Revised May 16, 2012
Health Insurance - Eligibility
- Must seasonal employees be offered health insurance
coverage? Many of our seasonal employees are students; how is
health insurance handled when they return to school?
Once an employee, including a seasonal employee, is WRS eligible,
they must be offered all ETF administered insurances the employer
participates in. The amount of the employer share of the health
insurance premium can be as little as 25% if the seasonal employee
works less than half-time, which is defined as 1,044 hours.
The seasonal employee's employment status upon return to school
dictates the options regarding health insurance. If considered
on leave or layoff they can continue coverage by pre-paying
the premiums to the employer and the employer will remit them
to ETF along with the employer's share. If considered terminated
they should be offered COBRA. If terminated, upon return to
work they have a new health insurance enrollment option.
- A part-time employee declined our health insurance
coverage when originally eligible due to being covered under their
spouse's plan. The employee's spouse has now cancelled their health
insurance with their employer. Can our employee now apply for
coverage due to losing coverage under the spouse's plan?
No, voluntary cancellation of other health insurance coverage
does not create an enrollment opportunity for the dependent
of that plan. However, if some other qualifying event occurs,
such as a part-time employee whose hours increase so as to make
them eligible for a greater employer share toward the premium.
- When a spouse who is the subscriber dies, is that considered
loss of coverage?
Yes, the widow(er) would have an enrollment opportunity.
- How many hours is considered less than half-time for
determining employer share of health premiums?
Half-time for local employers is defined as 1,044 hours, so
less than half time would be anything less than 1,044 hours.
- A part-time employee with health insurance coverage
cancelled their coverage and became coverer ed under their spouse's
health insurance. The part-time employee's hours subsequently
increased and they asked about re-enrolling. Does the increase
in hours allow for a new enrollment opportunity?
In this case, even though there was a previous cancellation
of coverage, there is a new enrollment opportunity but only
if the hours increase from less than half-time to half-time
or greater. Half-time is defined as 1,044 hours.
- An employee previously declined health insurance coverage
because they were covered under their spouse's plan. The spouse's
employer subsequently stopped contributing to the premium. Does
that create a health insurance enrollment opportunity for our
Yes. When the employer share toward the health insurance premium
ends (not decreases) under the spouse's health insurance, your
employee may take advantage of a 30 day enrollment period without
waiting periods for pre-existing conditions.
- An employee elected single coverage because their spouse
and dependents were covered under the spouse's health insurance
plan. Their spouse has now terminated their employment and gone
to a new employer. Does that constitute a loss of coverage permitting
our employee to switch to family coverage?
Yes, employees enrolled in single coverage (though eligible
for family coverage) may change to family coverage if any eligible
dependents covered under another health plan lose eligibility
for that coverage. So, even if the spouse goes to another employer
who provides health insurance, this would be considered a loss
of coverage event.
- An eligible employee declined ETF administered health
insurance coverage because they had other comparable coverage.
Due to that coverage being lost, they now want to apply for the
group health insurance administered by ETF. Is something needed
to substantiate the loss of coverage?
Yes, when application is being made due to loss of other comparable
coverage, the Health Insurance Application/Change Form (ET-2301)
must be accompanied by documentation from the previous health
plan that includes the reason for and date of the coverage loss.
- Can the employer pay varying premium percentages for
different employee groups?
Yes, as long as the employer pays at least the required minimum
percentage of the premium for every covered employee.
- We have certain groups of employees who are under WRS
but due to the limited number of hours we haven't offered them
health insurance coverage. Can we offer them coverage now?
First, all WRS eligible employees must be offered health insurance
coverage and any other insurance administered by ETF. Coverage
cannot be limited to a particular department, a classification
of employee, special interest group, part-time versus full-time,
or union contract group. If an employer failed to offer health
insurance coverage to an otherwise eligible employee, the employee
is limited to the annual It's Your Choice Open Enrollment period,
unless some enrollment event occurs. There's no employer error
provision for health insurance.
- When an employee is covered under their spouse's plan
and the spouse's employer contribution to the premium decreases
or the plan deductible increases, is that considered a loss of
coverage that would allow the employee to enroll under the Wisconsin
Public Employers Health Insurance program administered by ETF?
No, the employer share would have to cease altogether otherwise
it would be a voluntary cancel.
- If covered under the spouse's health insurance and the
spouse switches jobs where the new employer's health insurance
isn't available until after working 6 months, is that considered
loss of coverage?
Yes, that would constitute an event qualifying your employee
for a health insurance enrollment opportunity.
- An insured employee is adopting and the adoption agency
told the employee that health insurance typically won't cover
the adopted child for several months following adoption; is that
No, the Wisconsin Public Employers Group Health Insurance
program covers an adopted child immediately upon adoption or
placement for adoption.