2024 Wisconsin SHIP Cheat Sheet Packet

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 1

This packet is designed as a quick-reference tool for State Health Insurance Assistance Program (SHIP)

counselors. It is not a comprehensive guide to eligibility and costs.

Table of Contents

Eligibility and Enrollment

Medicare Coverage Choices .........................................................................................................................................................2

Who to Contact to Get Your Medicare Questions Answered ..................................................................................................3

Medicare Eligibility and Enrollment ..........................................................................................................................................4

Medicare Enrollment Periods ......................................................................................................................................................5

Costs and Coverage

Original Medicare Costs ...................................................................................................................................................................6

Original Medicare Part A (Hospital) ...........................................................................................................................................7

Original Medicare Part B (Medical) ............................................................................................................................................8

Wisconsin Medigap Coverage Chart: Comprehensive .............................................................................................................9

Wisconsin Medigap Coverage Chart: Condensed .................................................................................................................. 10

Medicare Supplement (Medigap) Enrollment ....................................................................................................................... 11

Part B IRMAA ............................................................................................................................................................................. 12

Part D IRMAA ............................................................................................................................................................................ 13

Part D Standard Coverage and Cost of Drug Benefit ............................................................................................................ 14

Financial Assistance Programs

SeniorCare ................................................................................................................................................................................... 15

Part D Extra Help [Low Income Subsidy (LIS)] .................................................................................................................... 16

Medicare Savings Programs (MSP) ......................................................................................................................................... 17

Medicaid Eligibility .................................................................................................................................................................... 18

Coordination of Benefits

Who Pays First ........................................................................................................................................................................... 19

Appeals

Original Medicare Part A and B Appeals ................................................................................................................................ 21

Medicare Advantage (Part C) Appeals: Before Receiving Services ..................................................................................... 22

Medicare Advantage (Part C) Appeals: After Receiving Services or Payment ................................................................. 23

Medicare Appeals: Termination of Facility Coverage ........................................................................................................... 24

Part D Coverage Appeals ........................................................................................................................................................... 25

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 2

Medicare Coverage Choices

Step 1:

Enroll in Medicare

through Social Security.

The default coverage is Original Medicare Parts A and/or B.

People already receiving Social Security benefits are automatically enrolled in

Parts A and B.

Elderly, blind, and disabled Medicaid members with Medicaid managed care

plans may be default enrolled in (start off with) a Dual Eligible Special Needs

Plan, unless they opt out.

Step 2:

Choose how you want to

get your coverage.

Without coverage you

could incur penalties.

Original Medicare

Medicare Advantage

(a.k.a. Part C)

and/or

Step 3:

Add drug coverage.

Without coverage you

could incur penalties.

Step 4:

Decide if you want

supplemental coverage.

You can’t have and don’t need

a Medigap.

Financial assistance

programs

Medicaid, the Medicare Savings Program, Extra Help, and pharmaceutical

assistance programs (like SeniorCare) work with both Original Medicare and

Medicare Advantage.

Part B

Medical

insurance

Part A

Hospital

insurance

Advantage plans

bundle hospital and

medical insurance.

You must have

Medicare Parts A and

B to be eligible.

Check if the plan

covers prescription

drugs.

Most do. You may be

able to add drug

coverage in some types

of plans if it’s not

included.

Part D

Prescription drug coverage

Medicare Supplement

(a.k.a. Medigap)

You must have Parts A and B to

be eligible.

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 3

Who to Contact to Get Your Medicare Questions Answered

If you... Contact…

Want to:

• Enroll in Medicare Part A and/or Part B

• Check your Medicare eligibility or entitlement

• Change your personal information (like your name or

address)

• Report a death

• Replace your Medicare card

• Ask about Medicare premiums

• Apply for Extra Help with Medicare prescription drug

costs

Social Security

1-800-772-1213

TTY:1-800-325-0778

www.ssa.gov

Have questions about your current Part D plan, Medicare

Advantage Plan (like an HMO or PPO), or Medicare

Supplement Insurance (Medigap) policy

Your plan or policy

See your membership card and the plan

materials.

Have railroad retirement benefits and want to:

• Check Medicare eligibility

• Enroll in Medicare

• Replace your Medicare card

• Change your name or address

• Report a death

The Railroad Retirement Board

Your local office or 1-877-772-5772

TTY: 312-751-4701

For questions about your Part B medical

services and bills, call 1-800-833-4455.

Want to report changes to insurance that pays before

Medicare:

• Report that your other insurance is ending

(for example, you stop working)

• Report that you have new insurance

• (for example, you start working)

Benefits Coordination &

Recovery Center (BCRC)

1-855-798-2627

TTY:1-855-797-2627

Have questions about or want to apply for Medicaid (Medical

Assistance)

Your State Medicaid office

dhs.wisconsin.gov/medicaid

1-800-362-3002

Have questions about Medicare in Wisconsin

Medigap Helpline:

800-242-1060

Part D Helpline:

855-677-2783

Disability Rights Wisconsin Part D Helpline:

800-926-4862

Office for the Deaf and Hard of Hearing:

262-

347-3045 videophone

Judicare Legal Aid:

800-472-1638

Have questions about SeniorCare, the Wisconsin state

prescription assistance program

SeniorCare Hotline:

1-800-657-2038

www.dhs.wisconsin.gov/seniorcare

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 4

Medicare Eligibility and Enrollment

Eligibility

• U.S. citizen

a lawfully admitted non-citizen with 5 years’ continuous residence at time of filing,

and

• 65 years or older,

•

Under age 65 and receiving disability

benefits from Social Security or Railroad Retirement Board for 24

months,

•

A person of any age who has End-Stage Renal Disease (ESRD)

(is receiving regular dialysis or has

received a kidney transplant due to kidney failure) starting the month of their kidney transplant or up to

the fourth month after dialysis begins,

•

A person of any age who has been diagnosed with Amyotrophic Lateral Sclerosis (ALS),

also known as

Lou Gehrig’s disease

Enrollment

Automatic

Certain individuals will automatically be enrolled in Part A and/or Part B of Medicare:

•

Retirement benefits:

Individuals who are already receiving federal retirement benefits (SSA retirement

check) will be automatically enrolled into Parts A and B; coverage will begin the first day of their 65

birthday month.

•

Disability benefits:

If the individual is under age 65 and disabled, Part A and/or Part B should

automatically begin on the 25

month after they have been receiving disability benefits from SSA or

Railroad Retirement Board (RRB).

• Disabled individuals with Medicaid managed care may be “default enrolled” in a Dual Eligible

Special Needs Plan (D-SNP) unless they opt out; go to the DHS D-SNP webpage

(https://dhs.wisconsin.gov/benefit-specialists/d-snp.htm) to learn more.

•

ALS:

If a person has ALS, they will automatically qualify for both Part A and Part B the month their

disability benefits begin.

A Medicare card will be mailed as early as three months prior to their 65

birthday or 25

month of

disability award.

If a person does not want to be enrolled in Part A and/or B, they should follow the instructions that

come with the card and send back the form to delay enrollment. Should they keep the card, Medicare

Part A and/or B will begin on their eligibility month and premiums will be charged.

Not automatic, action required

•

Age 65:

Not receiving benefits from Social Security or Railroad Retirement Board, that is, people who

have not reached their full SSA retirement age, are still working and have employer group health

coverage, or are retired employees from certain municipal fields.

 These individuals will need to contact SSA or RRB to sign up for Part A and/or Part B to enroll

during one of the enrollment periods.

 When they should sign up for Part A and/or Part B will depend on if they have other health and

drug insurance coverage that is “creditable” (considered as good as Medicare).

•

ESRD:

Individuals with ESRD should sign up for Part A and B by visiting their local SSA office or RRB

or calling SSA at 1-800-772-1213 (TTY 1-800-325-0778).

•

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 5

Medicare Enrollment Periods

Parts A and B Part D Part C Medigap

Initial enrollment opportunities

Initial Enrollment

Period (IEP)

Seven-month window

surrounding month of

entitlement to

Medicare

during which

you can sign up for

Medicare

Medigap Open

Enrollment Period

Six-month window

after Part B first

starts (and, for

Medicare due to

disability, again

when turning 65)

You have

guaranteed issue

rights when

applying for a

Medigap.

Special Enrollment

Period (SEP)

Granted in certain

situations

Special Enrollment

Period (SEP)

Granted by Medicare in

certain situations

Special Enrollment Period

(SEP)

Granted by Medicare in

certain situations

General Enrollment

Period

(

GEP)

Jan. 1–March 31

(effective next

month)

If you use GEP

and

don’t

already have Part A:

You can sign up for Part

April 1–June 30

(effective July 1)

If you use GEP:

You can sign up for Part C

Three months before Part B

starts (effective same date as

Part B)

Opportunities to change coverage

N/A

Medicare Annual Open Enrollment Period (OEP)

for Parts C and D: Oct. 15–Dec. 7

You can change Part C or D. (effective Jan. 1)

You can apply for a

new or different

Medigap at any time,

but may be denied or

subject to:

• Higher premiums

• Underwriting

(waiting period

for coverage of

pre-existing

conditions for up

to six months)

N/A

Medicare Advantage Open

Enrollment Period

(MA-OEP)

Jan. 1–March 31

You must already be enrolled

in an MA plan. You can make

one change: Switch your MA

plan or return to Original

Medicare and enroll in Part D

Note: Health savings accounts (HSAs)

If you sign up for

Medicare:

During your IEP

You can avoid a tax penalty by making your last HSA

contribution the month before you turn 65.

Two months after your

IEP ends

If you wait to sign up

for Medicare:

Less than six months

after you turn 65

You can avoid a tax penalty by stopping HSA

contributions the month before you turn 65.

Six or more months

after you turn 65

You can avoid a tax penalty by stopping HSA

contributions six months before the month you apply

for Medicare.

Note

: If you go without creditable coverage, Medicare coverage may be delayed and late enrollment penalties may

apply.

References:

Medicare and You Handbook; Medicare.gov

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 6

2024 Original Medicare Costs

(Without Medigap or secondary coverage)

Part A

You pay

Benefit period deductible

covering the first 60 days of Medicare-

covered inpatient hospital care in a benefit period

$1,632

Inpatient hospital care copays

Days

61–90

in a benefit period

$408 per day

Days

91–150

(lifetime reserve) in a benefit period

$816

per day

Days 151+

in a benefit period

All costs

Skilled nursing facility (SNF) copays

Days

1–20

in a benefit period

Nothing

Days

21–100

in a benefit period

$204 per day

Monthly premium*

For beneficiaries with

40 quarters

of coverage

For beneficiaries with

30–39 quarters

of coverage

$278

For beneficiaries with

less than 30 quarters

of coverage

$505

Part B

You pay

Monthly premium

$174.70**

Annual deductible

$240

Part B coinsurance

20%

If the Part B provider doesn’t

accept assignment

, they can bill

excess

charges.

Up to 15%

A divorced spouse may be able to apply for Medicare benefits on the work record of their former

spouse.

The

hold harmless provision

prevents the Part B premium from increasing more than the annual

increase for the Social Security benefit payments for certain individuals.

Medicare beneficiaries with ESRD who received a kidney transplant 36 months ago can continue Part B

coverage of immunosuppressive drugs by paying a $103 monthly premium (+ any IRMAA).

References

: CMS Newsroom Press Releases; NCOA Open Enrollment Toolkit; Medicare Rights Center: Hold Harmless;

Medicare.gov

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 7

2024 Original Medicare Part A (Hospital)

(Without Medigap or secondary coverage)

Service

Benefit

You pay

(Per benefit period*)

Medicare pays

Inpatient

hospitalization*

Semi–private

room and board,

general nursing,

inpatient drugs,

and miscellaneous

hospital services

and supplies

First 60 days

$1,632

All but $1,632

to 90

day

$408 per day

All but $408 per day

Lifetime reserve days

to 150

day

(these 60 reserve

days may be used

only once in your

lifetime)

$816 per day

All but $816 per day

Beyond 150 days

All costs

Nothing

Skilled nursing

facility (SNF)

care**

Custodial

care not covered

First 20 days

Nothing

Full cost of services

through 100

day

$204 per day

All but $204 per day

Beyond 100 days

All costs

Nothing

Home health care

After a covered

inpatient hospital

stay; up to 100

visits

Visits limited to

medically necessary

part-time skilled

care of a

homebound

individual

Nothing

Full cost of services

(see durable medical

equipment)

Hospice care

Available to

terminally ill

Unlimited

renewable benefit

period

$5 for each outpatient

prescription drug and

5% of Medicare-

approved amount for

respite care

All but limited costs for

outpatient drugs and

inpatient respite care

*A new Part A benefit period begins after being home for 60 consecutive days.

**You must be hospitalized under Part A as an inpatient for at least

three consecutive days

for the same illness

prior to admission to the Medicare-approved SNF.

References

: CMS Newsroom; Medicare.gov Hospice Care

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 8

2024 Original Medicare Part B (Medical)

(Without Medigap or secondary coverage)

Service

Benefit

You pay

Medicare pays

Medical

expenses

Physician’s services,

some diagnostic tests,

physical and speech

therapy, ambulance,

etc.

$240 annual

deductible*

plus 20% of approved

amount**

80% of approved

amount

(after $240

deductible)

Home

health care

Visits limited to

medically necessary

part-time skilled care of

a homebound

individual

Nothing

Full cost of services

(see durable medical

equipment)

Outpatient

hospital

services

Medically necessary

treatment such as

outpatient surgery,

diagnostic procedures,

or emergency room

visits

$240 annual

deductible* plus

copayment or

coinsurance for each

procedure

A set amount for each

specific procedure

Durable

medical

equipment

(DME)

Medically necessary

equipment and

supplies such as

walkers, wheelchairs, or

hospital beds

$240 annual

deductible* plus 20% of

approved amount**

80% of approved

amount

(after $240

deductible)

*After paying $240 for covered Part B services, the Part B deductible is met for the rest of the

calendar year.

**If the doctor is not a “participating provider” who “accepts assignment,” meaning they

accept Medicare’s approved amount as payment in full, then you can be charged an

additional 15% of the Medicare-approved amount.

Note:

Medicare Part D pays for outpatient prescription drugs you can take on your own.

However,

Medicare Part A or Part B helps pay for certain oral anti-cancer drugs and

immunosuppressive drugs taken after a Medicare covered organ transplant.

•

Reference

: CMS Newsroom

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 9

2024 Wisconsin Medigap Coverage Chart: Comprehensive

Type of Medigap policy

High

deductible

25% cost

sharing

50% cost

sharing

Basic

High deductible amount

$2,800

N/A

Out-of-pocket limit

N/A

$3,530

$7,060

N/A

Basic benefits

Kidney disease

√

Diabetes care √ √ √ √

Chiropractic care

√

Three pints of blood

√

Anesthesia for dental √ √ √ √

Breast reconstruction

√

Colorectal cancer screening

√

Cancer clinical trials

√

Part A

Deductible: $1,632 √ 25% 50%

(50%/100%)

Inpatient copays:

≥$400/day

√ √ √ √

Skilled nursing facility

(SNF) copay: $200/day

√ √ √ √

Inpatient mental health

stay: 175 days/lifetime

√ √ √ √

Hospice copay/coinsurance √ 25% 50% √

A/B

Home health: 40 extra

visits

√ √ √ √

Home health: 365 visits

total

√ R R R

Part B

Deductible: $240* √* R*

Coinsurance: 20% √

5% up to

$3,530

10% up to

$7,060

Excess charges: 15% √ R

Other

Non-Medicare SNF:

30 days

√ √ √ √

Foreign travel emergency

(limits apply)

√ R

√ = Always covered; R = Optional rider

Medigap coverage of the Part B deductible will no longer be available to people who

are eligible for Medicare

(not necessarily enrolled)

on or after Jan. 1, 2020.

References

: OCI’s Guide to Health Insurance for People with Medicare in Wisconsin; Medicare.gov;

CMS.gov Deductible Announcements; CMS.gov Out-of-Pocket Limits Announcements; NCOA

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 10

2024 Wisconsin Medigap Coverage Chart: Condensed

(Policy differences only)

Type of Medigap policy

High

deductible

25% cost

sharing

50% cost

sharing

Basic

High deductible amount

$2,800 N/A N/A N/A

Out-of-pocket limit

N/A $3,530 $7,060 N/A

Part A deductible: $1,632

√ 25% 50%

(50%/100%)

Part A hospice

copay/coinsurance

√ 25% 50% √

Home health:

365 visits total

√ R R R

Part B deductible: $240*

√* R*

Part B coinsurance: 20%

√

5% up to

$3,530

10% up to

$7,060

Part B excess charges:

15%

√ R

Foreign travel emergency

(limits apply)

√ R

√ = Always covered

R = Optional rider

Medigap coverage of the Part B deductible will no longer be available to people who

are new to Medicare on or after Jan. 1, 2020.

Note that one must have only been Medicare eligible, not necessarily enrolled,

before Jan. 1, 2020.

References: OCI’s Guide to Health Insurance for People with Medicare in Wisconsin; Medicare.gov;

CMS.gov Deductible Announcements; CMS.gov Out-of-Pocket Limits Announcements; NCOA

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 11

Medicare Supplement (Medigap) Enrollment

What are Medigaps

Medigap policies, sold by private insurance companies, help pay some of the health

care costs that Medicare Parts A and B don’t cover. Policies have a monthly

premium.

Medigap Open Enrollment Period

•

What:

Gives a guaranteed right to buy any Medigap policy sold in-state

The issuing company may impose a pre-existing condition waiting period (six months

maximum) unless the beneficiary has had “creditable” and “continuous” coverage (no

break in coverage of more than 63 days).

•

When: six-month period that starts the first month they’re (a) under 65 and qualify for

Medicare due to disability and enrolled in Part B, and/or (b) at least 65 and enrolled in

Part B

When a Medicare beneficiary who is on Medicare due to disability turns age 65, they are

eligible for a second Medigap open enrollment period to purchase any Medigap policy,

guaranteed issue, at age 65 premium rates.

Guaranteed issue rights

•

What:

63-day protected time to buy a Medigap policy, regardless of health status, after a

qualifying event

•

When:

A comprehensive list of qualifying events is in the “Guaranteed Issue” section of

OCI’s Guide to Health Insurance for People with Medicare in Wisconsin, including:

o The beneficiary loses Medicaid.

o The beneficiary moves outside the plan’s service area.

o The plan discontinues or leaves the service area.

o The beneficiary exercises Medicare Advantage trial rights when they:

• Enroll in a Medicare Advantage plan or a Medicare Cost plan after first becoming

eligible for Medicare Parts A and B at age 65, then decide to return to Original

Medicare within the first 12 months of enrollment.

• Terminate an employer group plan to enroll in a Medicare Advantage plan, then

disenroll from the Medicare Advantage plan during a federal enrollment period

within the first 12 months of coverage in the Medicare Advantage plan.

• Drop a Medigap policy to join a Medicare Advantage plan or Medicare Cost plan,

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

policy within one year after joining (guaranteed issue only for the original

Medigap policy; if that’s not still available, then for any policy).

Purchasing a Medigap policy after the Medigap open enrollment period

or without guaranteed issue rights

A person can try to purchase or change Medigap policies at any time, but insurance

companies can:

o Deny coverage.

o Charge higher premiums.

o Impose waiting periods for coverage of pre-existing conditions for up to six

months.

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 12

For higher income individuals

2024 Part B IRMAA

(Income-Related Monthly Adjustment Amount)

If your 2022 annual income is:

In 2024 you pay:

Beneficiaries who file

individual tax returns

with income:

Beneficiaries who file

joint tax returns with

income:

Income-

monthly

adjustment

amount

Total monthly

premium

amount

(per person)

$103,000 or less $206,000 or less $0 $174.70

Above $103,000 and up to

$129,000

Above $206,000 and up

to $258,000

$69.90 $244.60

Above $129,000 and up to

$161,000

Above $258,000 and up

to $322,000

$174.70 $349.40

Above $161,000 and up to

$193,000

Above $322,000 and up

to $386,000

$279.50 $454.20

Above $193,000 and less

than $500,000

Above $386,000 and less

than $750,000

$384.30 $559.00

$500,000 or more $750,000 or more $419.30 $594.00

Beneficiaries who are married and lived with

their spouses at any time during the year, but

who file separate tax returns from their spouses:

Income-

monthly

adjustment

amount

Total

monthly

premium

amount

$103,000 or less

$174.70

Above $103,000 and less than $397,000

$384.30

$559.00

$397,000 or more

$419.30

$594.00

Beneficiaries with ESRD who pay a Part B premium to continue coverage of

immunosuppressive drugs

should consult CMS.gov to view IRMAA costs.

Reference

: CMS Newsroom

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 13

For higher income individuals

2024 Part D IRMAA

(Income Related Monthly Adjustment Amount)

If your 2022 annual income is:

In 2024 you pay:

Beneficiaries who file

individual tax returns with

income:

Beneficiaries who file joint

tax returns with income:

Income-related monthly

adjustment amount

$103,000 or less $206,000 or less $0.00 + plan premium

Above $103,000 and up to

$129,000

Above $206,000 and up to

$258,000

$12.90 + plan premium

Above $129,000 and up to

$161,000

Above $258,000 and up to

$322,000

$33.30 + plan premium

Above $161,000 and up to

$193,000

Above $322,000 and up to

$386,000

$53.80 + plan premium

Above $193,000 and less than

$500,000

Above $386,000 and less

than $750,000

$74.20 + plan premium

$500,000 or more $750,000 or more $81.00 + plan premium

Beneficiaries who are married and lived with their

spouses at any time during the year, but who file separate

tax returns from their spouses:

Income-related monthly

adjustment amount

$103,000 or less

$0 + plan premium

Above $103,000 and less than $397,000

$74.20 + plan premium

$397,000 or more

$81.00 + plan premium

Reference

: Medicare.gov; CMS Newsroom

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 14

2024 Part D Standard Coverage and Cost of Drug Benefit

Coverage

stag

Payers and costs

You

(Medicare

beneficiary)

Plan

Drug

manufacturers

Government

Deductible

You pay up to $545.

In some plans, preferred generics are not subject to

the deductible.

2. Initial coverage

Until total drug

costs reach 5,030

3. Coverage gap

("donut hole")

Until your total

out-of-pocket

costs reach

$8,000

For generics:

For brand-name drugs:

4. Catastrophic

coverage

You pay $0

for the rest of the calendar year.

•

Late enrollment penalty (LEP)

1% of the Part D national base premium ($34.70 in 2024) times the number of

months without creditable drug coverage

References:

Medicare.gov Part D late enrollment penalty; NCOA Part D Graphic; NCOA Part D Cost Sharing Chart

up to 25%

25%

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 15

SeniorCare

• SeniorCare is a prescription drug assistance program that covers most generic and brand name drugs

and over-the-counter insulin. Vaccines are covered at no cost.

• SeniorCare is considered creditable coverage for Medicare Part D. Beneficiaries can have SeniorCare

and a Part D plan; SeniorCare will coordinate coverage with the other plan.

Non-financial

eligibility

•

Wisconsin resident

• U.S. citizen or have qualifying immigrant status

• At least 65 years old

• Not enrolled in Medicaid

2024 financial level Coverage (per person)

Level

Annual income limit Deductible Out-of-pocket costs for covered drugs

≤$24,096 individual

≤$32,704 couple

[≤160% federal poverty

level (FPL)]

None • $5 copay for each generic drug

• $15 copay for each brand name drug

$24,097–$30,120

individual

$32,705–$40,880

couple

(160%–200% FPL)

$500

• Pay the SeniorCare rate for drugs until the $500

deductible is met.

• After $500 deductible is met, pay a $5 copay for

each generic drug and a $15 copay for each brand

name drug.

$30,121–$36,144

individual

$40,881–$49,056

couple

(200%–240% FPL)

$850

• Pay the SeniorCare rate for covered drugs until

the $850 deductible is met.

• After $850 deductible is met, pay a $5 copay for

each generic drug and a $15 copay for each brand

name drug.

$36,145+ individual

$49,057+ couple

(≥240% FPL)

$850 after

spend-down

• Pay retail price for covered drugs during

spenddown (the difference between gross annual

income and 240% FPL).

• After the spenddown is met, meet the deductible.

• Pay the SeniorCare rate for covered drugs until

the $850 deductible is met.

• After $850 deductible is met, pay a $5 copay for

each generic drug and a $15 copay for each brand

name drug.

Enrollment and

renewal

•

Fees

: $30 annual fee for all participants

•

Timing

: The earliest you can apply is during the calendar month

of your 65

birthday. If you are already age 65 or older, you can

apply at any time.

•

Effective date

: The month after you apply

•

How to apply

: Call SeniorCare Customer Service at 800-657-2038

(TTY 711), or download the form:

https://www.dhs.wisconsin.gov/library/f-10076.htm

References:

DHS SeniorCare Publications: Information about SeniorCare (P-10078); DMS Operations Memo 24-02

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 16

2024 Part D Extra Help [Low Income Subsidy (LIS)]

Beneficiaries with low income and assets can qualify for help with their Medicare drug

costs through the Extra Help program, also known as the Low Income Subsidy (LIS).

Eligibility

Automatically

eligible

Receive SSI, Medicare Savings Program (MSP), or full Medicaid

Financially

eligible

Household size Income

(150% FPL

)

Assets (excluding

$1,500 burial funds)

Apply through

Social Security

online, phone, or

request a paper app.

1 $1,903 $15,720

2 $2,575 $31,360

Benefits and costs

Premiums: LIS helps pay the Part D plan premium. “Benchmark plan” premiums

will be $0 for people with LIS.

Copays** during the Part D coverage phases:

LIS recipients do not pay a deductible. They may need to pay small copays for their

drugs until their total drug costs reach the catastrophic coverage period threshold.

Initial coverage

Until total drug

costs reach

$11,447.39

Category 1:

Full Medicaid with

income between

100-150% FPL

MSP-only

Category 2:

Full Medicaid with

income up to or at

100% FPL

Category 3:

Receive home and

community-based

services (HCBS) or

institutional Medicaid

$4.50 generics

$11.20 brand

name

$1.55 generics

$4.60 brand name

Catastrophic $0

** Pharmacies may charge for bubble packaging of medication.

Duration of coverage

If someone loses of Extra Help eligibility:

• Before July 1: keep Extra Help for the remainder of the calendar year

• Between July – Dec.: keep Extra Help for the remainder of the calendar year and the

entire following calendar year

References:

NCOA LIS Eligibility Chart;

HHS.gov Federal Poverty Level Guidelines (FPL)

POMS; 2024 rate announcement; CY2024 LIS

Resource Limits Memo 508 Correction v2; Medicare Interactive

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 17

2024 Medicare Savings Programs (MSP)

• The Medicare Savings Program (MSP) is a state Medicaid program that can help pay Medicare health premiums and possibly other costs.

Medicare beneficiaries with SSI or certain Medicaid programs automatically get MSP. Others who qualify can apply at access.wi.gov.

•

It may take two months for payments to begin; refunds will be backdated to the effective date.

Programs Non-financial

eligibility

Monthly

income limits

Asset limits Program pays Effective date

Qualified Medicare

Beneficiary

(QMB)

Entitled to Part A

$1,255.00 individual

$1,703.33 couple

(100% FPL)

$9,430 individual

$14,130 couple

Parts A and B

premiums,

deductibles, and

coinsurance

First day of the month after

the application is approved

Specified Low-

Income Medicare

Beneficiary

(SLMB)

Entitled to Part A

$1,506.00 individual

$2,044.00 couple

(120% FPL)

$9,430 individual

$14,130 couple

Part B premiums Up to three months prior to

application date

Specified Low-

Income Medicare

Beneficiary Plus*

(SLMB+)*

• Entitled to Part A

• Not enrolled in full,

Family Planning, or

Tuberculosis Only

Medicaid

$1,694.25 individual

$2,299.50 couple

(135% FPL)

$9,430 individual

$14,130 couple

Part B premiums Up to three months prior to

application date

Qualified Disabled

and Working

Individual

(QDWI)

• Entitled to Part A

• Disabled and

employed

• Not enrolled in

Medicaid

$2,510.00 individual

$3,406.66 couple

(200% FPL)

$4,000 individual

$6,000 couple

Part B premiums

Up to three months prior to

application date

*FYI:

Other states refer to this eligibility category as Qualified Individual (QI), and SLMB+ as eligibility for SLMB and full Medicaid.

Note:

Medicaid estate recovery is eliminated

for MSP per the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).

References:

Medicare Savings Programs (P-10062) (available in multiple languages); DMS Operations Memo 23-02, Medicaid Eligibility Handbook 39.4; 2024 Medicaid

financial eligibility memo

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 18

2024 Medicaid Eligibility

Program*

See P-02383 or the DHS

website for all programs.

Non-financial eligibility

Other eligibility criteria may apply.

Countable monthly

income limit

Countable

asset limits

BadgerCare Plus

• Non-Medicare,

and

• Age 19–64,

• Parents or caretaker relatives of

dependent children up to 18 years

$1,255.00 individual

$1,703.33 couple

(100% FPL)

No limit

BadgerCare Plus

• Non-Medicare,

and

• Pregnant,

• Children up to 19 years

$3, 840.30 individual

$5, 212.19 couple

(306% FPL)

No limit

Elderly, Blind or

Disabled (EBD)

Categorically Needy

Receiving Supplemental Security

Income (SSI

)

$943 individual

$1,415 couple

(SSI limits)

$2,000 individual

$3,000 couple

Elderly, Blind or

Disabled (EBD)

Medically Needy

• Age 65 or older,

• Determined blind or disabled by the

Disability Determination Bureau (DDB)

$1,255.00** individual

$1,703.33** couple

(100% FPL)**

$2,000 individual

$3,000 couple

**Can have income above the limit and become eligible by meeting a deductible. The deductible period is 6 months long.

The deductible is the difference between the household’s countable monthly income and the medically needy

income limit, times six.

Beneficiaries with BadgerCare+ who become eligible for Medicare will be reassessed for EBD Medicaid eligibility.

They will either lose Medicaid or transition to EBD Medicaid.

References

: BadgerCare+ Eligibility Handbook; Medicaid Eligibility Handbook; DMS Operations Memo 24-02; DHS Annual Income Limits; SSA.gov; CMS

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 19

Who Pays First

If you…

And your situation is…

Pays first

Pays second

Are covered by Medicare

and Medicaid

Entitled to Medicare and

Medicaid

Medicare

Medicaid

Are 65 or older and

covered by a group health

plan because you or your

spouse is still working

Entitled to Medicare

Group health plan

Medicare

The employer has 20 or more

employees

The employer has less than 20

employees

Medicare

Group health

plan

Have an employer group

health plan through your

former employer after

you retire and are 65 or

older

Entitled to Medicare

Medicare

Retiree

coverage

Are disabled and covered

by a large group health

plan from your work or

from a family member

(like spouse, domestic

partner, son, daughter, or

grandchild) who is

working

Entitled to Medicare

Large group health

plan

Medicare

The employer has 100 or more

employees.

The employer has less than 100

employees

Medicare

Group health

plan

Have end-stage renal

disease (ESRD)

(permanent kidney failure

requiring dialysis or a

kidney transplant) and

group health plan

coverage (including a

retirement plan)

First 30 months of eligibility or

entitlement to Medicare

Group health plan

Medicare

After 30 months of eligibility or

entitlement to Medicare

Medicare

Group health

plan

Have ESRD and

Consolidated Omnibus

Budget Reconciliation Act

(COBRA) coverage

First 30 months of eligibility or

entitlement to Medicare based

on having ESRD

COBRA

Medicare

After 30 months

Medicare

COBRA

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 20

Who Pays First

If you…

Condition

Pays first

Pays second

Are 65 or over

disabled

(other than by ESRD)

and covered by Medicare

and COBRA coverage

Entitled to Medicare

Medicare

COBRA

Have been in an accident

where no-fault or liability

insurance is involved

Entitled to Medicare

No-fault or liability

insurance for services or

items related to accident

claim

Medicare

Are covered under

workers’ compensation

because of a job-related

illness or injury

Entitled to Medicare

Workers’ compensation

for services or items

related to workers’

compensation claim

Medicare usually

doesn’t cover these

claims. However,

Medicare may make

a conditional

payment (a payment

that must be repaid

to Medicare when a

settlement,

judgment, award, or

other payment is

made).

Are a Veteran and have

Veterans’ benefits

Entitled to Medicare

and Veterans’ benefits

Medicare pays for

Medicare-covered

services or items.

Veterans’ Affairs pays

for VA-authorized

services or items.

Note:

Generally,

Medicare and VA can’t

pay for the same service

or items.

Not applicable.

Medicare does not

pay for claims

covered by VA

insurance, and vice

versa.

Are covered under

TRICARE

Entitled to Medicare and

TRICARE

Medicare pays for

Medicare-covered

services or items.

TRICARE pays for

services or items from a

military hospital or any

other federal provider.

TRICARE may pay

second.

Have black lung disease

and are covered under the

Federal Black Lung

Benefits Program

Entitled to Medicare

and the Federal Black

Lung Benefits Program

The Federal Black Lung

Benefits Program for

services related to black

lung.

Medicare

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 21

2024 Original Medicare Part A and B Appeals

Appeal

level

Minimum

amount*

How to file the appeal

Deadline to request appeal

When to

expect a

decision

None

File appeal using

Medicare Summary

Notice (MSN) with

Medicare administrative

contractor (MAC): CGS

Administrators

120 days

after receiving the

initial determination on

Medicare Summary Notice

(MSN)

60 days

None

Request reconsideration

and provide any

additional evidence to

qualified independent

contractor (QIC)

180 days

after receiving

Medicare Redetermination

Notice (MRN)

60 days

$180

Request hearing with

administrative law judge

(ALJ)

60 days

after receiving

qualified independent

contractor (QIC) notice of

decision,

after expiration of

the QIC reconsideration

timeframe if no decision is

received

90 days, but may

be delayed due to

volume

None

Request review from

Medicare Appeals Council

60 days

after receiving ALJ

notice of decision,

after

expiration of the ALJ hearing

timeframe if no decision is

received

90 days if

appealing an ALJ

decision,

180

days if ALJ

review time

expired without a

decision

$1,840 Request judicial review

60 days

after receiving notice

of Medicare Appeals Council

decision,

after expiration of

the Medicare Appeals Council

hearing timeframe if no

decision is received

No deadline

*The appeal can only proceed to the next level if the denied service is worth at least the “amount in

controversy.”

Note:

A beneficiary can appoint an authorized representative to file appeals for them.

References:

CMS.gov; Medicare.gov

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 22

2024 Medicare Advantage (Part C) Appeals:

Before Receiving Services

Before appealing,

the beneficiary requests coverage of a service from the plan.

The plan has 14 days to process a standard request or 72 hours for an expedited request.

If the plan denies coverage

and sends a Notice of Denial of Medical Coverage:

Appeal

level

Minimum

amount*

How to file the appeal

Deadline

request

appeal

When to expect a

decision

Standard

appeal

Expedited

appeal

None File appeal with plan 60 days 30 days 72 hours

None

Send supporting documents

independent review entity

(IRE)**

days**

30 days 72 hours

$180

Request hearing

with

administrative law judge (ALJ)

60 days No deadline

None

Request review

from Medicare

Appeals Council

60 days No deadline

$1,840 Request judicial review 60 days No deadline

*The appeal can only proceed to the next level if the denied service is worth at least the

“amount in controversy.”

**After upholding the denial, the plan will automatically escalate the appeal to the IRE.

After

receiving notice that the appeal was sent to the IRE, beneficiaries have 10 days to send the

IRE supporting documents (if they wish to).

Note:

A beneficiary can appoint an authorized representative to file appeals for them.

References:

CMS.gov; Medicare.gov; SHIP TA Center’s OCCT Course 3.2 supplemental materials

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 23

2024 Medicare Advantage (Part C) Appeals:

After Receiving Services or Payment

If the plan denies coverage

and sends a Notice of Denial of Medical Coverage:

Appeal

level

Minimum

amount*

How to file the appeal

Deadline

request

appeal

When to expect a

decision

Standard

appeal

Expedited

appeal

None File appeal with plan 60 days 60 days 72 hours

None

Send supporting documents

independent review entity

(IRE)**

days**

60 days 72 hours

$180

Request hearing

with

administrative law judge (ALJ)

60 days No deadline

None

Request review

from Medicare

Appeals Council

60 days No deadline

$1,840 Request judicial review 60 days No deadline

*The appeal can only proceed to the next level if the denied service is worth at least the

“amount in controversy.”

**After upholding the denial, the plan will automatically escalate the appeal to the IRE. After

receiving notice that the appeal was sent to the IRE, beneficiaries have 10 days to send the

IRE supporting documents (if they wish to).

Note:

A beneficiary can appoint an authorized representative to file appeals for them.

References:

CMS.gov; Medicare.gov; SHIP TA Center’s OCCT Course 3.2 supplemental materials

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 24

2024 Medicare Appeals: Termination of Facility Coverage

After the beneficiary receives a Notice of Medicare Non-Coverage for termination of

coverage at the following types of facilities:

• Skilled nursing facility (SNF)

• Home health agency (HHA)

• Comprehensive outpatient rehabilitation facility (CORF)

• Hospice facility

Appeal

level

Minimum

amount*

How to file the appeal

Deadline to

request

appeal

When to

expect a

decision

None File appeal with beneficiary and

family- centered care quality

improvement organization (BFCC-

QIO): Livanta

Hospital

Discharge

date

Within one

day of

receiving all

information

Non-hospital facility**

By noon of

the day that

care is set to

end

The day that

care is set to

end

None File appeal with BFCC-QIO: Livanta 60 days 14 days

$180

Request hearing

with administrative

law judge

60 days 90 days

None

Request review

from Medicare

Appeals Council

60 days 90 days

$1,840 Request judicial review 60 days No deadline

*The appeal can only proceed to the next level if the denied service is worth at least the

“amount in controversy.”

Note:

A beneficiary can appoint an authorized representative to file appeals for them.

References:

CMS.gov; Medicare.gov; SHIP TA Center’s OCCT Course 3.2 supplemental materials

2024 Wisconsin SHIP Cheat Sheet Packet P-03179A (02/2024) | 25

2024 Part D Coverage Appeals

Appeal

level

Minimum

amount*

How to file the appeal

Deadline to

request

appeal

Decision deadline

Standard

Expedited

Before

appealing

None Request coverage

determination from plan**

N/A 72 hours 24 hours

None Request redetermination

from plan*

60 days 7 days 72 hours

None File appeal with

Independent Review Entity

(IRE)

60 days 7 days 72 hours

$180

Request hearing

with

Administrative Law Judge

(ALJ)

60 days 90 days 10 days

None Request review from

Medicare Appeals Council

60 days 90 days 10 days

$1,840 Request judicial review 60 days No

deadline

*The appeal can only proceed to the next level if the denied claim is worth at least the

“amount in controversy.”

**Coverage requests can be for formulary or tiering exceptions.

The beneficiary, their authorized representative, or their doctor or prescriber can

file the

request.

References:

CMS.gov; Medicare.gov; SHIP TA Center’s OCCT Course 3.3 Part D Appeals Handout