Medigap in Wisconsin
You have guaranteed rights to purchase Medigap coverage — also called Medicare supplemental insurance — if you live in Wisconsin. But the plans in Wisconsin are different from the standardized choices of Medigap plans available in most other states.
Medigap Policies Available in Wisconsin
Wisconsin is one of three states with federal waivers to set standards for Medigap plans sold there. The other two states are Minnesota and Massachusetts.
There are four types of Medigap plans available in Wisconsin: The Basic plan and three cost-sharing plans. All three offer the same core benefits.
- Pays Medicare Part A coinsurance for inpatient hospital care
- Pays Medicare Part B coinsurance (typically 20 percent of the Medicare-approved amount) for medical costs
- Pays for first three pints of blood you need each year
- Pays for coinsurance or copayment of Medicare Part A hospice coverage
Beyond the basic core benefits, each of the three types of Wisconsin Medigap plans provides other health care benefits.
Wisconsin Medigap Basic Plan
Wisconsin’s Medigap Basic plan is designed to supplement Original Medicare benefits by paying your coinsurance — 20 percent of the Medicare-approved costs not covered by Medicare Part A or Part B.
The Basic plan includes the minimum core benefits included in all Medicare Supplement plans sold in the state.
In addition, insurance companies can offer additional benefit options. Each option is individually priced and is sold separately from the Medigap Basic plan.
These options are called riders and may be added to any plan so long as the insurance company selling a plan offers them.
- 100 percent of your Medicare Part A deductible
- 50 percent coverage of your Medicare Part A deductible
- Additional 365 home health care visits (including those Medicare pays for)
- Foreign travel emergency health care coverage
- Medicare Part B copay or coinsurance
- Medicare Part B deductible if you were enrolled in Medicare prior to Jan. 1, 2020 (those eligible for Medicare but not enrolled by the deadline may still be eligible)
- Medicare Part B excess charges
The Basic plan allows you to receive health care services from the doctor of your choice, but you may have to submit your claim to the insurance company for payment.
Wisconsin Cost-Sharing and High-Deductible Medigap Plans
There are two cost-sharing plans and one high-deductible Medigap plan available in Wisconsin. All three include Wisconsin’s basic core benefits.
Because you are left with higher out of pocket costs or a higher deductible with these plans, the monthly premiums you pay may be lower.
- 50 or 25 Percent Cost-Sharing
- Similar to the standardized Medigap Plan K (50 percent) and Plan L (25 percent) in most states. Pays 50 percent or 25 percent of Original Medicare copayments or coinsurance for certain hospital and medical costs.
- High-Deductible Medigap Plan
- The high-deductible plan features a $2,370 deductible in 2021. The deductible consists of expenses usually covered by the policy. No plan is allowed to cover the Medicare Part B deductible since Jan. 1, 2020, but the Part B deductible counts toward the deductible on this plan.
The maximum out-of-pocket (MOOP) cost for the 25 percent plan was $3,110 in 2021. The MOOP for the 50 percent plan was $6,220.
- Medicare Part A inpatient deductible until all lifetime reserve days are used
- Adds an additional 365 days hospital coverage after lifetime reserve days are exhausted
- Coinsurance and copay for days 21 through 100 at a skilled nursing facility
- Coinsurance and copay for medical expenses and respite care
- Coinsurance and copay for costs for the first three pints of blood per year
The 25 and 50 percent cost-sharing plans also pay 100 percent of some other costs. These include at least 175 days in a mental health hospital, home care expenses, diabetes treatment, breast reconstruction and 365 home health care visits.
Medigap Riders Medicare SELECT Policies
In addition to the four types of standardized Medigap plans available in Wisconsin, insurers are allowed to offer seven riders that allow you to tailor your policy to your needs. You can also buy a Medicare SELECT policy — a special type of Medigap plan that uses a network of health care providers.
In addition, Medicare enrollees in Wisconsin can purchase a Medicare SELECT policy from some insurers in the state. Each Medicare SELECT plan has its own network of health care providers that contracts with the insurance company or a health maintenance organization (HMO).
If you purchase a Medicare SELECT plan, you can receive covered services through these providers and the plan pays the full benefits provided in the policy.
If you go outside the network for nonemergency health care, Medicare will still pay its full share of approved costs. But you may have to pay higher out of pocket costs than if you stayed within the network.
5 Cited Research Articles
- Wisconsin Office of the Commissioner of Insurance. (2021, January). Guide to Health Insurance for People With Medicare in Wisconsin. Retrieved from https://oci.wi.gov/Documents/Consumers/PI-002.pdf
- Wisconsin Office of the Commissioner of Insurance. (2020, November). Medicare Supplement Insurance Policies List 2020. Retrieved from https://oci.wi.gov/Documents/Consumers/PI-010.pdf
- Wisconsin Department of Health Services. (2018, November 9). Medicare. Retrieved from https://www.dhs.wisconsin.gov/guide/medicare.htm
- Wisconsin Office of the Commissioner of Insurance. (2016, March). Form Filing Checklist – Individual & Group Medicare Supplement. Retrieved from https://oci.wi.gov/Documents/OCIForms/ChecklistMedSupp.pdf
- U.S. Center for Medicare & Medicaid Services. (n.d.). Medigap in Wisconsin. Retrieved from https://www.medicare.gov/supplements-other-insurance/how-to-compare-medigap-policies/medigap-in-wisconsin