from an in-network provider, and primary physicians need to refer members to specialist care, medical testing and extra services. While HMOs cannot prevent members from seeing an out-of-network provider, with the exception of certain preapproved treatments and services, HMOs won’t cover any out-of-network expenses.
Preferred Provider Organizations (PPOs)
First established to ensure seniors in rural areas had access to Medicare Advantage plans, Preferred Provider Organizations are managed care organizations made up of numerous health care professionals, agencies and facilities. PPO providers are contracted with the insurance company to deliver services to beneficiaries at a reduced, pre-negotiated rate. While PPO members can seek care outside of their PPO network, these costs are not fully covered, and members are charged a significantly higher co-pay than for in-network services. PPO plans tend to cost more than HMO plans, but with this added cost comes flexibility, and most PPO plans allow members to access specialists without a referral from a primary physician. PPO plans may also provide some domestic travel benefits for beneficiaries who require care outside of Wisconsin.
Prior to enrolling in Medicare Advantage, seniors must first be enrolled in Original Medicare. Anyone who is eligible for Medicare Parts A and B is also eligible to enroll in Medicare Advantage. However, certain Medicare Advantage plans, such as SNPs, may have additional eligibility requirements.
Medicare Advantage has specific enrollment periods. One can only join a Medicare Advantage plan during the following periods:
Additionally, Medicare Advantage plan participants can change their plan outside of these enrollment periods under certain qualifying circumstances, such as moving to a new state.
In Wisconsin, seniors who need prescription drug coverage can enroll in an MA-PD, a Medicare Advantage plan that includes drug benefits comparable to Medicare Part D. Wisconsin also offers SeniorCare, a state-run prescription drug assistance program for seniors 65 and older who meet enrollment requirements. As with MA-PD plans, SeniorCare members must pay an annual fee, and SeniorCare coverage and co-pays are based on each members’ annual income. All SNPs automatically include Medicare Part D.
Selecting the right Medicare Advantage plan can be challenging. Seniors need to consider their current and projected health care needs, plan costs and coverage options. Adding to the complexity is the fact that MA plan availability is different in each of the 72 counties in Wisconsin. A number of state and local agencies and nonprofit organizations work to help seniors navigate the Medicare system, weigh coverage options and deal with any concerns related to Medicare Advantage.
The Wisconsin State Health Insurance Assistance Program provides free, unbiased information and enrollment assistance to Medicare beneficiaries, their family members and seniors who are nearing retirement. The SHIP program is federally funded and administered through the Wisconsin Department of Health Services, and SHIP workshops, outreach services and a statewide network of vetted SHIP volunteers primarily delivers one-on-one counseling. Most SHIP volunteers work out of regional aging and disability resource centers (ADRCs), and face-to-face Medicare counseling is usually conducted at these centers.
The Wisconsin Senior Medicare Patrol (SMP) is a statewide organization that works to prevent, detect and respond to Medicare fraud, billing errors and issues with service delivery. The Department of Health and Human Services funds the program through grants, and a network of volunteers delivers most SMP services. SMP volunteers staff information booths at outreach events, deliver group presentations at service clubs and senior centers and distribute educational materials. The SMP also processes complaints and reports from Medicare Advantage beneficiaries and forwards information to the appropriate authorities if Medicare fraud is suspected.
To learn more about the SMP or to file a complaint, call 1-888-818-2611
The Wisconsin Chronic Disease Program (WCDP) is a state-funded program that helps Wisconsin residents pay for specific disease-related medical services and essential supplies. WCDP covers costs only once all other benefits and coverage options have been exhausted. WCDP members with annual incomes equal to or greater than 300% of the Federal Poverty Level are required to pay a percentage of their out-of-pocket costs before WCDP benefits become available. There are three parts to the WCDP — the Chronic Renal Disease Program, Adult Cystic Fibrosis Program and Hemophilia Home Care Program. These programs cover specific treatments, tests, medications and home supplies.
For more information, call the Wisconsin Chronic Disease Program office at 800-362-3002.
The Wisconsin Office of the Commissioner of Insurance (OCI) regulates health insurance in the state. Medicare Advantage plan members who have a specific complaint about their insurance provider should first try to resolve the issue with the insurance company. If that doesn’t lead to a satisfactory outcome, MA members can file a complaint with the OCI through its website or by calling the Wisconsin Insurance Complaint Hotline.
SeniorLAW is a free legal assistance program open to Milwaukee County seniors aged 60 and older, with a focus on marginalized and low-income elders. Volunteer benefit specialists provide legal information related to civil matters, including Medicare, elder abuse, long-term care and consumer issues. If a complainant requires legal representation, attorneys are available to deal with eligible court cases. SeniorLAW services are provided at no cost; however, seniors who can make a donation to cover some of the costs are encouraged to do so.
To contact SeniorLAW, call 855-947-2529.
The Aging and Disability Resource Center of Brown County provides information, referrals and resources to help seniors remain independent and active in the community. The center operates a number of senior nutrition sites throughout the county and is the local SHIP counseling office for the region for seniors who need assistance with Medicare Advantage. Seniors aged 60 and older in Brown County who require durable medical equipment, such as walkers, wheelchairs, canes or crutches, can try out various mobility devices for free through the Assistive Equipment Loan Closet.
To learn more about Medicare counseling, medical equipment loans and other services offered by the ADRC, call 920-448-4300.