Medicare in Wisconsin: Key takeaways
- Wisconsin residents enrolled in Medicare comprise nearly 20 percent of the state’s population.
- Wisconsin is one of three states with different Medigap standardization rules.
- Wisconsin regulations guarantee access to Medigap plans for people under 65, but their premiums are considerably higher.
- As of 2016, Medicare spent $8,248 per enrollee in Wisconsin, for enrollees in Original Medicare.
- About 39 percent of Wisconsin’s Medicare population had Medicare Advantage plans in 2017.
- Wisconsin has 461,649 Medicare beneficiaries enrolled in stand-alone Part D prescription drug plans as of December 2018.
Medicare enrollment in the Badger State
1,152,127 Wisconsin residents had Medicare coverage as of December 2018. That’s nearly 20 percent of the state’s population, versus a little more than 18 percent of the total US population enrolled in Medicare.
In most cases, Americans become eligible for Medicare when they turn 65. But Medicare also provides coverage for disabled Americans under age 65, once they have been receiving disability benefits for 24 months. Nationwide, 16 percent of Medicare beneficiaries are disabled and under age 65; in Wisconsin, it’s 15 percent. In Alabama, Kentucky, and Mississippi, 23 percent of Medicare beneficiaries are under 65, while just 9 percent of Hawaii’s Medicare beneficiaries are eligible due to disability.
Wisconsin has its own standardization for Medigap plans, and protects access for people under age 65
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 them to conduct their 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 F” (as enrollees in most states would do if they wanted the most comprehensive Medigap plan), Wisconsin enrollees would buy the basic plan and then add on the optional riders.
Wisconsin Medigap insurers have to offer “basic benefits” that includes 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, insurers can offer up to seven optional riders that enrollees 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 (as of January 2020, people who are newly eligible for Medicare will not be able to purchase Medigap coverage for the Part B deductible; those who already have this coverage will be able to keep it; 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 F sold in other states, they would need to buy the Basic Plan plus riders for the Part A deductible, Part B 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, and high-deductible plans that require the member the pay all costs until they meet the deductible for the year.
There are at least 33 insurers that offer traditional Medigap plans in Wisconsin as of 2019, in addition to six insurers that offer Medicare Select 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). 280,899 Wisconsin Medicare beneficiaries had Medigap coverage as of 2016, according to an AHIP analysis. That’s about 42 percent of the state’s Original Medicare enrollees (Medigap coverage cannot be used with Medicare Advantage plans).
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). The type of rating each insurer uses is available here.
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).
People who aren’t yet 65 can enroll in Medicare if they’re disabled and have been receiving disability benefits for at least two years, and 15 percent of Medicare beneficiaries in Wisconsin are under age 65. Federal rules do not guarantee access to Medigap plans for people who are under 65, but the majority of the states — including Wisconsin — have implemented rules to ensure that disabled Medicare beneficiaries have at least some access to Medigap plans.
Medigap insurers in Wisconsin are required to offer coverage to disabled enrollees under age 65, with the same six-month open enrollment period that begins when the person is enrolled in Medicare Part B. But premiums for people under the age of 65 are considerably higher than premiums for people who are 65.
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, as long as they don’t have kidney failure. Medicare Advantage plans are otherwise available to anyone who is eligible for 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 $6,700 per year 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.
Per-beneficiary Medicare spending in Wisconsin
Original Medicare’s average per-beneficiary spending in Wisconsin was 13 percent lower than the national average in 2016, at $8,248; only 13 states had lower average per-beneficiary Original Medicare spending. The spending amounts are based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for Medicare Advantage. Nationwide, average per-beneficiary Original Medicare spending stood at $9,533.
Medicare Advantage in Wisconsin
Medicare beneficiaries can choose to get their coverage through private Medicare Advantage plans, or directly from the federal government via Original Medicare. Medicare Advantage plans are offered by private insurers, so plan availability varies from one area to another. Wisconsin’s Medicare Advantage market is robust: Plans are available state-wide, and residents in every county have access to at least nine plans, and in most cases, more than 20. In Waukesha County, there are 47 Medicare Advantage plans for sale.
Thirty-nine percent of Medicare beneficiaries in Wisconsin had Medicare Advantage coverage as of 2017, versus about 33 percent nationwide. As of December 2018, there were 478,038 Wisconsin Medicare beneficiaries enrolled in private Medicare coverage (not counting private supplemental coverage like Part D and Medigap). That’s 42 percent of the state’s Medicare population, but some Wisconsin Medicare beneficiaries are enrolled in Medicare Cost plans, which are another form of private Medicare coverage (three insurers in Wisconsin offer Medicare Cost plans). The other 674,089 Medicare beneficiaries in Wisconsin had coverage under Original Medicare as of late 2018.
The popularity of Medicare Advantage varies from one state to another. In Minnesota, 56 percent of the state’s Medicare population is enrolled in Advantage plans, whereas only 1 percent of Alaska Medicare beneficiaries have Advantage plans (and those are via employer-sponsored coverage, as there are no Medicare Advantage plans available for individuals to purchase in Alaska).
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 (out-of-pocket costs are not capped under Original Medicare).
Original Medicare includes Medicare Parts A and B. Medicare Advantage includes all of the coverage provided by Medicare Parts A and B, and the plans often include additional benefits, such as integrated Part D prescription drug coverage and 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. There are pros and cons to either option, and the right solution is different for each person.
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 switch to a different Medicare Part D prescription plan). Starting in 2019, people who are already enrolled in Medicare Advantage also have the option to switch to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31.
Part D coverage in Wisconsin
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.
But Medicare beneficiaries who do not have Medicaid or employer-sponsored drug coverage need Medicare Part D in order to have coverage for prescriptions. 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. Both options are available for purchase (or plan changes) from October 15 to December 7 each year, with the new coverage effective January 1 of the coming year.
There are 28 stand-alone Part D plans for sale in Wisconsin in 2019, with premiums that range from about $14 to $112/month.
About 40 percent of Wisconsin’s Medicare beneficiaries (461,649 people) had stand-alone Part D plans as of December 2018. Another 373,796 Wisconsin Medicare beneficiaries had Part D prescription coverage integrated with their Medicare Advantage plans.
Health insurance in Wisconsin if you’re not eligible for Medicare
Are you in need of health insurance in Wisconsin and not eligible for Medicare? We have information on Wisconsin health insurance and the Wisconsin health insurance marketplace at our health insurance site.
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.