Wisconsin Medicare Recepients

[JAM]

If there is anyone from the great state of Wisconsin () that has gone down the rabbit hole of Medicare Advantage vs Medicare Supplemental or Medigap coverage and can answer some ?’s for me please reach out.

My PAL’s is 58 currently on A & B no other insurance. We need to find something w/drug coverage or add it at a minimum.

It seems supplemental insurance will be quite expensive bc he is 58 ?, but Advantage one nurse told us is referred to as Medicare Disadvantage and to be careful before doing anything etc. I called our aging/disability center last week, but the specialist still has not returned my call.
I know a lot is State dependent. TIA

 

[KimT]

I'm not from Wisconsin, but I can give you some advice. I went on disability at 60. I live in Florida. I looked at all my options and selected a supplement (Plan G) that would pay for all that Medicare B did not pay. Because I was under 65, the plan cost more. If not for the Affordable Care Act (Obama Care) it could have cost even more than it did. When I turned 65, the cost (premium dropped from $600 a month to $178 a month. Now, five years later, it has gone to $210 a month.

I also got Plan D. I think that was about $50 a month. I now have a $0 a month plan. Under Biden's Inflation reduction legislation, the maximum I can pay out of pocket on drugs beginning this year is $2,000. I've never paid close to that because I bought some of my drugs from Canada and used GoodRx for others. There is also a company called Healthwell Foundation that offers grants to cover drug co-pays. The ALS fund is usually open.

I looked at every Medicare advantage plan and when I added up all the co-pays, I would have paid more than my premium, especially with the durable medical equipment.

Every state is different. In NY State, premiums for disabled people is averaged in with those 65 and over and in some states it is not.

I'd suggest using a broker who is independent of any particular company. I ended up with Florida Blue Cross as my supplemental, but the agent did a hard sell on the advantage plan which I figured out long before I went to the offices was not for me.

Independent brokers will help you compare plans. Just make sure you do your due diligence before signing anything and make sure they understand that you will have lots of durable medical equipment, with a power wheelchair being the most expensive.

You can compare all plans online, but it is time consuming. I ended up doing that. I didn't have a CALS and I was still working, so it took a lot out of me, but it was the right decision in the end.

 

[JAM]

We have ordered his power chair. Is it not going to be covered by Medicare A or B? Ugh I thought you were allowed 1 every 5 years (after meeting your deductible).
I’ve left messages for 2 people hoping they can help with all this.

 

[Nikki J]

It should be covered 80% under part b but you need a supplement for the 20% after deductible Or an advantage plan should cover after deductible and copays but would also likely need a prior authorization

After deductible both a and b are a 20% copay which is why you need a supplement or ma plan Sorry

 

[JAM]

I would like to help info on supplement - how do I know if a rep is independent?? Please.

 

[lgelb]

The power chair is covered by Part B if submitted correctly, but subject to your deductible and copay. It sounds like some expenses back to September will have to be readjudicated for the 2024 calendar year, but we are now in 2025 so another deductible and, of course, always a copay without a supplement.

On medicare.gov, you can enter your zip code and see all the possibilities for MA plans and supplements (aka Medigap). It looks like Wisconsin only has one Medigap plan design, so that makes it pretty simple if you go that route. But Wisconsin also has some different Medigap laws than most other states. You need to talk with someone who knows the laws, which are more complicated bc he's under 65 (this may be good for your Medigap window through; being >6 months since he was Medicare-eligible, can in some cases close the Medigap window, which would put you in the MA market, but open enrollment for MA adds may close a week from today).

If you end up staying with A/B, (edit: I meant with a supplement + Part D, as Steve notes below, you do not want to be without either a supplement OR a Medicare Advantage plan, whichever is better for you) you can enter his drugs on the Medicare site for Part D plan comparisons.

These are the numbers for Wisconsin:

The Medigap Helpline Services are free, confidential counseling services for Medicare beneficiaries.

call 1-800-242-1060,
Prescription Part D call 1-855-677-2783

If you end up in the MA market, Medicare Advantage plans have star ratings on the site. They are not perfect, but they are directional. Also look at the network of doctors and hospitals and DME suppliers (especially in re the wheelchair) each allows.

 

[KimT]

When I bought my first PWC, the provider did all the paperwork. The provider should have obtained a pre-approval and let you know what your co-pay would be. It sounds like you will be paying 20% of the price of the chair if you have no supplement.

Once you get drug insurance, do an application at Healthwell. It really helps. They also have funds to cover the cost of the Medicare Part B premium if that is greater than your drug co-pays each month.

 

[swalker]

I am not in Wisconsin. I do have some experience as a Medicare participant, and will share some thoughts.

Medicare parts A and B are great for me and I believe are essential. But, they are not enough.

I chose to get a Medicare Supplement plan (Medigap). All the Medicare Advantage plans in my area have very limited networks of doctors and medical facilities. They would essentially force me to drive 100 miles each way to work with an in-network provider. My Medicare Supplement (Plan G) has no such limitation.

Be aware that the copays for medical equipment can be very high if you only have Medicare Parts A and B.

For example, my latest wheelchair, which I picked up in August 2024, was billed at over $96,000. That is not a typo!

I need a sophisticated bipap machine (my doctor calls it a ventilator). I use a Resmed Astral 150. They have determined that I need a backup as well, so I have two of them. They are leased. The ventilators are billed out at $2,500 per ventilator per month. That does not include the supplies that are provided monthly. Add that all up and it is more than $60,000 per year.

I have other equipment as well. All told, last year, covered items added up to close to $200,000. I would not want to have to pay 20% ($40,000) of that myself. I am very glad that I have a Medicare Supplement plan.

Steve

 

[KimT]

I have the same situation as Steve, minus Bipap. My PWC was replaced in 2024. The cost was $30,000. I paid nothing because I have the Florida Blue Cross Medigap.

I go to Mayo Clinic and have a team of local providers. I've not found one that doesn't accept my insurance. So, for me, it's worth it. Especially with Healthwell giving me a grant that covers my Medicare Part B Premium.

 

[JAM]

I hope to be able to get a supplement. I am meeting with an agent on Friday. Shoukd I hold off on arranging for a bi-pap until I have coverage? The bi-pap he just found out is recommended based on a sleep study he did. He has no issues breathing during day or shortness of breath, but apparently at night during REM they saw something.
Anyway, should I hold off contacting the company until we get a supplement. Hopefully soon!

If for some reason we can’t bc of the 60 day issue will an Advantage plan cover these things?? My head is swirling rn given the costs mentioned above

 

[lgelb]

Yes, all Medicare Advantage plans have to cover the same medical equipment items under the same conditions as Medicare. The differences are in your deductible and copays, and which DME providers are "in network." You can find all this out on the Medicare site.

In case you are limited in your choice of DME firms, it would be best to hold off until you're enrolled in whatever you end up with. Also, it's much easier to get after-sales support, if needed, from the DME firm that ordered your item.

 

[JAM]

I met with a representative today and am more confused than ever. She was really wonderful and patient! She was shocked tho when she saw the difference in monthly premiums under a supplement at 58 y/o versus 65 y/o. She must not deal that often with people under 65 trying to get a supplement.

Fortunately she was able to find a company to provide us supplemental coverage. I thought for sure if we could get a supplement we would do that over an Advantage plan, but boy that $700 difference monthly premiums is a hard pill to swallow. I’m nervous about it, BUT I don’t want to be penny wise but pound foolish.

Also she said for the DME once he reached his deductible ($3850) he doesn’t pay any more and that DME counts toward deductible. That sounds too good to be true.

His Neuro at Froedert is covered under Advantage but the Neuro at Nortwestern is not. We do prefer the Neuro at Northwestern and that clinic.
In the end after comparing everything it’s a difference of about $5k per year between the supplement vs Advantage. In the scheme of all the costs of ALS it seems minor… but then again we are going to need a lot of $ down the road, maybe every little bit counts.

If anyone has advise regarding extra money well spent or saved please advise.
TIA

 

[lgelb]

I'd also be looking at what Part D will cost (and getting it). That will add to the cost and you want to choose a plan with a formulary that meets your needs.

 

[Nikki J]

From my experience with a supplement it is true once you meet the deductible you are done. The part d is separate mine has a deductible and also copays but this year it has a max out of pocket of 2000

Only you can know if you can afford the supplement but having the flexibility to see the doctors you want and go to any hospital is a big thing especially as you already know you like the NW doctor better. The difference is 5000 when you compare the cost of plans plus the max out of pocket for both?

Does the advantage plan have a formulary that meets your needs?

 

[JAM]

Yes the 5k difference is calculated comparing costs of each monthly and max out of pocket yearly.
The drug plans on both run about the same per year, which is in addition to the cost of each but since they’re are basically the same it’s 5k difference.

What is formulary?

Also, would that seem correct under an Advsntage plan, once I meet my $3850 deductible all my DME will be covered for the year? That seems really reasonable in a year that he is getting a PWC & a bi-pap & prob a hoyer lift. (My cost $3850 and all those coveted)
unfortunately he is progressing faster than I hoped for so I think this will be a high DmE year.