All Medigap plans in Wisconsin are required to provide the same basic benefits. These include Medicare Part A coinsurance for inpatient hospital care, Medicare Part B coinsurance for medical services (outpatient treatment), the first three pints of blood used each year for medical treatment, and Medicare Part A hospice coinsurance or co-payments.
Medigap plans help offset some of the individual costs that traditional Medicare doesn’t pay. These are typically coinsurance for medical treatments, co-pays for regular doctors and specialists visits, and some hospital treatments. Medigap plans get their name because they fill in the gaps in traditional Medicare coverage. They’re not intended to replace traditional Medicare coverage, but simply supplement it.
Wisconsin regulations stipulate that insurance companies must offer Medigap plans to everyone eligible for one. Those who receive traditional Medicare coverage under Part A and B are eligible for Medicare gap coverage. Those who opt for Medicare Advantage coverage instead of Original Medicare aren’t eligible for Medigap plans.
Enrollment in Medigap plans in Wisconsin works the same way as in the rest of the country. First, you have to be enrolled in Medicare Part A, which you may automatically be enrolled in when you turn 65. However, enrollment in Medicare Part B must be done manually during your Open Enrollment Period (OEP), which includes the three months prior to your 65th birthday, the month of your birth, and the three months afterward. You may enroll in a Medigap plan during this time, as well, once you’ve been approved for traditional Medicare coverage.
During the OEP, you’re protected with “guaranteed-issue” rights, which means that the private insurance companies offering these supplement plans aren’t allowed to require medical underwriting or charge a higher premium due to your current health issues. For those with preexisting conditions or disabilities, the OEP for Medicare is the best time to enroll.
Although Medicare enrollment is typically only offered during certain periods each year, Medicare Supplement plans are open for enrollment year-round. Bear in mind, however, that if you enroll in a Medicare Supplement plan outside the OEP, you may have higher premiums or be denied coverage altogether, depending on your health status.
If you choose to switch Medigap plans, you may have a 30-day “free look” that allows you to try out a new plan while retaining coverage under your old Medigap policy. You’ll be responsible for paying both premiums during this time, but you have to cancel your old policy when you apply for the new plan. There are a few other exceptions with applying for Supplemental Medicare and retaining your guaranteed usage rights, but these typically occur when the covering insurance company isn’t compliant with Medicare regulations.
In addition to the basic benefits that all Medicare Supplement plans are required to offer in Wisconsin, there are seven different “riders” that subscribers can choose to add to their Medigap plan. Many of these plans – the Base Plan plus riders – closely resemble the Medigap Plans offered in other states. The riders can give beneficiaries greater flexibility for coverage, as they only select and pay for the coverage types they need.
Wisconsin offers the Medigap Base plan, which covers coinsurance for hospital stays, hospice coinsurance, co-pays, and the first three pints of blood each year. In addition to this plan, there are several customizable add-on options for insurance coverage, allowing beneficiaries to “mix and match” coverage for their personal health needs.
The basic plan includes the coverage offered under the Medigap Base plan. It also covers the coinsurance for a skilled nursing facility required under Medicare Part A and inpatient mental health coverage from Medicare Part A. Mental health coverage includes the traditional Medicare benefit of 190 total days in the recipient’s lifetime as well as 175 days per beneficiary lifetime, for a total of 265.
Forty visits for home health coverage in addition to those covered by Medicare Part A are also included. Finally, state-mandated benefits including services related to treating kidney diseases and diabetes are also covered under this plan.
Wisconsin also offers two different cost-sharing plans, similar to Medicare Part K and Medicare Part L plans offered in other states. These Medigap plans supplement the recipient’s Original Medicare benefits of either a 25% or 50% cost-sharing basis. These two plans offer benefits that are similar to the Basic Plan, but they exclude the full cost of coinsurance for a skilled nursing home facility and the first three pints of blood benefit.
Depending on which cost-sharing plan you select, your own expenses will either be 25% or 50%. If you choose the 25% cost-sharing plan, for example, the insurance company will pay for 75% of the costs not covered by traditional Medicare, and you’ll pay the remaining 25%. These plans may be a better option for those who don’t need regularly scheduled specialist services or ongoing care.
Wisconsin residents have the option to add one or more of the following riders to their Base or Basic plans. These include:
In addition to the plans listed above, Wisconsin also offers Medicare Select plans that require members to use in-network providers, similar to a PPO or HMO insurance plan. These plans offer different basic benefits, optional riders, and cost-sharing options than traditional Medigap plans.
If you visit a health care provider or hospital outside of the plan’s network of service providers, a Medicare Select plan won’t pay for the services, or may only pay a small amount. Emergency situations are excluded. If traditional Medicare coverage pays for the treatment or services, you’re responsible for the costs not covered by Medicare.
Some of these plans offer cost-sharing options, as well, which differ from the regular cost-sharing plans sold in Wisconsin.
There are many different kinds of plans, and determining the right coverage at the right price can be tricky. You may opt to call each insurance company directly to get plan options and pricing. Bear in mind, however, that adding “riders” to your Wisconsin Medigap coverage can affect the cost. Before you call, make sure you’re comparing plans with the same coverage. You can also contact an independent broker to learn what’s available for your age and zip code and for help comparing plans.
A preexisting condition is a health condition that you had before the start of your policy. These conditions may include diabetes, kidney disease, heart conditions, or certain kinds of cancer. The presence of preexisting conditions may limit your coverage or prevent you from being covered entirely. Each plan can have its own definition for “preexisting conditions” and coverage options, so it’s important to read your plan’s policy and ask for clarification before enrolling. If you know you have a preexisting condition that may affect your coverage, enrolling during the OEP is even more important.
The state of Wisconsin requires Medigap insurance to provide several benefits, including up to 30 days of skilled nursing care in a group facility, up to 40 home health care visits, kidney disease services such as dialysis, transplants, and donor services, and diabetes treatments, including an insulin pump. Other mandated coverage includes chiropractic care, surgery center care, breast reconstruction, and colorectal cancer screening.
Most vision and dental services such as regular exams, eyeglasses, dental cleanings and fillings aren’t covered by Medigap plans. However, many of these plans do cover testing for glaucoma, cataracts, and other diseases. Oral dental exams required prior to kidney disease treatments or surgery are also typically covered.
Medigap plans may cover certain medications such as insulin required to treat diabetes, but prescription drugs are covered under Medicare Part D and some Medicare Advantage plans.