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Employer Bulletin

State Agencies & Local Health Employers
Vol. 18, No. 18
November 20, 2001

Bulletin Contains Health Insurance Reporting Forms for 2002

The 2002 Health Insurance Additions, Deletions and Change Reports; Monthly Coverage Reports; and Summaries for 2002 are enclosed with this Employer Bulletin. We have also included mailing labels to use when remitting reports to the Department of Employee Trust Funds (ETF).

It is critical that you destroy any old health reporting forms and only use the new reports for 2002. Also, please make sure you are using the most recent revision of the following forms:

  • Health Insurance Application (ET-2301), Rev. 2/2001
  • Health Insurance Application (ET-2302), Rev. 3/2001 (UW Grad Assistants only)
  • Health Insurance Information Change (ET-2329), Rev. 9/2000

If you need additional reporting forms or applications, please contact the forms request line of the Supply and Mail Services Section at (608) 266-3302. The reporting forms may also be downloaded from our Internet site at

Important Reminder for Completing Health Insurance Applications and Corresponding Reports

It is extremely important that the monthly reporting forms are complete and accurate. When hiring a new employee, the "Prospective Date of Coverage" entered on theHealth Insurance Application must agree with the date entered on the Monthly Additions Report (ET-2610) in the "Effective Date" column.

When completing the Monthly Deletions Report (ET-2612) for an employee, who is terminating employment, the "Event Date" should be the same day as the employee's termination date.

2002 Dual-Choice Reporting Instructions and Due Dates

Dual-Choice transactions should be entered on the January 2002 Health Insurance Reports. Submit two sets of Additions, Deletions, and Change Reports. One set will include Dual-Choice elections and the second set will include regular monthly transactions. Please be sure to write "DUAL- CHOICE" on the Dual-Choice set and "REGULAR TRANSACTIONS" on the regular transaction set. It is important to keep the Dual-Choice transactions separate from the regular transactions because statistics are monitored separately for these two different types of transactions.

The January 2002 Health Insurance Reports are due Thursday, December 20, 2001. ETF would appreciate receiving your January 2002 reports as early as possible, given the volume of changes as a result of Dual-Choice.

January 2002 Health Insurance Reports will include:

  1. Two copies of your Summary and the corresponding monthly Coverage Reports.

  2. Two copies of the Additions, Deletions, and Change Report that reflect regular monthly transactions (titled "Regular Transactions").

  3. Two copies of the Additions, Deletions, and Change Report that reflect Dual-Choice transactions (Enrollment Types 40 and 43 titled "Dual-Choice"). The carrier copies of the Dual-Choice applications are to be attached to the corresponding Additions Reports.

    NOTE: Each entry on the Additions Report must indicate the suffix number of the previous plan (i.e., the employee's current plan). Do not substitute the name of the plan for the plan suffix number.

    Each entry on the Deletions Report must indicate the suffix number of the newly selected plan. Do not substitute the name of the plan for the plan suffix number.

  4. Complete Deletions Reports for each plan showing employees leaving plans at year-end.

  5. Complete Coverage Reports for each plan showing the contracts deleted during the month of December as follows:

    1. On Line 1 enter the number of contracts in effect in December.

    2. On Line 3 enter the number of deletions that were made during Dual-Choice.

    3. Line 1 minus Line 3 should equal zero for Line 6 contracts in effect this month.

  6. Attach the Coverage Report completed in Step 5 to the Deletion Report completed in Step 4 for that plan.

It is important that you follow these instructions because Dual-Choice statistics are used to track the movement of individuals between the participating plans and counties. The information is then used in the rate setting process for the Group Health Insurance Program. Deviations from these instructions must be pre-approved by submitting a written request and sample forms to:

Ron Diehl
Division of Employer Services
Employee Trust Funds
PO Box 7931
Madison, WI 53707-7931


Assembly of Health Insurance Reports

The start of a new year is a good time to review the proper way to assemble your monthly health insurance reports. Following these instructions will ensure the prompt and efficient processing of your reports by both ETF and the designated plans and provide the best possible service for you if questions arise. Please assemble your reports in the following order (you will end up with two sets of reports in descending order):

1. ETF Copies:

  1. Summary with a check (if paying by check) paper clipped to the front.
  2. Monthly Coverage Reports - these should be placed in the order that they appear on the Summary. Corresponding forms should be attached (stapled in the upper left corner) to the respective Coverage Report in the following order:

1) Additions Report
2) Deletions Report
3) Changes Report

2. Carrier Copies:

  1. Make a photocopy of the Summary and staple your check stub, WiSMART document or a photocopy of the check to the back of the photocopied Summary.
  2. Monthly Coverage Reports - these should be placed in the same order as they appear on the Summary. Corresponding forms should be attached (stapled in the upper left-hand corner) to the respective Coverage Report in the following order:

1) Health Applications and Transfer Reports - placed in the order they appear on the Additions Report.
2) Additions Report.
3) Transfers and/or Cancellation Reports as listed on the Deletions Report.
4) Deletions Report.
5) Health Applications related to the Changes Report.
6) Changes Report.

Mail both sets of reports to:

Division of Employer Services
Department of Employee Trust Funds
PO Box 7931
Madison WI 53707-7931

For questions about the proper way to assemble your monthly health insurance reports, call the Employer Communication Center at (608) 264-7900.

Late Dual-Choice Applications

If you received any late 2002 Dual-Choice Applications, follow the instructions in Subchapter 406 of the Health Insurance Employer Administration Manual (ET-1118 Revised 1/97 for state agencies and ET-1144 Revised 6/97 for local employers). Please forward a photocopy of the application, the letter from the employee and your memo to Mary Hensen, Department of Employee Trust Funds, P.O. Box 7931, Madison, WI 53707-7931 or send via fax (608) 266-5801.

Clarification on Late Applications for Network Plans

The new contract provision effective January 1, 2002 that allows a subscriber to choose another network within the same plan (i.e., Compcare, Humana, Unity) was written for the sole purpose of maintaining access to current providers.


CompcareBlue-Northwest is no longer available on January 1, 2002. CompcareBlue-North is offered under the same insurer "Compcare." The subscriber may select CompcareBlue-North and select the same provider(s) he or she had while insured with CompcareBlue-Northwest.

This situation does not require an appeal letter and the employer can accept the Health Insurance application (ET-2301 or ET-2302 for UW Graduate Assistants) submitted by the subscriber. Coverage is effective January 1 or the first of the month following the employer's receipt of the application, whichever is later. There is no time limit for applications to be submitted; however, the subscriber must use providers in the network currently enrolled until coverage under the new plan becomes effective.

If a plan leaves, as in the case for CompcareBlue-Southeast, and the subscriber failed to make a Dual-Choice election, unless the new network (i.e., CompcareBlue-Aurora/Family) offers the same providers, the employee must submit an application through the late Dual-Choice Appeal process. The individual will be limited to the Standard Plan unless the late Dual-Choice Review Committee approves the new plan. Coverage under an HMO approved through the Dual-Choice appeal process is prospective. If a late Dual-Choice situation is identified after June 30 following the Dual-Choice Enrollment period, then the employee is limited to the Standard Plan with a 180-day waiting period for preexisting conditions.

If you have any questions about the use of a particular form or other Dual-Choice reporting requirements, please call our Employer Communication Center at (608) 264-7900.


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