Guide to Health Insurance for People with Medicare in ...

2024 Guide to Health Insurance for People

with Medicare in Wisconsin

This guide gives an overview of the Medicare program and the health and

prescription drug insurance available to those on Medicare in Wisconsin.

Wisconsin Office of the Commissioner of Insurance

125 South Webster Street, P.O. Box 7873, Madison, WI 53707-7873

T: 608-266-3585 | T: 1-800-236-8517 | F: 608-264-8115

ociinformation@ | oci.

Free Health Insurance Counseling for Seniors

The following statewide toll-free phone numbers are set up by the Wisconsin Board on Aging and

Long-Term Care and funded by the Office of the Commissioner of Insurance (OCI) to answer

questions about health insurance, other healthcare benefits, and prescription drug benefits for

people with Medicare. They have no connection with any insurance company.

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Medigap Helpline: 1-800-242-1060

Medigap Part D and Prescription Drug Helpline: 1-855-677-2783

Disclaimer

This guide is intended as a general overview of current law in this area but is not intended as a

substitute for legal advice in any particular situation. You may want to consult your attorney about

your specific rights. Publications are updated annually unless otherwise stated and, as such, the

information in this publication may not be accurate or timely in all instances. Publications are

available at oci.Publications. If you need a printed copy, use the online order form

oci.Pages/Consumers/Order-a-Publication.aspx or call 1-800-236-8517. One copy of this

publication is available free to the general public. This may be printed or copied without permission.

File a Complaint

If you have a specific complaint (pages 4-5) about your insurance, refer it first to the insurance

company or agent involved. If you do not receive satisfactory answers, contact the Office of the

Commissioner of Insurance (OCI).

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Reach out to OCI (1-800-236-8517, ocicomplaints@) to speak with our staff. If

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File a complaint with OCI. You can file a complaint online at plaints. If you would

sending an email, please indicate your name and phone number.

like to file your complaint by mail, visit plaints, email

ocicomplaints@, or call 1-800-236-8517 for a form.

PI-002 (R 03/2024)

Contents

Introduction .............................................................................................................................................................................. 4

What is Medicare? .................................................................................................................................................................. 5

Medicare Part A ....................................................................................................................................................................5

Medicare Part B ....................................................................................................................................................................6

Medicare Part C/Medicare Advantage.........................................................................................................................6

Medicare Part D/Prescription Drug...............................................................................................................................6

What Are Specific Limitations Under Medicare? ......................................................................................................7

Skilled Nursing Care Limitations ....................................................................................................................................7

Home Health Limitations ..................................................................................................................................................7

What Preventive Care Is Covered Under Medicare? ...............................................................................................7

What Is Meant by Out-of-Pocket Expenses? .............................................................................................................7

What Does Accepting Assignment Mean? .................................................................................................................8

What is Medicare Part D? .................................................................................................................................................... 8

Enrollment ..............................................................................................................................................................................8

Premiums ................................................................................................................................................................................8

Coverage .................................................................................................................................................................................9

The Donut Hole ....................................................................................................................................................................9

Out-of-Pocket Expenses ...................................................................................................................................................9

Extra Help for People with Limited Income and Resources .................................................................................9

Tips to Remember ............................................................................................................................................................ 10

Contact ................................................................................................................................................................................. 10

Coverage Options Available When You are Eligible for Medicare ..................................................................... 10

Individual Policy Options ................................................................................................................................................... 11

Medicare Supplement Policies .................................................................................................................................... 11

Outline of Coverage ........................................................................................................................................................ 11

Medicare SELECT Policies .............................................................................................................................................. 12

Medicare Cost Policies .................................................................................................................................................... 13

Medicare Advantage Plans (Medicare Part C) ........................................................................................................ 13

Medicare Advantage Health Maintenance Organization Plans ....................................................................... 14

Medicare Advantage Preferred Provider Organization Plans........................................................................... 14

Medicare Advantage Private Fee-For-Service Plans ............................................................................................ 15

Group Insurance Options................................................................................................................................................... 15

PI-002 (R 03/2024)

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Employer Group Plans .................................................................................................................................................... 15

Employer Plans .................................................................................................................................................................. 15

Employers with 20 or More Employees .................................................................................................................... 16

Employers with Less Than 20 Employees................................................................................................................. 16

COBRA Coverage .............................................................................................................................................................. 16

Special Enrollment Period ............................................................................................................................................. 17

Health Savings Account ................................................................................................................................................. 17

Voluntary Association Plans.......................................................................................................................................... 17

What Are Wisconsin Mandated Benefits? .................................................................................................................... 17

Basic Facts About Medicare Supplement Policies .................................................................................................... 19

Open Enrollment ............................................................................................................................................................... 19

Guaranteed Issue .............................................................................................................................................................. 19

Suspension of Medicare Supplement Policy .......................................................................................................... 21

30-Day Free Look.............................................................................................................................................................. 21

Renewability ....................................................................................................................................................................... 21

Midterm Cancellation...................................................................................................................................................... 21

Waiting Periods, Limitations, and Exclusions.......................................................................................................... 21

Creditable Coverage ........................................................................................................................................................ 22

Basic Benefits Included in Medicare Supplement Policies ..................................................................................... 24

Basic Benefits Included in Medicare SELECT Policies............................................................................................... 25

Policy Description ................................................................................................................................................................. 26

Policy Benefits ¨C Traditional Insurers ......................................................................................................................... 26

Policy Benefits ¨C Traditional Insurers Cost-Sharing 50% and 25% ................................................................. 27

Policy Benefits ¨C Medicare SELECT ............................................................................................................................. 28

Policy Benefits ¨C Medicare SELECT Cost-Sharing 50% and 25% ..................................................................... 29

Policy Benefits ¨C Cost Insurance ¨C Basic and Enhanced ..................................................................................... 30

Policy Benefits ¨C High-Deductible Plan .................................................................................................................... 31

Filing a Claim .......................................................................................................................................................................... 32

Your Grievance and Appeal Rights ................................................................................................................................. 33

Medicare Supplement Mandated Benefits .............................................................................................................. 33

Prescription Drug Discount Options .............................................................................................................................. 34

SeniorCare Prescription Drug Assistance Program .............................................................................................. 34

Consumer Buying Tips ........................................................................................................................................................ 34

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Cost of Policies .................................................................................................................................................................. 34

Policy Delivery and Refunds ......................................................................................................................................... 35

Policy Storage .................................................................................................................................................................... 35

Duplicate Coverage.......................................................................................................................................................... 35

Health History .................................................................................................................................................................... 36

Payment ............................................................................................................................................................................... 36

Replacing Existing Coverage ........................................................................................................................................ 36

Insurance Agents and Companies .............................................................................................................................. 36

What if I Cannot Afford a Medicare Supplement Policy? ...................................................................................... 37

Medicaid Program ............................................................................................................................................................ 37

Qualified Medicare Beneficiary (QMB) and Specified Low-Income Medicare Beneficiary (SLMB)

Programs.............................................................................................................................................................................. 37

State Health Insurance Assistance Program (SHIP) .................................................................................................. 38

Limited Policies ...................................................................................................................................................................... 38

What if I Have Additional Questions? ........................................................................................................................... 39

Health Insurance ............................................................................................................................................................... 39

Elder Benefit Specialists.................................................................................................................................................. 39

Medicare .............................................................................................................................................................................. 40

Prescription Drug Helplines for Medicare Beneficiaries ..................................................................................... 40

Acronyms ................................................................................................................................................................................. 41

Glossary of Terms ................................................................................................................................................................. 42

Introduction

This publication provides a general overview of the Medicare program. It also describes the

health and prescription drug insurance available to those on Medicare. A list of Medicare

Supplement Insurance Policies marketed in Wisconsin is available on the OCI website at

oci.Pages/Consumers/PI-010.aspx or the Medicare website at plancompare.

If you have a specific complaint about your insurance, you should first attempt to resolve your

concerns with your insurance agent or with the company involved in your dispute. If you do not

get satisfactory answers from the agent or company, contact OCI. A complaint form is available

on the OCI website at plaints.

PI-002 (R 03/2024)

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To file a complaint with OCI:

Visit the OCI website at plaints or call the Insurance Complaint Hotline:

1-800-236-8517 (Statewide)

(608) 266-0103 (Madison)

Deaf and hearing or speech-impaired callers may reach OCI through WI TRS.

You may also find companies offering Medicare Advantage and Prescription Drug Plans (PDPs)

on the Medicare website at plan-compare. These plans are regulated by

Medicare rather than the OCI. Therefore, these plans have their own appeal processes that

should be followed if you have a complaint or wish to appeal a decision.

Important Notice

The State of Wisconsin has received a waiver from the federal A-N standardization regulations

on Medicare Supplement insurance. This means policies sold in Wisconsin are somewhat

different from those available in other states. This publication describes only those policies

available in Wisconsin.

What is Medicare?

Medicare is the health insurance program administered by the federal Centers for Medicare &

Medicaid Services (CMS) for people 65 years of age or older, people of any age with permanent

kidney failure or Lou Gehrig¡¯s disease (ALS), and some individuals with disabilities under age 65.

Although Medicare may pay a large part of your health care expenses, it does not pay for all

your expenses. Some services and medical supplies are not fully covered. A publication titled

Medicare & You is available at in several different formats (English and Spanish)

including large print, eBook, audio, and braille versions: forms-help-

resources/medicare-you-handbook/download-medicare-you-in-different-formats. You can also

request a paper handbook by calling 1-800-MEDICARE (1-800-633-4227) or from any Social

Security office. The publication provides a detailed explanation of Medicare.

Medicare is divided into four types of coverage: Part A, Part B, Part C, and Part D.

Medicare Part A

Medicare Part A is commonly known as hospitalization insurance. For most people, Part A is

premium-free, meaning you do not have a monthly payment for coverage. It pays your hospital

bills and certain skilled nursing facility expenses. It also provides very limited coverage for

skilled nursing care after hospitalization, rehabilitative services, home health care, and hospice

PI-002 (R 03/2024)

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