2024 Guide to Health Insurance for People with Medicare in Wisconsin

PI-002 (R 03/2024)

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@wisconsin.gov | oci.wi.gov

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.

• 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.wi.gov/Publications. If you need a printed copy, use the online order form

oci.wi.gov/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).

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

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

• File a complaint with OCI. You can file a complaint online at oci.wi.gov/complaints. If you would

like to file your complaint by mail, visit oci.wi.gov/complaints, email

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

PI-002 (R 03/2024) 2

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) 3

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 – Traditional Insurers ......................................................................................................................... 26

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

Policy Benefits – Medicare SELECT ............................................................................................................................. 28

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

Policy Benefits – Cost Insurance – Basic and Enhanced ..................................................................................... 30

Policy Benefits – 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

PI-002 (R 03/2024) 4

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.wi.gov/Pages/Consumers/PI-010.aspx or the Medicare website at medicare.gov/plan-

compare.

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 oci.wi.gov/complaints.

PI-002 (R 03/2024) 5

To file a complaint with OCI:

Visit the OCI website at oci.wi.gov/Complaints 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 medicare.gov/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 Medicare.gov in several different formats (English and Spanish)

including large print, eBook, audio, and braille versions: medicare.gov/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) 6

care for the terminally ill. It does not pay for your personal (custodial) care, such as help with

eating, dressing, or moving around.

Under Medicare Part A, a period of hospitalization is called a benefit period.

A benefit period begins the day you are admitted into a hospital. It ends when you have been

out of the hospital or a nursing facility for 60 consecutive days. If you are re-admitted within

the 60 days, you are still in the same benefit period and would not pay another deductible. If

you are admitted to a hospital after the benefit period ends, an entirely new benefit period

begins, and a new deductible must be paid.

If you do not qualify for premium-free Medicare Part A, you may be able to buy it. Visit ssa.gov

or call Social Security at 1-800-772-1213 for more information.

Medicare Part B

Medicare Part B is commonly known as medical insurance. It helps pay your doctors’ bills and

certain other charges, such as surgical care, diagnostic tests and procedures, some hospital

outpatient services, preventive services, laboratory services, physical and occupational therapy,

and durable medical equipment. It does not cover your prescription drugs, dental care,

physicals, or other services not related to the treatment of an illness or injury. The premium is

automatically taken out of your Social Security check each month if you receive Social Security

benefits. If not, you may be billed for it.

Medicare Part C/Medicare Advantage

Medicare Part C is the Medicare program more commonly known as Medicare Advantage

providing Medicare coverage through private insurance plans.

Medicare Advantage plans bundle all Medicare health benefits (with or without drug coverage)

and may include extra services such as vision, hearing, dental, and more. You do not need to

purchase a Medicare Supplement policy if you enroll in a Medicare Advantage plan.

However, your Medicare Advantage plan may include deductibles and copayment and/or

coinsurance amounts (out-of-pocket expenses) that don’t apply to Wisconsin standardized

Medicare Supplement policies. You may also have to see doctors in the plan’s network or go to

certain hospitals to get services. Additional information is available in the OCI publication

Medicare Advantage in Wisconsin: oci.wi.gov/Pages/Consumers/PI-099.aspx.

Effective Jan. 1, 2021, people with End-Stage Renal Disease (ESRD) may enroll in Medicare

Advantage plans.

Medicare Part D/Prescription Drug

Medicare Part D is the Medicare program that helps you pay for outpatient prescription drug

costs. It is an optional program available to you because you are eligible for Medicare Part A

PI-002 (R 03/2024) 7

and/or enrolled in Medicare Part B. Additional information about Medicare Part D is included

on pages 8-10 of this publication.

What Are Specific Limitations Under Medicare?

Medicare was not designed to pay all your health care expenses. It does not cover long-term

care expenses. Medicare provides limited coverage for skilled nursing care and home health

care. Medicare does not pay for personal care, such as eating, bathing, dressing, or getting into

or out of bed. Most nursing home care is not covered by Medicare.

Skilled Nursing Care Limitations

If you need skilled nursing care (as defined by Medicare), Medicare pays limited benefits in a

Medicare-approved skilled nursing facility. For more information, visit oci.wi.gov or contact OCI

to request a copy of Guide to Long-Term Care: oci.wi.gov/Pages/Consumers/PI-047.aspx.

Home Health Limitations

Medicare pays limited benefits for your home health care services considered medically

necessary by Medicare. For more information, visit oci.wi.gov or contact OCI and request a copy

of the publication Guide to Long-Term Care: oci.wi.gov/Pages/Consumers/PI-047.aspx.

What Preventive Care Is Covered Under Medicare?

Medicare helps cover some of your preventive care services to help maintain your health and

keep certain illnesses from getting worse. You may be required to pay a portion of the costs for

these services. Information regarding Medicare preventive services is available in your Medicare

& You publication (medicare.gov/medicare-and-you).

What Is Meant by Out-of-Pocket Expenses?

Out-of-pocket expenses refer to the costs you will have to pay yourself. Out-of-pocket expenses

occur when there is a cost-share for a service, or you receive a service not covered by Medicare.

There are three types of out-of-pocket expenses you typically have to pay yourself:

Medicare deductibles, coinsurance, and copayments.

Fees that exceed the Medicare-approved amount (depending on whether the provider

accepts Medicare assignment or not – see below).

Services not covered by Medicare.

There are insurance policies you can purchase to cover some of your out-of-pocket expenses not

covered by Medicare called supplement policies. Medicare Supplement policies are described in

the Individual Policy Options section of this publication.

PI-002 (R 03/2024) 8

What Does Accepting Assignment Mean?

Some doctors and other providers accept Medicare assignment. This means the doctor or

provider is paid directly by Medicare and accepts the Medicare-approved amount.

A doctor or other provider who does not accept assignment can charge you 15% over

Medicare’s approved amount. In this case, you are responsible not only for the usual cost-

sharing of 20% of the approved charge for the service but also for the full 15% excess charge.

What is Medicare Part D?

Medicare Part D is the Medicare Prescription Drug Plan (PDP). A program created by the federal

Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to provide those on

Medicare assistance paying for outpatient prescription drug costs. It is an optional program

available when you are eligible for Medicare Part A and/or enrolled in Part B.

Enrollment

Medicare Part D includes an annual open enrollment period from October 15 through

December 7, during which time you can enroll or choose to change to another PDP. Your

coverage will begin on January 1 of the following year. Provided you are not yet on Medicare,

you will be able to join a PDP whenever you become eligible for Medicare.

Although your enrollment in Medicare Part D is voluntary, you may have to pay a penalty if you

decide to sign up after your eligible enrollment period ends, and there were 63 days or more in

a row when you did not have either Medicare drug coverage or other creditable prescription

drug coverage such as SeniorCare, a group employer plan, or veterans benefits Currently, the

late enrollment penalty is equal to one percent of the national base beneficiary premium

($34.70 in 2024) for every month you wait to enroll. This penalty amount changes every year,

and you will have to pay it as long as you have Medicare prescription drug coverage.

Medicare Part D coverage is offered by approved PDPs. The PDP benefits are administered by

private companies, some of which may be insurance companies. There are two types of

Medicare PDPs. One is a stand-alone PDP, which offers you only prescription drug coverage.

The other is a Medicare Advantage plan with prescription drugs (MA-PD), which provides all

your Medicare-covered services as well as prescription drug coverage.

You should review your drug coverage during every annual open enrollment period to make

sure you still have the best plan for your prescription drug needs.

Premiums

The cost of your Medicare Part D coverage will vary based on the PDP you choose. If you are

not eligible for low-income assistance (referred to as Limited Income Subsidy), you will pay a

monthly premium, an annual deductible, and a percentage of your drug costs. Your PDP will

PI-002 (R 03/2024) 9

pay for your outpatient prescription drug expenses after you have met deductible, copayment,

and coinsurance amounts.

Coverage

The prescription drugs covered by your PDP will vary based on the plan you choose. If you

enroll in a Medicare Part D PDP, it is important to understand your PDP will pay for only those

prescriptions in the plan’s formulary. A formulary is a list of specific drugs your Medicare PDP

will cover. Only the cost of drugs covered by your PDP will count toward the deductible and

out-of-pocket limits.

Outpatient prescription drug expenses not covered by your PDP or drugs covered by a drug

discount card will not count toward the out-of-pocket expense requirement of your PDP.

The Donut Hole

Most Medicare Part D PDPs have a coverage gap or “donut hole.” A coverage gap means after

you and your plan have spent a certain amount of money for covered drugs, you must pay all

out-of-pocket costs for your drugs while you are in the gap. The 2024 coverage gap

threshold starts after $5,030 is spent by you and your plan. This amount may change each

year.

If you reach the donut hole, you’ll pay no more than 25% of the price of the prescription drugs,

and you may get a discount on generic prescription drugs. The donut hole will eventually be

phased out and closed. Please see medicare.gov/drug-coverage-part-d/costs-for-medicare-

drug-coverage/costs-in-the-coverage-gap for further details.

If you meet certain income and resource limits, you may qualify for Extra Help. People with

Medicare who get Extra Help paying Medicare Part D costs won’t enter the coverage gap:

medicare.gov/your-medicare-costs/get-help-paying-costs/lower-prescription-costs

Out-of-Pocket Expenses

Once your out-of-pocket costs in 2024 reach $8,000, the coverage gap ends and catastrophic

coverage begins. Catastrophic coverage assures once you have reached your plan’s out-of-

pocket limit for covered drugs, you pay a smaller coinsurance amount or smaller copayment for

covered drugs the rest of the year.

Extra Help for People with Limited Income and Resources

If your income is low, you may qualify for Extra Help, also called Low Income Subsidy (LIS):

medicare.gov/your-medicare-costs/get-help-paying-costs/find-your-level-of-extra-help-part-d

This is a federal program to help you pay for most of the costs of Medicare prescription drug

coverage. The amount of assistance you qualify for depends on your income. Income and

resources standards are adjusted annually, and the amounts are released in January of each

PI-002 (R 03/2024) 10

year. For example, in 2024, if your resources are less than $17,220 for individuals or

$34,360 for married couples living together, you may qualify for Extra Help.

You can apply for Extra Help to assist in paying for your Medicare prescription drug coverage

with the Social Security Administration (SSA) through paper or online application. You may

contact the SSA at ssa.gov or by phone at 1-800-772-1213. You may also apply for Extra Help at

your local Medicaid office.

Tips to Remember

• Your participation in the Medicare Part D program is voluntary. However, if you do not

enroll in a Part D plan when you are first eligible and you decide to join later, you may have

to pay a late enrollment penalty unless you have had creditable drug coverage, such as

Wisconsin’s SeniorCare Prescription Drug Assistance Program.

• You do not have to pay an enrollment fee or pay for assistance to enroll in Medicare Part D.

• You will have to pay for Medicare Part D coverage, which may include monthly premiums

and cost-sharing, such as annual deductibles, coinsurance, and copayments.

• You may be eligible for Extra Help to pay for your Medicare Part D prescription drug

coverage based on your income.

• You do not have to enroll in Medicare Part D to keep your Medicare Part A and Part B

coverage.

• You do not have to buy any additional insurance products to be eligible to enroll in

Medicare Part D and you should be wary of any individual who uses a Part D sales pitch to

sell other insurance products.

Contact

You can get information about Medicare Part D by calling the Part D Helpline: 1-855-677-2783.

Coverage Options Available When You are Eligible for Medicare

Finding the right coverage at an affordable price may be difficult as no one policy is right for

everyone. Although there are many options available, this publication focuses on the coverage

options under individual Medicare Supplement insurance policies, Medicare SELECT insurance

policies, Medicare Cost insurance policies, Medicare cost-sharing policies, Medicare high-

deductible policies, and Medicare Advantage plans.

Before you decide to purchase a policy to help fill Medicare gaps, you need to familiarize

yourself with Medicare options, benefits, and rules.

PI-002 (R 03/2024) 11

CMS, which administers the Medicare Program, produces several guides, all of which are free

and can be obtained by writing to CMS or contacting 1-800-MEDICARE (1-800-633-4227) or

Medicare.gov.

Generally, when you become eligible for Medicare, you are not eligible to purchase a new plan

on the Federally Facilitated Marketplace (FFM). Information regarding Medicare and FFM

coverage can be found at HealthCare.gov/medicare.

Individual Policy Options

If you are eligible for Medicare, many insurance companies offer individual policies

supplementing the benefits available under Medicare. Options include Medicare Supplement

(aka Medigap), Medicare SELECT, and Medicare Advantage policies.

Medicare Supplement Policies

Medicare Supplement policies provide you with coverage for some of the costs not covered by

Medicare Part A and Medicare Part B. You are eligible for open enrollment in an individual

Medicare Supplement plan for six months starting with the first day you are enrolled in

Medicare Part B, regardless of your health history.

Medicare was never intended to pay 100% of your medical bills but was created to offset your

medical expenses by providing a basic foundation of benefits. While it will pay a significant

portion of your medical bills, Medicare does not cover all the services you might need. Even

those services covered are not covered in full.

Your Medicare Supplement policy does not restrict your ability to receive services from the

doctor of your choice. However, these policies may require you to submit your claim to the

insurance company for payment.

Your individual Medicare Supplement policy includes a basic core of benefits. In addition to the

basic benefits, your Medicare Supplement insurance company offers specified optional benefits.

Each of the options the insurance company offers you must be priced and sold separately from

the basic policy.

Medicare requires you to pay deductibles and many Part B expenses are paid at 80% of the

Medicare-approved amount. Medicare Supplement policies may be purchased from insurance

companies to cover the remaining 20% of Medicare-approved expenses not covered by

Medicare.

Outline of Coverage

The Outline of Coverage is a summary of your benefits provided by Medicare Parts A

and B and your Medicare Supplement policy. The outline includes a chart showing your

PI-002 (R 03/2024) 12

expenses both covered and not covered by either Medicare or the Medicare Supplement

policy. An agent or insurance company must give you an Outline of Coverage when

selling you a new policy or replacing the one you already own.

Some insurance companies offer Medicare Supplement or Medicare SELECT cost-sharing

policies. These plans require you to pay a portion of the costs for Medicare-covered

services until you reach an out-of-pocket limit. For 2024, the out-of-pocket limit for

25% cost-sharing plans is $3,530, and the out-of-pocket limit for 50% cost-sharing

plans is $7,060. The out-of-pocket limits for Medicare Supplement or Medicare SELECT

cost-sharing policies are updated each year and are based on estimates of the United

States Per Capita Costs of the Medicare program published by the Centers for Medicare

& Medicaid Services.

Some insurance companies may offer you a Medicare Supplement high-deductible plan.

High-deductible Medicare Supplement plans offer benefits after you have paid a

calendar year deductible of $2,800 for 2024. This deductible consists of expenses

ordinarily paid by the policy. As of January 1, 2020, Medicare Supplemental high-

deductible plans sold to people who are new to Medicare are not allowed to cover the

Part B deductible. As a result of this, the Part B deductible is not covered (reimbursed) if

you are newly eligible for Medicare on or after January 1, 2020, however, it does count

towards your High Deductible plan’s deductible. If, in the rare circumstance, your Plan’s

High Deductible is met with all Part A expenses and Part B Deductible expenses are then

incurred, these expenses will not be covered expenses until you meet the Medicare Part

B deductible.

Medicare SELECT Policies

Medicare SELECT policies are supplemental policies paying benefits only if your covered

services are obtained through network medical providers selected by the insurance company or

health maintenance organization (HMO). Each insurance company offering a Medicare SELECT

policy contracts with its own network of doctors or other providers to provide services. Each of

these insurance companies has a provider directory listing the doctors and other providers with

whom they have contracts.

If you buy a Medicare SELECT policy, each time you receive covered services from a plan

provider, Medicare pays its share of the approved charges and the insurance company pays the

full supplemental benefits provided for in the policy. Medicare SELECT insurers must pay

supplemental benefits for emergency health care furnished by providers outside the plan

provider network.

PI-002 (R 03/2024) 13

In general, Medicare SELECT policies will deny payment or pay less than the full benefit if you

go outside the network for nonemergency services. However, still pays its share of approved

charges if the services you receive outside the network are services covered by Medicare.

Important Notice

Coverage Changes to Part B Deductible - The Medicare Access and CHIP Reauthorization Act of 2015

(MACRA) changed Medicare Supplement policies’ coverage of Part B deductibles for those who

became “newly eligible” Medicare Beneficiaries on or after January 1, 2020, prohibiting first dollar

Part B coverage. This means a Part B Deductible Rider, Medicare SELECT policy, or High Deductible

Plan (which covers the Part B deductible as part of the plan) cannot be sold to you if you are “newly

eligible” for Medicare. If you either became eligible for or were enrolled in Medicare before January

1, 2020, you may keep or purchase a Part B Deductible Rider, Medicare SELECT policy, or High

Deductible Plan (which covers the Part B deductible as part of the plan) after December 31, 2019.

Medicare Cost Policies

Medicare Cost policies are offered by certain HMOs through a special arrangement with CMS.

Insurers marketing Medicare Cost policies offer both basic and enhanced Medicare Cost

policies. The basic Medicare Cost policy supplements only those benefits covered by Medicare

and does not provide the benefits mandated under Wisconsin insurance law.

You must live in the plan’s geographic service area to apply for Medicare Cost insurance. The

doctors or other providers are selected by the HMO, and agree to provide your Medicare

benefits, or may provide you with additional benefits at additional cost. Medicare Cost

insurance will only pay your full supplemental benefits if covered services are obtained through

HMO plan doctors or other providers, called the plan’s “network.”

If you purchase a Medicare Cost policy, Medicare pays its share of approved charges if you

receive services from outside the plan’s network area. If you go to a doctor or other provider

who does not belong to your HMO without a referral from your HMO doctor, you will

pay for your Medicare deductibles and copayments. The HMO will not provide your

supplemental benefits.

Medicare Advantage Plans (Medicare Part C)

Medicare Advantage plans are offered by certain HMOs and insurance companies that have

entered into special arrangements with CMS. Under these arrangements, the federal

government pays the HMO or insurance company a set amount for each Medicare enrollee. The

HMO or insurance company agrees to provide all Medicare benefits and may provide some

PI-002 (R 03/2024) 14

additional benefits, which may be at an additional cost. To receive optimum benefits, you must

receive services from only network providers.

It is important to note your Medicare Advantage plan can terminate at the end of the contract

year if either the plan or CMS decides to terminate their agreement. Medicare beneficiaries may

also make changes to their Medicare coverages between Oct. 15 – Dec. 7 during the Medicare

Annual Enrollment. Those already covered by a Medicare Advantage plan have another

opportunity to switch Advantage plans between Jan. 1 – Mar. 31 during the Medicare

Advantage Open Enrollment.

Your Medicare Advantage plan may include deductibles and copayment/coinsurance amounts

that do not apply to Wisconsin standardized Medicare supplement policies.

Medicare Advantage plans are not regulated by OCI. Therefore, these plans are NOT required

to cover Wisconsin mandated benefits, nor is your plan guaranteed renewable for life, like

Medicare Supplement policies. You can find information regarding Wisconsin Mandated

Benefits on page 17 of this publication or by contacting OCI at oci.wi.gov or the phone

numbers listed in this publication.

You may obtain more information by requesting a copy of the OCI publication Medicare

Advantage in Wisconsin: oci.wi.gov/Pages/Consumers/PI-099.aspx. You may also call CMS at

1-800-MEDICARE (1-800-633-4227) for information.

Medicare Advantage Health Maintenance Organization Plans

If you enroll in a Medicare Advantage plan through a health maintenance organization

(HMO) contracting with CMS, you are required to seek care from plan providers. This

means, except for emergency or urgent care situations away from home, you must receive all

services from HMO contracted medical providers. If you go to a doctor or other provider who

does not have a contract with your HMO without a referral from your doctor, you will be

responsible for the entire cost of the services you receive, including Medicare costs. To be

eligible for a Medicare Advantage plan through an HMO, you must live in the HMO’s

geographic service area.

Medicare Advantage Preferred Provider Organization Plans

If you enroll in a Medicare Advantage plan through a preferred provider organization

plan (PPO), to receive full coverage under the PPO option, you must receive all services,

except for emergency or urgent care situations away from home, from plan providers.

You may also enroll in a Medicare Advantage plan through an insurance company with a

preferred provider organization plan contracted with CMS. However, you may receive services

from providers outside the plan at an additional cost.

PI-002 (R 03/2024) 15

Medicare Advantage Private Fee-For-Service Plans

Medicare Advantage private fee-for-service (PFFS) plans differ from Medicare Advantage HMO

and PPO plans because they allow you to go to any doctor, hospital, or health care provider

agreeing to accept the PFFS plan’s terms of payment. PFFS plans do not have contracts with

doctors, hospitals, or health care providers. You do not have to obtain a referral from the plan

to go to a doctor, hospital, or specialist of your choice. However, it is your responsibility to

verify the doctor or other provider is willing to accept the PFFS plan’s payment terms. Doctors

and other providers can stop accepting the Medicare Advantage PFFS plan’s terms and

reimbursement rates at any time they choose.

Group Insurance Options

If you are covered under an employer group plan, you may still be eligible for coverage after

you reach age 65 either as an active employee or as a retiree. You may also be eligible to

purchase coverage through a voluntary association.

Employer Group Plans

If you are currently covered under an employer’s group insurance plan, you should determine

whether you have the option of continuing coverage or converting to suitable coverage that

will supplement Medicare before you decide to retire, become eligible for Medicare, or reach

age 65. State and federal laws require many employers to offer continued health insurance

benefits for a limited time if your group coverage ends because of divorce, death of a spouse,

or termination of employment for reasons other than a discharge for misconduct.

You should check with your employer for more information. You should also submit a written

request to your insurance company regarding the benefits you will have under the group

insurance policy after you or your spouse become eligible for Medicare.

If either you or your spouse plan to continue working after age 65, you need to take

extra care in making insurance decisions. Your group insurance plan may not provide the

same coverage you received before you turned 65.

Employer Plans

Federal law determines when Medicare is the primary payer and when it is the secondary payer.

This determination is based on whether you meet the definition of employee or dependent

under the group insurance policy and whether the group insurance policy is offered by an

employer with 20 or more employees. In some cases, your employer may offer a supplement to

Medicare through a group retiree plan.

PI-002 (R 03/2024) 16

Employers with 20 or More Employees

If you continue to work past age 65, and your employer has at least 20 employees, your group

plan will be the primary payer over Medicare. If you are 65, retired, covered under your actively

employed spouse’s group plan, and your spouse’s employer has at least 20 employees, the

group plan will be the primary payer. In either of these cases, when the employee (you or

your spouse) retires and is no longer considered an active employee, each Medicare-

eligible beneficiary (you and/or your spouse) may have a Special Enrollment Period (SEP)

and should enroll in Medicare Part B (if not already enrolled).

If you do not enroll in Medicare Part B and are allowed to continue your employer’s group

health plan, the group policy may pay only 20% of covered expenses and you will be

responsible for paying the remaining 80%. This is because your group policy may calculate its

benefit payment as if you are enrolled in Medicare Part B regardless of whether you sign up for

Medicare Part B. Also, to apply for a Medicare Supplement or Medigap policy, most insurance

companies require you to have both Medicare Part A and Part B.

Employers with Less Than 20 Employees

If you continue to work past age 65 and are considered an active employee but your employer

has fewer than 20 employees, Medicare is the primary payer, and your group policy is the

secondary payer. If you do not enroll in Medicare Part B when you become eligible, your group

policy may pay only 20% of covered expenses and you will be responsible for paying the

remaining 80%. This is because your group policy may calculate its benefit payment as if you

are enrolled in Medicare Part B regardless of whether you sign up for Medicare Part B. If your

spouse is covered under your employer’s plan and becomes eligible for Medicare because of

disability or retirement, your group policy may change to paying only 20% because Medicare is

primary as soon as your spouse becomes eligible for Medicare.

You can search for the publication Medicare and Other Health Benefits: Your Guide to Who Pays

First online at medicare.gov/publications (or view it online by clicking here). You can also

contact your local Social Security office to request the publication.

Remember: Employer group coverage is often available regardless of your health and usually

does not include any waiting periods for preexisting conditions.

COBRA Coverage

The Consolidated Omnibus Budget Reconciliation Act (COBRA) is the law allowing some people

to keep their group health coverage for a limited time after they leave their employment.

However, there are important time frames affecting COBRA coverage when you are eligible for

Medicare and Medicare Supplement policies.

PI-002 (R 03/2024) 17

Additional information regarding COBRA coverage and Medicare Part B is in the publication

Medicare & You, available on the Medicare website or by contacting your local Social Security

office.

Special Enrollment Period

If you did not enroll in Medicare Part B when you were first eligible because you or your spouse

were working and had group health plan coverage through you or your spouse’s employer or

union, you may be eligible to enroll in Medicare Part B during a Special Enrollment Period (SEP).

You or your spouse (or your family member if you are disabled), also have an eight-month SEP

to sign up for Part B that starts at one of these times (whichever happens first):

1. The month after employment ends.

2. The month after group health plan insurance based on current employment ends.

COBRA and retiree health plans aren’t considered coverage based on current employment. D

Details regarding more events that trigger a SEP are available from the Social Security

Administration: ssa.gov/pubs/EN-05-10043.pdf.

Health Savings Account

If you have a Health Savings Account (HSA) with a High Deductible Health Plan (HDHP) through

current employment, you may be eligible for a SEP. To avoid a tax penalty, you should stop

contributing to your HSA at least six months before you apply for Medicare. We suggest you

consult a tax professional regarding your specific situation to discuss necessary changes to

avoid excess contributions. You can withdraw money from your HSA after you enroll in

Medicare to help pay for medical expenses (like deductibles, premiums, coinsurance, or

copayments).

Voluntary Association Plans

Many associations offer group health insurance coverage to their members. Association plans

are not necessarily less expensive than comparable coverage under an individual policy. Be sure

you understand the benefits included and then compare prices. Association groups offering

Medicare Supplement insurance must comply with the same rules applying to other Medicare

Supplement policies.

What Are Wisconsin Mandated Benefits?

Wisconsin insurance law requires that individual Medicare Supplement policies, Medicare

SELECT policies, and some Medicare Cost policies contain the following mandated benefits.

These benefits are available even when Medicare does not cover these expenses. Medicare

Advantage plans are NOT required to provide these benefits.

PI-002 (R 03/2024) 18

Skilled Nursing Facilities—Medicare Supplement and Medicare SELECT policies cover 30 days

of skilled nursing care in a skilled nursing facility. The facility does not need to be certified by

Medicare and the stay does not have to meet Medicare’s definition of skilled care. No prior

hospitalization may be required. The facility must be a licensed skilled care nursing facility. The

care must also meet the insurance company’s standards as medically necessary.

Home Health Care—Medicare Supplement and Medicare SELECT policies cover up to 40 home

care visits per year in addition to those provided by Medicare if you qualify. Your doctor must

certify that you would need to be in the hospital or a skilled nursing home if the home care was

not available to you. Home nursing and medically necessary home health aide services are

covered on a part-time or intermittent basis, along with physical, respiratory, occupational, or

speech therapy.

Medicare Supplement insurance companies are required to offer an option to purchase

coverage for 365 home health care visits in a policy year. Insurance companies may charge an

additional premium for the additional coverage. Medicare provides coverage for all medically

necessary home health visits. However, “medically necessary” is narrowly defined, and you must

meet certain other criteria.

Kidney Disease—Medicare Supplement and Medicare SELECT policies cover inpatient and

outpatient expenses for dialysis, transplantation, or donor-related services of kidney disease in

an amount not less than $30,000 in any calendar year. Policies are not required to duplicate

Medicare payments for kidney disease treatment.

Diabetes Treatment—Medicare Supplement and Medicare SELECT policies cover the usual and

customary expenses incurred for the installation and use of an insulin infusion pump or other

equipment or nonprescription supplies for the treatment of diabetes. Self-management services

are also considered a covered expense. This benefit is available even if Medicare does not cover

the claim.

Medicare Supplement and Medicare SELECT policies issued beginning January 1, 2006, do not

cover prescription medication, insulin, and supplies associated with the injection of insulin as

policies are prohibited from duplicating coverage available under Medicare Part D.

Chiropractic Care—Medicare Supplement and Medicare SELECT policies cover the usual and

customary expense for services provided by a chiropractor under the scope of the

chiropractor’s license. This benefit is available even if Medicare does not cover the claim. The

care must also meet the insurance company’s standards as medically necessary.

Hospital and Ambulatory Surgery Center Charges and Anesthetics for Dental Care—

Medicare Supplement and Medicare SELECT policies cover hospital or ambulatory surgery

center charges incurred and anesthetics provided in conjunction with dental care for an

individual with a chronic disability or an individual with a medical condition requiring

PI-002 (R 03/2024) 19

hospitalization or general anesthesia for dental care. The care also must meet the insurance

company’s standards as medically necessary.

Breast Reconstruction—Medicare Supplement and Medicare SELECT policies cover breast

reconstruction of the affected tissue incident to a mastectomy.

Colorectal Cancer Screening—Medicare Supplement and Medicare SELECT policies cover

colorectal cancer examinations and laboratory tests. Coverage is subject to any cost-sharing

provisions, limitations, or exclusions applying to other coverage under the policy.

Coverage of Certain Health Care Costs in Cancer Clinical Trials—Medicare Supplement and

Medicare SELECT policies cover certain services, items, or drugs administered in cancer clinical

trials in certain situations. Coverage is subject to all terms, conditions, and restrictions applying

to other coverage under the policy, including the treatment under the policy of services

performed by participating and nonparticipating providers.

Catastrophic Prescription Drugs—Medicare Supplement policies issued beginning January 1,

2006, do not include catastrophic prescription drug coverage as these policies are not allowed

to duplicate benefits available under Medicare Part D. This coverage does not qualify as

Medicare Part D creditable coverage.

Basic Facts About Medicare Supplement Policies

Open Enrollment

Medicare Supplement and Medicare SELECT insurance companies must make coverage

available to you, regardless of your age, for six months beginning with the date you enroll in

Medicare Part B. This six-month period is called the open enrollment period. Insurance

companies may not deny or condition the issuance of a policy on your health status, claims

experience, receipt of healthcare, or medical condition and may not charge you an additional

premium because of your use of tobacco. The policy may still have waiting periods before

preexisting health conditions are covered. In addition, if you are under age 65 and enrolled in

Medicare due to disability or end-stage renal disease, you are entitled to another six-month

open enrollment period upon reaching age 65.

Medicare Cost and Medicare Advantage insurance plans accept applicants who live in the

plan’s geographic service area and have Medicare Part A and Part B.

Guaranteed Issue

In addition to the open enrollment period, in some situations, you have the right to enroll in a

Medicare Supplement or Medicare SELECT policy regardless of your health status if your other

health coverage terminates. The insurance company must offer you one of these Medicare

Supplement policies if:

PI-002 (R 03/2024) 20

• Your Medicare Advantage or Medicare Cost plan stops participating in Medicare or

providing care in your service area; or

• You move outside the plan’s geographic service area; or

• You leave the health plan because it failed to meet its contractual obligations to you; or

• Your employer group health plan ends some or all of your coverage; or

• You terminate your employer group plan to join a Medicare Advantage plan but leave the

Medicare Advantage plan within 12 months of enrollment; or

• Your insurance company ends your Medicare Supplement or Medicare SELECT policy and

you are not at fault (for example, the company goes bankrupt); or

• You drop your Medicare Supplement policy to join a Medicare Advantage plan, a Medicare

Cost plan, or buy a Medicare SELECT policy for the first time, and then leave the plan or

policy within one year after joining. You may return to your previous plan or to any available

Medicare supplement plan if your prior plan is no longer available; or

• You join a Medicare Advantage plan or a Medicare Cost plan when you first become eligible

for Medicare Parts A and B at age 65 and within one year of joining you decide to leave the

health plan; or

• You have Medicare Parts A and B and are covered under Medical Assistance and lose

eligibility in Medical Assistance; or

• Your employer group plan increases your cost from one 12-month period to the next by

more than 25% and the new payment for the employer-sponsored coverage is greater than

the premium charged under the Medicare Supplement plan for which the individual is

applying.

If you qualify for a guaranteed issue plan, you must apply for your new Medicare

Supplement policy no later than 63 calendar days after your health plan or policy ends.

The Medicare Supplement insurance company:

• Cannot deny you insurance coverage or place conditions on the policy (such as a waiting

period),

• Must cover you for all preexisting conditions, and

• It cannot charge you more for a policy because of past or present health problems.

If your policy was terminated, the insurance company must provide a notification explaining

individual rights to the guaranteed issue of Medicare Supplement policies. You must submit a

copy of this notice (creditable coverage) or other evidence of termination with the application

for the new policy.

PI-002 (R 03/2024) 21

Suspension of Medicare Supplement Policy

Medicare Supplement and Medicare SELECT policies must allow Medicare beneficiaries with

coverage the right to suspend their Medicare Supplement coverage when they have employer

group health plan coverage. This option was created by federal law and is referred to as a Ticket

to Work provision. If you are a Medicare beneficiary with Medicare Supplement coverage and

you want to suspend your Medicare Supplement policy, you may do so by calling your

Medicare Supplement insurance company. If you later lose your employer group health plan

coverage, you may contact the Medicare Supplement insurance company within 90 days of

losing your employer coverage and receive your Medicare Supplement policy back.

30-Day Free Look

All Medicare Supplement and Medicare SELECT insurance policies sold in Wisconsin have a 30-

day free-look period. If you are dissatisfied with a policy, you may return it to the insurance

company within 30 days and get a full refund if no claims have been made. You should use the

time to make sure the policy offers the benefits you expected. Check your application for

accuracy and check the policy for any limitations, exclusions, or waiting periods.

Renewability

All Medicare Supplement and Medicare SELECT policies sold today must be guaranteed

renewable for life. This means you can keep the policy as long as you pay the premium. It does

not mean the insurance company cannot raise the premium. Policies that are guaranteed

renewable offer added protection. Be sure to ask the insurance agent or company about the

renewability of the policy.

Medicare Advantage plans are not guaranteed renewable. Medicare Advantage plans are a

special arrangement between federal CMS and certain HMOs or insurance companies. CMS,

HMOs, or insurance companies may choose to terminate plans at the end of any calendar year.

Midterm Cancellation

All Medicare Supplement and Medicare SELECT policies include the right to a prorated refund

of premium if you want to cancel a policy before the end of a term. All you need to do is to

send a letter requesting cancellation to the insurance company. The right to midterm

cancellation does not apply to Medicare Cost or Medicare Advantage plans.

Waiting Periods, Limitations, and Exclusions

Many Medicare Supplement insurance policies have waiting periods before coverage begins. If

your policy excludes coverage for preexisting conditions for a limited time, it must provide this

information on the first page of the policy. The waiting period for preexisting conditions may

not be longer than six months, and only conditions treated during the six months before the

effective date of the policy may be excluded.

PI-002 (R 03/2024) 22

Insurance companies are required to waive any waiting periods for preexisting conditions if you

buy a Medicare Supplement policy during the open enrollment period and have been

continuously covered with creditable coverage for at least six months before applying for the

Medicare Supplement policy. Insurance companies are also required to waive any waiting

periods for preexisting conditions when one Medicare Supplement policy is replaced with

another.

Creditable Coverage

Health Creditable Coverage

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires health

insurance issuers, group health plans, and/or employers to issue a HIPAA certificate of

creditable coverage when your health coverage ends. The certificate indicates the date your

coverage ends and how long you had the coverage. You should retain this document for your

records because the certificate provides evidence of your prior coverage. If certain conditions

are met, evidence of prior coverage may entitle you to a reduction or total elimination of a

preexisting condition exclusion period under subsequent health benefits coverage you may

obtain. CMS does not request or require a copy of this HIPAA certificate of creditable coverage.

Therefore, you should not be instructed to send the certificate to CMS.

Prescription Drug Creditable Coverage

The Medicare Modernization Act imposes a late enrollment penalty if you do not maintain

creditable drug coverage (coverage at least as good as Part D coverage) for 63 days after your

initial enrollment period is over. Wisconsin’s SeniorCare Prescription Drug Assistance Program

(dhs.wisconsin.gov/seniorcare/index.htm) does qualify as creditable drug coverage. The

Medicare Modernization Act mandates certain entities offering prescription drug coverage

disclose to all Medicare-eligible individuals with prescription drug coverage whether such

coverage is creditable. You should retain this document for your records. CMS does not request

or require a copy of this creditable coverage documentation during the Initial Enrollment

Period. Therefore, you should not be instructed to send the certificate to CMS unless

challenging a penalty.

For more information on creditable coverage as it relates to Part D, go to

cms.gov/Medicare/Prescription-Drug-Coverage/CreditableCoverage/index.html.

Common Exclusions

No insurance policy will cover everything not covered by Medicare. Medicare excludes certain

types of medical expenses and so do many Medicare Supplement, Medicare SELECT, Medicare

Cost, and Medicare Advantage plans.

Some services frequently excluded under these policies are:

• private duty nursing

PI-002 (R 03/2024) 23

• routine check-ups

• eyeglasses

• hearing aids

• dental services

• cosmetic surgery

• prescription drugs

Medicare Supplement policies include two other frequently misunderstood exclusions:

1. Approved Charges — Medicare pays only for charges considered reasonable and services

considered necessary. Medicare’s determination of a reasonable or “approved” charge may

be considerably less than the actual charge for a covered service. For example:

Doctor’s bill $115

Medicare-approved amount 100

Medicare pays (80% coinsurance) 80

In the example above, Medicare pays 80% of the approved charge ($80). Medicare Supplement

policies pay only the 20% difference between what Medicare approves and what Medicare pays

($20). If your doctor accepts assignment, you will not be charged the difference between what

Medicare approves and the doctor’s bill. Otherwise, you will be responsible for that portion of

the bill. If you have the Medicare Part B Excess Charges Rider, the policy will pay the difference

between what Medicare approves and what the doctor charges.

Medicare SELECT and Medicare Cost policies cover the entire charge for covered services if you

use doctors and hospitals connected to the plan. Medicare Advantage plans may charge a

copay for doctor's office and emergency room visits.

2. Custodial Care — Medicare pays for skilled nursing care in a facility approved by Medicare

if your doctor certifies it is medically necessary and the care meets the insurance company’s

standards as medically necessary. There are no benefits for custodial care. In general,

Medicare Supplement, Medicare SELECT, Medicare Cost, and Medicare Advantage Plans

cover only skilled care and do not cover custodial or intermediate care. Skilled nursing care

is quite narrowly defined. Read more about Medicare’s coverage of skilled nursing care at

medicare.gov/what-medicare-covers/what-part-a-covers/medicare-part-a-coverage-skilled-

nursing-facility-care

PI-002 (R 03/2024) 24

Basic Benefits Included in Medicare Supplement Policies

Inpatient Hospital Care: Covers the Medicare Part A coinsurance.

Medical Costs: Covers the Medicare Part B coinsurance (generally 20% of the Medicare-

approved payment amount).

Blood: Covers the first three pints of blood each year.

Medicare

Supplement

Benefits

Basic Plan

Basic Benefits

√

Medicare Part A:

Skilled Nursing

Facility Coinsurance

√

Inpatient Mental

Health Coverage

175 days per

lifetime

in addition to

Medicare

Home Health Care 40 visits in addition

to those paid by

Medicare

Medicare Part B:

Coinsurance

√*

Outpatient Mental

Health

√

Other Wisconsin

Mandated Benefits

√

Optional Riders

Insurance companies are allowed to offer

these seven riders to a Medicare

supplement policy.

1. Medicare Part A Deductible

2. Medicare 50% Part A Deductible

3. Additional Home Health Care (365

visits including those paid by

Medicare)

4. Medicare Part B Deductible**

5. Medicare Part B Copayment or

Coinsurance*

6. Medicare Part B Excess Charges

7. Foreign Travel Emergency

* Except if Part B Copayment or Coinsurance Optional Rider is purchased.

** Not available to people who are newly eligible for Medicare on or after January 1, 2020.

PI-002 (R 03/2024) 25

Basic Benefits Included in Medicare SELECT Policies

Inpatient Hospital Care: Covers the Medicare Part A coinsurance.

Medical Costs: Covers the Medicare Part B coinsurance (generally 20% of the Medicare-

approved payment amount).

Blood: Covers the first three pints of blood each year.

Medicare Select Benefits

Basic Plan

Basic Benefits

√

Medicare Part A: Deductible

√

Medicare Part A: Skilled Nursing

Facility Coinsurance

√

Inpatient Mental Health Coverage

175 days per lifetime in addition to

Medicare

Home Health Care

365 visits including those paid by Medicare

Medicare Part B: Deductible*

√*

Medicare Part B: Coinsurance

√

Other Wisconsin Mandated Benefits

√

Outpatient Mental Health

√

Foreign Travel Emergency

√

* Not reimbursed for people who are newly eligible for Medicare on or after January 1, 2020.

PI-002 (R 03/2024) 26

Policy Description

The information on the upcoming pages provides a brief description of the benefits of Medicare

Supplement and Medicare SELECT policies offered in Wisconsin. Check the Outline of Coverage

you receive from the company and the policy itself for details. The publication Medicare & You

(medicare.gov/Pubs/pdf/10050-Medicare-and-You.pdf) is available at Medicare.gov or free of

charge from your Social Security office and explains Medicare benefits in detail.

For information on Medicare Supplement insurance policies approved by OCI, visit

oci.wi.gov/Pages/Consumers/PI-010.aspx or contact OCI and request a copy of the publication

Medicare Supplement Insurance Policies List. The publication includes only policies offered by

companies agreeing to be listed in the publication and is updated on an annual basis.

Medicare Supplement insurance companies can only sell standardized Medicare Supplement

policies. Each standardized Medicare Supplement policy must offer the same basic benefits, no

matter which insurance company sells it. The optional benefits and cost are the major

differences among the Medicare Supplement policies sold by different insurance companies.

Policy Benefits – Traditional Insurers

All Medicare Supplement policies offered by traditional insurance companies provide the

following benefits:

Basic Benefits

1. Copayment for days 61 to 90 of hospitalization ($408 a day)

2. Copayment for days 91 to 150 of hospitalization ($816 a day for “lifetime reserve

days”) – full coverage after Medicare days are exhausted

3. Copayment for days 21 to 100 of skilled nursing care in a skilled nursing facility ($204 a

day)

4. 175 days per lifetime of inpatient psychiatric care in addition to Medicare’s 190 days per

lifetime

5. First three pints of blood

6. 40 home health care visits in addition to Medicare – must also meet the insurance

company’s standards as medically necessary

7. 20% of Medicare’s Part B services with no lifetime maximum or, in case of hospital

outpatient department services under a prospective payment system, applicable

copayments

8. Coverage for full usual and customary cost of non-Medicare-covered chiropractic care,

non-Medicare hospital and ambulatory surgery center charges, anesthetics for dental

PI-002 (R 03/2024) 27

care, and non-Medicare-covered breast reconstruction – must also meet the insurance

company’s standards as medically necessary.

9. Coverage for 30 days non-Medicare skilled nursing facility care – no prior hospitalization

required but must meet the insurance company’s standards as medically necessary.

Note: Policies may also include preventive health care services, such as routine physical

examinations, immunizations, health screenings, and private duty nursing services.

Optional Benefits

Insurance companies may offer the following optional benefits as a separate benefit for an

additional premium:

1. Part A deductible ($1,632)

2. Additional home health care (up to 365 visits per year). The care also must meet the

insurance company’s standards as medically necessary.

3. Part B excess charges up to the actual charge or the limiting charge, whichever is less

4. Foreign Travel Emergency: May have a deductible of up to $250. Must pay at least 80%

of billed charges for Medicare-eligible expenses for medically necessary emergency care

received outside the U.S. Emergency care must begin during the first 60 days of a trip

outside the U.S. Benefit limit must be at least $50,000 per lifetime.

5. Medicare 50% Part A deductible

6. Part B copayment or coinsurance rider. The policy covers Part B services after the Part B

deductible is met and Medicare has paid. The insured then pays a 20% coinsurance

copay (up to a maximum of $20) per doctor's office visit or a 20% coinsurance copay (up

to $50 maximum) per emergency room visit. The emergency room copayment or

coinsurance is waived if the emergency room visit results in hospitalization.

Policy Benefits – Traditional Insurers Cost-Sharing 50% and 25%

Medicare Supplement cost-sharing policies provide benefits after you have met your out-of-

pocket limit and your calendar year Part B deductible. The out-of-pocket limits for 2024 are

$7,060 or $3,530 for 50% or 25% cost-sharing policies, and the 2024 Part B deductible is $240.

All Medicare Supplement cost-sharing policies offered by traditional insurance companies

provide the following benefits:

Basic Benefits

1. Part A deductible ($1,632) (50% or 25%)

2. Copayment for days 61 to 90 of hospitalization ($408 a day)

3. Copayment for days 91 to 150 of hospitalization ($816 a day for “lifetime reserve

days”) – full coverage after Medicare days are exhausted

PI-002 (R 03/2024) 28

4. Copayment for day 21 to 100 of skilled nursing care in a skilled nursing facility ($204 a

day) (50% or 25%)

5. 175 days per lifetime of inpatient psychiatric care in addition to Medicare’s 190 days per

lifetime

6. First three pints of blood (50% or 25%)

7. 40 home health care visits in addition to Medicare. The care also must meet the

insurance company’s standards as medically necessary.

8. 20% of Medicare’s Part B services with no lifetime maximum or, in case of hospital

outpatient department services under a prospective payment system, applicable

copayments

9. Coverage for full usual and customary cost of non-Medicare-covered chiropractic care,

non-Medicare hospital and ambulatory surgery center charges, anesthetics for dental

care, and non-Medicare-covered breast reconstruction. The care also must meet the

insurance company’s standards as medically necessary.

10. Coverage for 30 days non-Medicare skilled nursing facility care – no prior hospitalization

required but must meet the insurance company’s standards as medically necessary

Note: Policies may also include preventive health care services, such as routine physical

examinations, immunizations, health screenings, and private duty nursing services.

Optional Benefits

Insurance companies may offer the following optional benefit as a separate benefit for an

additional premium:

1. Additional home health care (up to 365 visits per year). The care also must meet the

insurance company’s standards as medically necessary.

Policy Benefits – Medicare SELECT

All Medicare SELECT policies provide the following benefits:

Basic Benefits

1. Part A deductible ($1,632)

2. Copayment for day 61 to 90 of hospitalization ($408 a day)

3. Copayment for days 91 to 150 of hospitalization ($816 a day) – full coverage after

Medicare days are exhausted

4. Copayment for days 21 to 100 of skilled nursing care in a skilled nursing facility ($204 a

day)

PI-002 (R 03/2024) 29

5. 175 days per lifetime of inpatient psychiatric care in addition to Medicare’s 190 days per

lifetime

6. First three pints of blood

7. Part B deductible ($240) -- not reimbursed for people who are newly eligible for

Medicare on or after January 1, 2020

8. 20% of Medicare’s Part B services with no lifetime maximum and actual charges for

authorized referral services

9. 365 home health care visits including those paid for by Medicare. The care also must

meet the insurance company’s standards as medically necessary.

10. Foreign Travel Emergency: May have a deductible of up to $250. Must pay at least 80%

of billed charges for Medicare-eligible expenses for medically necessary emergency care

received outside the U.S. Emergency care must begin during the first 60 days of a trip

outside the U.S. Benefit limit must be at least $50,000 per lifetime.

11. Coverage for full usual and customary cost of non-Medicare-covered chiropractic care,

non-Medicare hospital and ambulatory surgery center charges, anesthetics for dental

care, and non-Medicare-covered breast reconstruction. The care also must meet the

insurance company’s standards as medically necessary.

12. Coverage for 30 days non-Medicare skilled nursing facility care - no prior hospitalization

required but must meet the insurance company’s standards as medically necessary.

Policy Benefits – Medicare SELECT Cost-Sharing 50% and 25%

Medicare SELECT cost-sharing policies provide benefits after you have met your out-of-

pocket limit and your calendar year Part B deductible. The out-of-pocket limits for 2024 are

$7,060 or $3,530 for 50% or 25% cost-sharing policies, and the 2024 Part B deductible is

$240.

All Medicare SELECT cost-sharing policies provide the following benefits:

1. Part A deductible ($1,632) (50% or 25%)

2. Copayment for 61st to 90th day of hospitalization ($408 a day)

3. Copayment for 91st to 150th day of hospitalization ($816 a day) – full coverage after

Medicare days are exhausted

4. Copayment for 21st to 100th day of skilled nursing care in a skilled nursing facility ($204

a day) (50% or 25%)

5. 175 days per lifetime of inpatient psychiatric care in addition to Medicare’s 190 days per

lifetime

6. First three pints of blood (50% or 25%)

PI-002 (R 03/2024) 30

7. Part B deductible ($240)