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.

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 also must 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 and Medicare select insurance companies are required to offer 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 defined quite narrowly, and you must meet certain other criteria.

Kidney Disease—Medicare supplement and Medicare select policies cover inpatient and outpatient expense for dialysis, transplantation, or donor-related services of kidney disease up to $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 non-prescription 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 prior to January 1, 2006, for individuals who do not enroll in Medicare Part D cover prescription medication, insulin, and supplies associated with the injection of insulin. Prescription drug expenses are subject to the $6,250 deductible for drug charges. This deductible does not apply to insulin.

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 the Medicare Part D.

Chiropractic Care—Medigap policies cover the usual and customary expense for services provided by a chiropractor. This benefit is available even if Medicare does not cover the claim.

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 that requires hospitalization or general anesthesia for dental care.

Breast Reconstruction—Medicare supplement and Medicare select policies cover breast reconstruction of the affected tissue incident to a mastectomy.

Coverage of Certain Health Care Costs in Cancer Clinical Trials—Medicare supplement and Medicare select policies issued or renewed beginning November 1, 2006, cover certain services, items, or drugs administered in cancer clinical trials in certain situations. The coverage is subject to all terms, conditions, and restrictions that apply 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 and Medicare select policies issued prior to January 1, 2006, to Medicare beneficiaries who do not enroll in Medicare Part D cover at least 80% of the charges for outpatient prescription drugs after a drug deductible of no more than $6,250 per calendar year. Medigap policies issued beginning January 1, 2006, and after will not include catastrophic prescription drug coverage as these policies are not allowed to duplicate benefits available under Medicare Part D creditable coverage.

Medicare Advantage insurance plans are not required to cover Wisconsin's mandated benefits. The limitation and exclusion section of the summary of benefits included in the Medicare Advantage plan lists any mandated benefits not covered by the plan.