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Employers

Employer Bulletin

State Agencies
Vol. 21, State D
November 30, 2004

2005 Group Health Insurance Reporting Forms; Dual-Choice Due Dates; Reporting and Assembly of 2005 Health Reports

The following 2005 Group Health Insurance reporting forms and documents are enclosed:

  • State Health Insurance Summary - 2005 (ET-1608) Rev. 10/2004
  • State Employees 2005 Monthly Coverage Report (ET-1607) Rev. 10/2004
  • Monthly Additions Report (ET-2610) Rev. 10/2001
  • Monthly Deletions Report (ET-2612) Rev. 10/2001
  • Monthly Changes Report (ET-2614) Rev. 10/2001
  • Mailing Labels to use when sending reports to the Department of Employee Trust Funds (ETF)

    Note: Changes to State Health Reporting Forms
    The State Health Insurance Summary - 2005 (ET-1608) and State Employees 2005 Monthly Coverage Report (ET-1607) have changed. Both reports now include a new Program Option Code and Surcharge Code. These changes appear in the title of the reporting forms as (PGM OPT P1) and (SRCHG S01). These codes are intended for ETF use only, with no current impact on State agency reporting.

It is critical that you use the 2005 Summary and Monthly Coverage reports when reporting for 2005. Destroy any Summary and Monthly Coverage reporting forms not labeled as 2005.

Please use the most recently revised enrollment and information change forms in Plan Year 2005:

  • Health Insurance Application (ET 2301) Rev. 9/2004
  • Health Insurance Application (ET 2302) Rev. 9/2004 (UW Grad Assistants only)
  • Health Insurance Information Change (ET 2329) Rev. 9/2003

For additional reporting forms or applications, contact ETF’s Supply and Mail Services Section at (608) 266-3302. Forms may also be downloaded or ordered from the Employer Section of our Internet site, http://etf.wi.gov.

2005 Dual-Choice Due Dates and Reporting Instructions

The January 2005 Health Insurance Reports are due Monday, December 20, 2004. Employers are encouraged to submit the January 2005 reports as early as possible, given the volume of changes resulting from Dual-Choice.

Note: Do not divide the January transactions between Dual-Choice and “regular.” Both Dual-Choice and regular (non-Dual-Choice) transactions must be combined on the State Employees 2005 Monthly Coverage Report (ET-1607), Monthly Additions Report (ET-2610), Monthly Deletions Report (ET-2612), and the Monthly Changes Report (ET-2614).

Tips for Completing Health Insurance Applications and Corresponding Reports Throughout 2005

Enrollment applications, monthly reporting forms, and premium remittances must be complete and accurate in order to ensure proper and prompt health insurance coverage for your employees. In addition, statistics generated from the monthly data submitted by employers are used to track the movement of individuals between the participating health plans and counties. This information is used in the rate setting process for the Group Health Insurance Program.

Consult Subchapter 501 and 502 of the Health Insurance Employer Administration Manuals (ET-1118) for information concerning the “Prospective Date of Coverage” entered on the Health Insurance Application (ET-2301 or ET-2302) and “Effective Date” entered on the Monthly Additions Report (ET-2610). Consult Subchapter 507 for information concerning effective dates of termination of coverage.

January 2005 Health Insurance Reports must include:

  1. Two copies of the completed State Health Insurance Summary - 2005 (ET-1608) and the corresponding State Employees 2005 Monthly Coverage Report (ET-1607) for each plan, indicating all of the contracts (Dual-Choice and regular) added and deleted for the coverage month of January 2005.
  2. Two copies of the Monthly Additions Report (ET-2610), Monthly Deletions Report (ET-2612), Monthly Changes Report (ET-2614) on which regular monthly transactions and Dual-Choice transactions (enrollment Type Codes 40 and 43 titled “Dual-Choice”) are combined. ETF Coverage Report plies of the Dual-Choice and the regular (non-Dual-Choice) applications must be attached to the corresponding Monthly Additions Report (ET-2610). A Monthly Deletions Report (ET-2612) for each health plan, listing each employee leaving that health plan at year-end, must be submitted.

    NOTE: Each entry on the Monthly Additions Report (ET-2610) must indicate the suffix number of the previous health plan in the ‘From’ column (the employee’s current health plan). Do not substitute the name of the health plan for the health plan suffix number.

    3. Each entry on the Monthly Deletions Report (ET-2612) must indicate the suffix number of the newly elected health plan in the ‘To’ column. Do not substitute the name of the health plan for the health plan suffix number.

Written requests to use an alternate form of reporting or to deviate from completing/ assembling the reports in the manner described herein, must be submitted to ETF and must be approved in advance. Requests must be received by ETF no later than Friday, December 3, 2004, and must include the alternate form(s) and/or alternate assembly method. Mail or e-mail your request to:

Ron Diehl
Division of Trust Finance & Employer Services
Department of Employee Trust Funds
P O Box 7931
Madison, WI 53707-7931
E-mail ron.diehl@etf.state.wi.us

Assembly of all Health Insurance Reports for 2005 (Including January Dual-Choice Reporting)

Assemble your reports in the following order (resulting in two sets of reports in descending order:

I. ETF Report Packet

  1. State Health Insurance Summary - 2005 (ET-1608) - Attach WiSMART document(s) directly behind the Summary. Note: If paying by check, attach the check to front of the Summary. (Please see instructions above for additional requirements for the Dual-Choice reports.)
  2. State Employees 2005 Monthly Coverage Report (ET-1607) - Attach one Monthly Coverage Report per health plan with contracts to report. Assemble in the order in which the plans are listed on the Monthly Coverage Report. (Please see instructions above for additional requirements for the Dual-Choice reports.

    Attach corresponding Monthly Additions Report (ET-2610), Monthly Deletions Report (ET-2612), and the Monthly Changes Report (ET-2614), along with applications and other supporting documentation (stapled in the upper left corner), to the respective Monthly Coverage Report in the order listed below.

    1. Monthly Additions Report (ET-2610)
      • Assemble ETF Coverage Report plies of Health Insurance (ET-2301) and Health Insurance Applications (ET-2302) in the order in which the specific subscriber information is listed on the Monthly Additions Report.
    2. Monthly Deletions Report (ET-2612)
      • Assemble any necessary supporting documents (i.e. Group Health Insurance Cancellation Reports [ET-1616], Group Health Insurance Transfer Reports [ET-1615]) in the order in which the specific subscriber information is listed on the Monthly Deletions Report.
    3. Monthly Changes Report (ET-2614)
      • Assemble ETF Coverage Report plies of Health Insurance Applications (ET-2301), Health Insurance Applications (ET-2302), and/or Medicare Eligibility Statement(s) (ET-4307) in the order in which the specific subscriber information is listed on the Monthly Changes Report.

II. Health Plan Report Packet (Carrier Copies):

  1. Copy of State Employees 2005 Monthly Coverage Report (ET-1607) – Attach one copy Monthly Coverage Report per health plan with contracts to report. Assemble in the order in which the plans are listed on the Monthly Coverage Report. Attach corresponding Monthly Additions Report (ET-2610), Monthly Deletions Report (ET-2612), and the Monthly Changes Report (ET-2614) in the order listed below.
    1. Monthly Additions Report (ET-2610) – No supporting documentation attached.
    2. Monthly Deletions Report (ET-2612) – No supporting documentation attached.
    3. Monthly Changes Report (ET-2614) – No supporting documentation attached.

Mail both sets of reports to:

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

For questions on the proper way to assemble your monthly health insurance reports, call Ron Diehl at (608) 266-2737 or e-mail ron.diehl@etf.state.wi.us.

Late Dual-Choice Applications

Follow the instructions in Subchapter 406 of the Health Insurance Employer Administration Manuals (ET-1118, Rev. 1/97 for state agencies) for any late 2005 Dual-Choice Applications. Please forward a photocopy of the Health Insurance Applications (ET-2301 for state 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 letter approving or denying the request, along with reporting instructions.