Introduction to Medicare Advantage in Wisconsin (Medicare Part C)

Medicare Replacement plans – which are Medicare supplement plans designed to replace your federal health benefits with a private coverage option – are also known as Medicare Advantage (or Medicare Part C). Medicare supplement policies are designed to help with the gaps in Traditional Medicare (Medicare Parts A and B) coverage. Without a supplement, these coverage gaps have been known to cause some seniors to face huge out-of-pocket medical bills. However, for one affordable monthly premium, it is possible to protect yourself against expensive coverage gaps.

Federal Regulations for Medicare Advantage

Existing federal laws mandate that, no matter what Medicare Advantage policy you choose, it must provide at least the same amount of coverage as Traditional Medicare. However, most Advantage policies attract seniors by offering as much or more, so being sold an inferior policy is an unlikely occurrence. Below, we’ll get into some of the more popular coverage options you can add to a Medicare Advantage policy.

Medicare Advantage Enrollment In Wisconsin

Medicare Advantage seems to be a little less popular in Iowa than it is in other states. Only about 18% of residents are allowing private companies to manage their Medicare benefits through an Advantage plan. The other 82% likely are sticking with Original Medicare or have some leftover plan from their previous employer.

Plan Type Enrollment Percentage
HMO Plans 59%
Local PPO Plans 13%
Special Needs Plans 11%
Regional PPO Plans 9%
Private Fee-For-Service Plans 5%
Other (Cost Plans, MSA’s, etc.) 3%

Plan Coverage & Cost

Living in Wisconsin means that you most likely pay a different monthly rate than someone in Iowa or Nebraska. However, there is enough data out there to offer up a rough estimate. Below are some examples of going rates for Medicare Advantage policies near you.

Most Popular Medicare Advantage Plans in Wisconsin

Our Medicare plan ratings work just about the same way most other ratings plans do. We look at every relevant aspect of the company and we give them an overall score out of a possible five stars. The better they are at care management, customer satisfaction, claims filing, and financial stability, the more stars they will receive. This can shorten the amount of time you spend shopping around and help you find the provider you want much faster.

Helpful Medicare Advantage Tips & Tricks

Doctor/Provider Network Restrictions

It’s best to do your homework and figure out what sort of Medicare Advantage network your preferred doctors are in (if you have them) before choosing your Medicare Advantage network. If you aren’t careful, you may end up having to switch doctors. It is also possible that your Advantage plan could change who they do and do not allow in your provider network unexpectedly.

Where you generally need to get your care and services from for:

  • HMO Plans – if your plan decides to incorporate a Health Maintenance Organization Network, then you have to pay very special attention to the network of doctors and facilities they allow you access to. Outside of that network, your plan will likely be rejected and you may have to pay full price for care. But there are exceptions if you absolutely need emergency treatment from a provider outside of your network.
  • PPO Plans – If your Medicare Advantage provider offers you a Preferred Provider Organization plan, it means you will be able to visit any doctor or facility which accepts your Medicare Advantage plan. Granted, not all of these sources of care will be on the list of your preferred providers, which may make them more expensive. Sticking to your preferred providers will be less costly, but you have more freedom to get care from outside providers at a somewhat reduced cost.
  • PFFS Plans – Private Fee-For-Service plans are different in that they approve or reject patients on a case-by-case basis – even if you are a returning customer. The restrictive status of the network will depend on the particular plan that you have. If you aren’t careful about communicating with your caregivers, you may be surprised with full price costs when you least expect them.
  • Special Needs Plans – SNPs are plans which cater to special needs patients. Usually these patients are suffering from very specific, serious diseases like ESRD or something similar. Like an HMO plan, your provider network is smaller – not just to cut costs, but make sure you get specialized care. Also like HMO plans, you can get emergency care if you absolutely cannot make it to a network-approved doctor or hospital. Furthermore, with a SNP, you may have the option to choose an out-of-network healthcare provider if you need to get care for your condition from a specialist who is out of your network. But you have to discuss it with your insurance company first.

Doctor/Providers List

Finding a doctor who accepts your Medicare Advantage plan:

  • HMO Plans – Medicare Advantage HMO plans are very similar to HMO plans on other types of insurance. You start by choosing a primary care provider who manages your overall health care needs, and who may refer you to certain specialists if you need additional treatment. These specialists may include doctors with a specific medical specialization, carefully selected hospitals, specialized surgical centers, labs and x-ray facilities, along with pharmacies that are approved by your plan if it does cover prescriptions. Aside from emergency care, any medical care you receive from out-of-network doctors and facilities will likely be paid 100% out-of-pocket by you.
  • PPO Plans – Like an HMO, PPO plans will have a list of doctors they want you to visit. Unlike an HMO plan, however, you can get care wherever you like as long as they accept your insurance. Granted, these out-of-network caregivers will cost you more money than the caregivers that are designated under your PPO plan. But some people believe that the higher expense is worth having more options.
  • PFFS Plans – There are doctors and facilities which accept Medicare (and also, in most cases, Medicare Advantage) and then there are doctors and facilities which accept Private Fee-For-Service plans. There’s a lot of overlap between the two, but it is not always 100% guaranteed. Furthermore, some insurance policies may have a wider provider network, while others may not. Lastly, the doctor or facility you seek care from may choose at any time to stop accepting your PFFS plan, even if you have been there before. You’ll likely have to put a little extra effort into making sure you visit the right facilities if you want to keep your costs low.
  • Special Needs Plans – SNPs are almost identical to HMOs in that you will be restricted to a carefully selected list of providers you may get care from. Only seniors who qualify with a chronic disease, who are eligible for Medicaid and Medicare, and/or who live in a nursing home will be able to enroll in a Special Needs Plan. On top of that, you may be able to get emergency care and disease-specific specialized care out of your network if you can get specialized care approval from your insurance provider.

For your convenience, Medicare.gov has an easy and efficient database you can search to see if your preferred doctor(s) and facilities are included in your plan.

Drug, Vision and Dental Coverage

Most supplements do not provide the option to add ancillary coverage options (such as dental or vision) to their policies. Likewise, few supplements allow you to incorporate prescription drug coverage into the same plan (for Medicare Advantage, they are called MAPD plans). But you can get all of these benefits and bundle them under the same Advantage policy. There is no need to hassle with dealing with multiple forms of insurance.

  • While there’s no option to get vision coverage from Medicare part A and B, your Medicare Part C plan may give you such an option. They will likely charge you for the extra coverage and offer you a list of approved providers to choose from. The providers on that list may or may not be someone you are familiar with.
  • Similarly, you don’t have the option to get dental coverage from Medicare Parts A or B either. But this isn’t always so if you go with a Medicare Part C plan. If your provider does offer you dental coverage, it will also likely require a higher premium each month. And like most types of health insurance, the dentists and dental surgeons you are allowed to visit will likely be restricted to a specific network.

Enrollment Options & Best Time To Enroll

The earlier you decide to enroll in a Medicare Advantage plan, the better. Within your first six months of receiving Medicare (your Initial Enrollment Period), you will face the fewest number of obstacles with regard to getting hassle-free coverage. However, waiting to enroll can make the process more complicated. You may also face difficulty finding coverage if you are dealing with a chronic health condition like ESRD. For more information on your enrollment options, contact your local insurance agent. You can also take a look at our Medicare Advantage Enrollment Options page.

  • Initial Enrollment Period: 6-month timeframe when you first enroll in Medicare to purchase a Medicare Advantage plan.
  • Annual Enrollment Period (AEP): This timeframe runs from October 15th through December 7th every year, and during this time you can change or cancel your Medicare Advantage and part D drug plan.
  • Special Enrollment Period (SEP): During special circumstances, you may be eligible to purchase/change a plan outside of the Annual Enrollment Period. Things such as moving out of the plans’ service area, losing group health or employer coverage, a company no longer offering plans in the area, etc. are all events that could trigger a SEP.

What Medicare Advantage Plan Is Best For Me?

It’s difficult to anticipate your future medical needs. It can be even harder to choose the right Medicare Advantage provider. You want to buy a policy from a company that is particularly skilled in helping people with your medical needs. You also want to make sure they are financially stable and that they have a strong track record of solid customer service.

On top of all these difficulties, you don’t have much time to make a decision. Medicare enrollment periods are very limited, and the time you have left to evaluate a plan and switch later if you don’t like it is shorter still. But with our help and our easy to understand five-star ratings system, picking the right company with an affordable plan will be a breeze.

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