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Employer Bulletin

State Agencies & Local Health Employers
Vol. 22, No. 19
December 2, 2005

Important Health Plan Updates, Late Dual-Choice Applications, and Dual-Choice Rescinds; Revisions to Health Insurance Forms; Student Status Documentation Guidelines

Health Plan Updates

Employers and payroll/benefit staff should be aware of the following health plan updates:

Atrium/CompcareBlue Northwest

CompcareBlue acquired Atrium Health Plan, effective November 1, 2005. As of this date, all forms and notifications (e.g., ET-2301, ET-2329, etc.) that were sent to Atrium should now go to CompcareBlue NW. Current members received new identification cards from CompcareBlue NW and were instructed to discard their Atrium cards, but they are allowed to continue using the Atrium provider network for the remainder of the year. If former Atrium members did not select a different health plan during Dual-Choice, they will remain in CompcareBlue NW for 2006.


  • In a recent mailing to existing members, Humana inadvertently excluded the terminated physician listing (terminated provider list) attachment referenced in the letter. Humana mailed correction notices with the appropriate attachment the week of October 24, 2005.
  • Humana Eastern recently added Waukesha IPA, previously reported as a terminated provider, to the network for 2006. Humana included this information in the correction letter noted above.

Humana informed participants that in the event this new information affected Dual-Choice selections for 2006, they should contact their payroll/benefits representative as soon as possible. Depending on how this information affects an employee’s decision, the employee may require information on filing a late Dual-Choice appeal to select another health plan or rescinding a Dual-Choice application to remain enrolled in Humana Eastern.

Group Health Cooperative Eau Claire (GHC-EC)

  • GHC-EC added a number of providers in additional counties after the It’s Your Choice booklet was printed, and continues to work on provider contracting in those counties. Consequently, the provider directory previously submitted to the Department of Employee Trust Funds (ETF) is incomplete. Participants should review GHC-EC’s Internet site,, for up-to-date information on provider availability. These late provider additions may result in late Dual-Choice appeals to select GHC-EC.

Late Dual-Choice Applications

Follow the instructions in Subchapter 406 of the Health Insurance Employer Administration Manuals (Subchapter 406 of ET-1118, Rev. 01/1997 for state agencies; Subchapters 404 and 405 of ET-1144, Rev. 07/2005 for local government employers) for any late 2006 Dual-Choice Applications. Please forward a photocopy of the Group Health Insurance Application (ET-2301 for state and local government employees and ET-2302 for University of Wisconsin graduate assistants), the letter from the employee, and your memo to:

Wendy Pink
Division of Trust Finance & Employer Services
Department of Employee Trust Funds
P.O. Box 7931
Madison, WI 53707-7931

You may also fax any late applications to (608) 266-5801. ETF will review the material and issue a written response approving or denying the request, along with reporting instructions, if approved.

Procedures for Withdrawing Dual-Choice Elections

Employees may rescind 2006 Dual-Choice elections by notifying their employers in writing prior to December 31, 2005. When you receive a request to rescind, do not send the employee’s written request to ETF or the health plans. Please follow these procedures as timely as possible to ensure all parties are aware of the rescind. Your timely action helps prevent confusion and incorrect enrollments.

    1. Make five copies of your ply of the Dual-Choice application initially submitted by the employee selecting a change.
    2. Write “Rescind” across each copy.
    3. Forward one copy to ETF.
    4. Forward one copy to the current health plan.
    5. Forward one copy to the health plan indicated as “Plan Selected.”
    6. Retain a copy for your records.
    7. Retain one copy for the employee’s records, along with their original written request.

Revisions to Health Insurance Forms

ETF recently revised the Group Health Insurance Application (ET-2301) and Health Insurance Information Change (ET-2329) form.

NOTE: Forms with revision dates prior to 07/2005 will be phased out by January 1, 2007.

We recommend you destroy forms with revision dates prior to 07/2005 and follow the instructions at the end of this bulletin to order the revised forms.

Group Health Insurance Application (ET-2301)

Revisions to the Group Health Insurance Application also apply to the application used by State agencies for graduate assistants (ET-2302) and include:

Section Description
A Adding a footnote under the change from family to single coverage.
A Moving the "change to Single Coverage - 44 or 45" and "dual-Choice - 40" to accommodate the footnote.
Reverse of the application Revisions to the "Terms and Conditions"

Adding the "Program Option Code" and "Surcharge Code":

  • For State agencies, the "Program Option Code" is P01 and the "Surcharge Option Code" is S01.

For local employers, the "Program Option Code" and "Surcharge Option Code" is located on the Monthly Coverage Report.

Health Insurance Information Change (ET-2329)

Revisions to the Health Insurance Information Change form include:

Section Description
3 and 4 Creating separate sections when adding dependents (Section 3) or deleting dependents (Section 4).
3 Specifying when documentation is required to add a dependent
3 Entering an “Applicant Relationship Code” when adding a dependent; codes are printed on the back of the form.
4 Obtaining address(es) of dependent(s) deleted for employer use in issuing continuation coverage notices.
2 Reporting changes in selected primary care physicians or clinics.
Reverse of the application Adding “Terms and Conditions”

Adding the “Program Option Code” and “Surcharge Code”:

  • For State agencies, the “Program Option Code” is P01 and the “Surcharge Option Code” is S01.

For local employers, the “Program Option Code” and “Surcharge Option Code” is located on the Monthly Coverage Report.

One Group Health Insurance Application (ET-2301) and one Health Insurance Information Change (ET-2329) form are attached to this bulletin. Destroy any of these forms with a revision date prior to 07/2005 and request an additional supply by one of the following methods:

  • Use the online order form through our Internet site at Please enter all requested information, especially your Employer Identification Number (EIN).
  • Contact ETF’s Supply and Mail Services, (608) 266-3302;
  • Complete the attached form and mail or fax to:

    ETF Supply and Mail Services
    P.O. Box 7931
    Madison, WI 53707-7931
    Fax: (608) 267-4549

Student Status: Documentation Guidelines

The attached Student Status Enrollment Coverage Change Reference Chart outlines the documents required and coverage begin dates for situations involving dependents meeting Student Status eligibility requirements. In all cases, either a Group Health Insurance Application (ET-2301 or ET-2302 for graduate students) or a Health Insurance Information Change form (ET-2329) is required. In some cases, additional documentation supporting the dependent status as full-time student is required. Questions regarding the topics discussed in this bulletin should be directed to the Employer Communications Center at (608) 264-7900.


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