Medicare

Medigap in Wisconsin

Medigap plans help pay for healthcare costs that aren’t covered by Original Medicare. In Wisconsin, Medigap plans are standardized differently than in the rest of the country.

Medigap in Wisconsin

Nearly 600,000 Wisconsin residents were enrolled in Original Medicare as of January 2022. This federal healthcare program helps people who are 65 and older, or those younger than 65 with certain disabilities or End-Stage Renal Disease. It helps to make medical expenses more affordable as people age and encounter more health issues. But while Medicare helps with expenses, it still has coinsurance, premiums, and other out-of-pocket costs. Medicare beneficiaries who want help paying for the costs Medicare doesn’t cover may benefit from Medicare Supplement Insurance, also known as Medigap. 

Medigap options in Wisconsin differ from the rest of the country. Wisconsin is one of just three states — Massachusetts and Minnesota are the others — that does not offer the typical standardized Medigap plans. Instead, Wisconsin 4 of its own types: a basic plan, 25% cost-sharing plan, 50% cost-sharing plan, and high deductible plan.

What Are Medicare Supplement Plans?

Medicare supplement plans, or Medigap plans, can help people with Original Medicare pay for their deductibles, copayments, and coinsurance. Some plans also provide coverage for benefits that Original Medicare doesn’t, such as foreign travel emergency care. This coverage can help make healthcare more affordable for people with Medicare, though it should be noted that Medigap plans can only accompany Original Medicare and not those with Medicare Advantage plans. 

Medigap is sold by private, Medicare-approved insurance companies, and are typically standardized with the letters A, B, C, D, F, G, K, L, M, or N. Each plan with the same letter covers the same set of benefits. For example, each Plan A is required to cover the same benefits, no matter which insurance company sells it. However, specific plans may offer slightly different additional benefits based on insurer and state regulations.

However, Wisconsin is one of three states that standardizes Medigap plans differently. Instead of the lettered plans available in the rest of the country, Wisconsin Medigap insurers may sell the following standardized plans: a Basic Plan, 25% Cost-Sharing Plan, 50% Cost-Sharing Plan, or a High-Deductible Plan. Insurers are also allowed to sell standardized riders that add coverage to Medigap.

In addition, Wisconsin residents have guaranteed issue rights to buy a Medigap policy during set enrollment periods, regardless of their age or health status. This means insurers are required to offer Medigap policies to eligible applicants with preexisting conditions, including people under 65 who have Medicare due to a disability or End-Stage Renal Disease.

Your Options for Wisconsin Medicare Supplement Plans

BenefitsBasic Plan25% Cost Sharing Plan50% Cost Sharing PlanHigh Deductible Plan
Medicare Part A hospitalization coinsuranceYesYesYesYes
Medicare Part B coinsuranceYesYesYesYes
First 3 pints of blood in a calendar yearYes75%50%Yes
40 additional home healthcare visitsYesYesYesCovers 365 home health visits
175 additional lifetime inpatient mental health daysYesYesYesYes
Outpatient mental healthcareYesN/AN/AN/A
State-mandated benefitsYesN/AN/AN/A
Part A deductibleN/A75%50%N/A
Coinsurance for days 21 through 100 of skilled nursing careN/A75%50%Yes
Non-Medicare-covered chiropractic careN/AYesYesN/A
30 days of non-Medicare-covered skilled nursing careN/AYesYesN/A
Part B excess chargesN/AN/AN/AYes
Foreign travel emergency careN/AN/AN/AYes

Basic Plan

The Basic Plan is one of the standardized Medicare Supplement plans in Wisconsin. Each basic plan is required to cover the following benefits, regardless of which insurer sells it:

  • Medicare Part A coinsurance and hospice coinsurance or copayment
  • Medicare Part B coinsurance
  • First 3 pints of blood in a calendar year
  • 40 additional home healthcare visits
  • 175 additional lifetime inpatient mental health days
  • Outpatient mental healthcare

Insurers are also required to cover state-mandated benefits, even if Original Medicare doesn’t cover those services. As of 2022, these benefits include kidney disease treatment, insulin infusion pumps, and chiropractic care.

People who enroll in the Basic Plan may choose to expand their coverage by purchasing riders:

  • Medicare Part A deductible: Covers the Part A deductible for inpatient hospital stays ($1,556 per benefit period in 2022)
  • Medicare Part A deductible (50%): Covers 50% of the Part A deductible
  • Additional home healthcare: Covers 365 visits in a policy year, including those covered by Medicare
  • Medicare Part B deductible: Covers the Part B deductible ($233 in 2022) for those who were eligible for Medicare on or before December 31, 2019.
  • Medicare Part B coinsurance: Covers 20% of the Medicare-approved cost for Part B services
  • Medicare Part B excess charges: Helps cover services from providers who charge more than the Medicare-approved amount
  • Foreign travel emergency care: Covers emergency care received outside the U.S.

25% Cost Sharing Plan (similar to Plan L)

Wisconsin’s 25% Cost-Sharing Plan is similar to Medigap Plan L in other states, but it covers some services that Plan L does not. In both plans, enrollees are responsible for 25% of the cost of certain covered services, while the plan covers the remaining 75%. This cost-sharing requirement ends when enrollees meet their annual out-of-pocket limit ($3,310 in 2022).

Services covered with the 25% cost-sharing requirement include:

  • Part A deductible
  • Coinsurance for days 21 through 100 of skilled nursing care
  • First 3 pints of blood

Other benefits are covered without a 25% cost-sharing requirement, including:

  • Medicare Part A hospitalization coinsurance
  • 175 additional lifetime days of inpatient psychiatric care
  • 40 additional home healthcare visits
  • Medicare Part B coinsurance
  • Non-Medicare-covered chiropractic care
  • 30 days of non-Medicare-covered skilled nursing care

Insurers who offer this plan may sell an additional home healthcare rider that covers 365 home health visits per year. 

50% Cost Sharing Plan (similar to Plan K)

Wisconsin’s 50% Cost-Sharing Plan is similar to the standardized Plan K available in the rest of the country. Both plans cover 50% of the cost of certain services. Enrollees are responsible for 50% of the cost of these services until they reach their annual out-of-pocket limit, which is $6,620 in 2022.

The 50% Cost-Sharing Plan covers the same list of services as the 25% Cost Sharing Plan. However, for services with a cost-sharing requirement, enrollees are responsible for 50% of the cost, rather than 25%. 

As with the 25% Cost-Sharing Plan, insurers may sell an optional rider that covers 365 medically necessary home health visits.

High Deductible Plan

Wisconsin’s High-Deductible Medicare Supplement plan starts covering services once an enrollee has reached the annual deductible ($2,490 in 2022). The Part A and Part B deductibles count toward this target.

Benefits covered by the High-Deductible Plan include:

  • Coinsurance for days 21 through 100 of skilled nursing care
  • Part A hospitalization coinsurance
  • Coinsurance for Part B services
  • Part B excess charges
  • 175 additional lifetime inpatient psychiatric care days
  • First 3 pints of blood
  • 365 home health visits, including those covered by Original Medicare
  • Foreign travel emergency care

Medigap Eligibility in Wisconsin

Wisconsin residents may be eligible for Medigap if they have Original Medicare (both Part A and Part B), regardless of their age or health status. The state requires Medigap insurers to offer 1 or more kinds of policies to people under 65 who are eligible for Medicare due to a disability or End-Stage Renal Disease. A larger range of plans may be available to Medicare members who are 65 or older.

When to Enroll in Medigap in Wisconsin

Medicare enrollment periods are set windows when eligible people can make changes to their coverage. Wisconsin residents who want to join, drop, or switch Medigap plans can mark these periods on their calendars. Otherwise, Medigap policies are sold throughout the year. However, if you apply outside of Medigap Open Enrollment and aren’t eligible for a Special Enrollment Period, insurers can use medical underwriting as part of their eligibility criteria and may decline to sell you a policy.

Medigap Open Enrollment Period

  • When: A 6-month window that begins when you enroll in Part B
  • What You Can Do: Enroll in a Medigap plan, regardless of health status

The Medigap Open Enrollment Period or Initial Enrollment Period is your first opportunity to enroll in a Medigap plan. In Wisconsin, this 6-month period begins when you enroll in Part B, regardless of your age. People who are eligible for Medicare due to disability receive a second 6-month Initial Enrollment Period for Medigap when they turn 65.

During this period, insurers are not permitted to deny coverage based on applicants’ health status or preexisting conditions, and they also are not permitted to charge higher premiums to tobacco users.

Special Enrollment Periods

  • When: A 63-day period that begins when your other health coverage ends
  • What You Can Do: Enroll in a Medigap plan, regardless of health status

Outside of Medigap Open Enrollment, Wisconsin residents who experience certain qualifying events have guaranteed issue rights to buy a Medigap policy. This means Medigap insurers are not permitted to deny coverage or charge higher premiums due to preexisting conditions.

Qualifying events that may trigger a Special Enrollment Period for Medigap include:

  • Losing your employer-sponsored health insurance
  • Losing your Medicare Advantage plan
  • Your insurance company ends your Medicare SELECT or Medicare Supplement coverage

Medigap vs. Medicare Advantage

Medicare Advantage, also known as Part C, is an alternative to Original Medicare offered by private insurers. It must cover Medicare Part A and B benefits, but often includes additional benefits as well, such as dental, vision, and Part D prescription drug coverage. Medicare-eligible Wisconsin residents may choose to join a Medicare Advantage plan, but those who do so become ineligible for Medigap. When deciding whether Medicare Advantage or Medigap is right for you, consider the following:

  • Budget: Compare each option’s monthly premiums, annual deductibles, and cost-sharing requirements. Estimate how much you might pay based on your typical health care needs. 
  • Health needs: Consider your health needs when deciding which option is right for you. For example, if your only recurring health need is diabetes care, Medigap may be a better choice because Wisconsin Medicare Supplement plans are required to cover diabetes treatment. Medicare Advantage plans, on the other hand, do not necessarily need to provide this coverage.
  • Current doctors: If you want to keep seeing your current doctors, find out which option they accept. Original Medicare and Medigap coverage can be used with any doctor that accepts Medicare payments. However, Medicare Advantage plans function more like Marketplace plans in that they require members to get care from in-network healthcare providers. 
  • Travel plans: If you plan to travel, consider each option’s service area. Medicare Advantage plans may provide a network of doctors and hospitals within a service area, but not outside of it. Original Medicare and Medigap can be used nationwide, so long as the doctor accepts Medicare.