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Medicare Advantage Plans in Wisconsin


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Wondering about your Medicare coverage options in Wisconsin? If you’re currently enrolled in Original Medicare (Part A and Part B), then Medicare Advantage plans (Medicare Part C) may be another way for you to get your Medicare benefits.

How Medicare Advantage plans work in Wisconsin

When the Medicare program was first implemented, beneficiaries had only one way to get their health-care coverage: Original Medicare (Part A and Part B), the federally administered program. Later, the Medicare program expanded to include Medicare Advantage plans as another way for beneficiaries to get their Medicare Part A and Part B coverage. Medicare Advantage plans are health insurance plans offered by Medicare-approved private insurance companies. If you enroll in a Medicare Advantage plan in Wisconsin, you get your coverage administered through the Medicare Advantage plan, as opposed to the government-run Medicare program.

While your exact benefits can vary when it comes to Medicare Part C, depending on the plan and your location, all Medicare Advantage plans must offer at least the same level of coverage as Original Medicare, Part A and Part B. So as you compare Medicare Advantage plan options in Wisconsin, you can do so knowing all plans must include the same baseline level of coverage.

One benefit of Medicare Advantage plans is that they may cover additional benefits beyond Original Medicare. While Original Medicare doesn’t cover routine vision or dental, hearing, or wellness programs, you may be able to find Medicare Advantage plans that cover these benefits.

Medicare Advantage plans can fall into several different types. Some of the most popular options include Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans, which work similarly as the HMOs and PPOs you might get through an employer-sponsored group plan.

Medicare Advantage HMO plan requires you to use in-network doctors and hospitals for health-care services; you’re normally not covered if you use non-network providers, with the exception of emergency or urgent care. You’ll get most of your care through your primary care doctor and be required to get referrals for specialist care.

In contrast, a Medicare Advantage PPO plan gives you the option to use out-of-network providers if you like, although your cost sharing is typically lower if you use in-network providers. You don’t need a primary care doctor and can see specialists directly without needing a referral.

If you like the provider flexibility of Original Medicare, a Private Fee-for-Service (PFFS) plan is another option. This type of Medicare Advantage plan doesn’t have provider networks, which can be convenient if you have to travel frequently and don’t want to be limited to providers in a single service area. Instead, you can use any provider that will accept the PFFS plan’s terms and conditions and agree to treat you on a case-by-case basis. Keep in mind that you’ll need to make sure your doctors and hospitals contract with your plan each time you need a health-care service.

For beneficiaries with unique situations, a Special Needs Plan (SNP) is another option. This type of Medicare Advantage plan restricts enrollment to beneficiaries in three groups: Those who have certain chronic illnesses; have Medicare and Medicaid; or live in an institution (for example, a nursing home). If you’re eligible for a Special Needs Plan and there’s one available for your target group in your service area, you may be able to enroll in the plan. One benefit of these plans is they design their benefits to meet the unique health needs of their members. For example, a Chronic-Condition Special Needs Plan for beneficiaries with diabetes might have provider networks with doctors who specialize in treating diabetes, or it could include wellness programs to help members stay healthy and manage their condition.

Medicare Savings Account (MSA) plans may be a good fit for beneficiaries who don’t mind having higher out-of-pocket expenses before the plan starts to pay for covered medical costs. These plans are a combination of a high-deductible health insurance plan and a medical savings account. Your Medicare Savings Account plan deposits a certain amount of money into a savings account every year, which you can use to pay for covered costs before you’ve reached your annual deductible.

Medicare Advantage Prescription Drug plans

One benefit of Medicare Part C is that you can get prescription drug coverage included as part of the Medicare Advantage plan. Medicare Advantage plans may combine prescription drug coverage with health benefits, also known as Medicare Advantage Prescription Drug plans.

If you like the convenience of managing all of your Medicare benefits under a single plan, this might be a good option. In contrast, you’d normally have to enroll in stand-alone prescription drug coverage if you have Original Medicare. Keep in mind that if you decide to enroll in Medicare Part C and want prescription drug benefits, you should get it through a Medicare Advantage Prescription Drug plan, not a separate Medicare Prescription Drug Plan.

Comparing Medicare Advantage plans in Wisconsin

As you can tell, you may have many different options when it comes to Medicare Part C. In addition, Medicare costs like premiums, copayments, coinsurance, and deductibles may vary when it comes to Medicare Advantage plans. Some Medicare Advantage plans may have premiums as low as $0, but remember that you’ll still need to pay your Medicare Part B premium in this case, along with any cost sharing required by the plan. Keep in mind that Medicare Advantage plans with lower monthly premiums could charge higher amounts for deductibles and copayments, so consider all out-of-pocket costs before enrolling in a plan.

One major benefit of Medicare Advantage plans is that they include a yearly out-of-pocket spending limit. This means that once your health-care costs (including the deductible) have reached the plan’s maximum limit, the Medicare Advantage plan covers 100% of covered medical expenses for the rest of the year. Original Medicare doesn’t include a maximum out-of-pocket limit, meaning there’s no cap on how much you could spend for health care in a given year.

Do you have questions about how Medicare Advantage plans work in Wisconsin? Contact eHealth to discuss your Medicare needs with a licensed insurance agent.

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