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:
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,
- 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, www.group-health.com,
for up-to-date information on provider availability. These late
provider additions may result in late Dual-Choice appeals to select
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:
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.
- Make five copies of your ply of the Dual-Choice application
initially submitted by the employee selecting a change.
- Write “Rescind” across each copy.
- Forward one copy to ETF.
- Forward one copy to the current health plan.
- Forward one copy to the health plan indicated as “Plan
- Retain a copy for your records.
- 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:
||Adding a footnote under the change from family to single coverage.
||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
Information Change (ET-2329)
Revisions to the Health Insurance Information Change form include:
|3 and 4
||Creating separate sections when adding dependents (Section
3) or deleting dependents (Section 4).
||Specifying when documentation is required to add a dependent
||Entering an “Applicant Relationship Code” when
adding a dependent; codes are printed on the back of the form.
||Obtaining address(es) of dependent(s) deleted for employer
use in issuing continuation coverage notices.
||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
- Use the online order form through our Internet site at http://etf.wi.gov.
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.