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FAQ

Frequently Asked Questions

Group Health Insurance Changes for 2016
Revised September 16, 2015

The following are answers to frequently asked questions related to changes to the State Group Health Insurance Program and the Wisconsin Public Employers (WPE) Group Health Insurance Program for 2016.

FAQ Topics

 


 

It’s Your Choice Open Enrollment

Q: When is the It’s Your Choice open enrollment period for the 2016 plan year?
A: October 5 – October 30, 2015.

 


 

Primary Health Plan Designs

Q: What are the primary health plan designs under the State of Wisconsin Group Health Insurance Program?
A: The following is a summary of the four primary health insurance plan designs of the State of Wisconsin Group Health Insurance Program, followed by answers to frequently asked questions. Note: Plan designs for local government employees are provided in the WPE Group Health Insurance Program FAQs, below.

  1. It’s Your Choice Health Plan (formerly Coinsurance Uniform Benefits): Approximately 98% of state members are enrolled in this plan. Participants can choose from a variety of health maintenance organizations and one preferred provider organization. These health plans administer the same uniform benefits package.
  2. It’s Your Choice High Deductible Health Plan (formerly High Deductible Health Plan): This plan offers the same uniform benefits package and the same choice of health plans as the It’s Your Choice Health Plan. The difference is that this design has a higher deductible and out-of-pocket limits. In exchange for the increased cost sharing, this design is also paired with a Health Savings Account into which your employer deposits money, if you are eligible. The monthly member premium cost for this plan design is also lower than the other plan designs.
  3. It’s Your Choice Access Health Plan (formerly Standard Plan): This plan design provides freedom of choice of doctors and hospitals across the country. In exchange for the increased flexibility in medical providers, the monthly member premium cost for this plan design is higher than the It’s Your Choice Health Plan and the It’s Your Choice High Deductible Health Plan designs.
  4. It’s Your Choice Access High Deductible Health Plan (formerly High Deductible Standard Plan): This plan design provides freedom of choice of doctors and hospitals across the country, along with a higher deductible and out-of-pocket limits. In exchange for the increased cost sharing, this design is also paired with a Health Savings Account into which your employer deposits money, if you are eligible. The monthly member premium cost for this plan design is lower than the It’s Your Choice Access Health Plan design.

 


 

State Employees:
Premiums

Q: How much will my health insurance premium contribution be in 2016?
A: Find the state employee premium contribution amounts for all the health plan designs here.

Q: Currently there are only individual and family rates, but the Group Insurance Board’s consultant recommended that more premium categories be added (e.g., employee + spouse). Why wasn’t this change approved by the GIB?
A: The current structure is mandated by state law. Legislation would need to be passed to add more premium categories.

 


 

State Employees:
Opt-out Incentive

Q: What is the opt-out incentive and how do I get it?
A: If you are a state employee: Starting in 2016, you may be eligible to receive $2,000 from your employer if you opt out of state group health insurance program coverage. To be eligible you can not have opted out in 2015, and you also can not be covered under the state group health insurance program as a dependent. You are required to submit a Group Health Insurance Application/Change Form (ET-2301) during It’s Your Choice open enrollment to receive the opt-out incentive for 2016.

Q: Will I receive the opt-out incentive in a lump sum?
A: No, incentive payments will be spread out over all applicable pay periods in the year.

Q: If I opted out of state group health insurance coverage in 2015, will I ever be eligible for the opt-out incentive?
A: No, not as the law is currently written.

Q: If I opt in before the end of 2015 will I be eligible for the incentive?
A: Yes, if you are not a covered dependent in the program. Reminder: You must experience a qualifying event in order to be eligible to opt in mid-year.

Q: Am I eligible for the opt-out incentive if I am covered under the Wisconsin Public Employers Group Insurance Program (WPE, a.k.a., “local” program)?
A: This opt-out incentive is available only to eligible State of Wisconsin employees. However, WPE employers may choose to offer a similar program in 2016.

Q: Will I be eligible for the opt-out incentive in 2016 if I am covered for even one day in 2016?
A: No.

Q: Can I opt in one year, then opt out the next and receive the incentive the next year, then opt in the following year -- and continue this pattern to be eligible for the incentive every other year? 
A. Yes.

Q: Am I eligible for the opt-out incentive if I am:

  • A limited-term employee? Yes, if you are eligible to participate in the State of Wisconsin Group Health Insurance Program and you meet the other eligibility requirements.
  • A less-than-half-time employee? Yes, as long as you meet the other eligibility requirements.
  • On a leave of absence? Yes, if you are eligible to participate in the State Group Health Insurance Program and you meet the other eligibility requirements.
  • A Craftworker? No, because you are not eligible for the employer premium contribution.

 


 

The following information about deductibles, copayments, coinsurance and out-of-pocket limits applies to:

  • State employees and state non-Medicare retirees

  • Local employees and non-Medicare retirees with the IYC Local Health Plan insurance for employees (Program Options 6 and 16):

Deductible / Copayment / Coinsurance / Out-of-Pocket Limit

Q: What is a Deductible?
A: A deductible is the amount you must pay out-of-pocket for the full cost of certain covered health care services before your health plan begins to pay.

Q: What is a Copayment?
A: A copayment is a fixed amount you pay for certain covered health care services or prescription drugs, usually due at the time you receive the service. Example: paying a copayment of $15 for a primary care visit.

Q: What is Coinsurance?
A: Coinsurance is your share of the costs of certain covered health care services or prescription drugs, calculated as a percent of the amount for the service or cost of the drug.
Example: If a diagnostic test costs $100 and you have met your deductible, your coinsurance payment of 10% would be $10 (10% of $100). The health plan pays the rest of the cost ($90).

Q: What is an Out-of-Pocket Limit?
A: An out-of-pocket limit (OOPL) is a plan provision that limits a member’s cost sharing. The OOPL is the maximum amount that a member will pay for in-network, covered services during a plan year (same as calendar year).

The State and WPE (local government) health insurance programs have OOPLs in place that apply to certain medical and prescription drug out-of-pocket costs. The federal government also enforces out-of-pocket maximums that are much higher than the OOPLs of the State and WPE (local government) Group Health Insurance Programs. For any essential health benefit costs that do not stop at the program OOPL, the federal maximum out-of-pocket limits provide a safety net that does not allow you to incur any out-of-pocket expenses more than $6,850 individual or $13,700 family. Note: For the State of Wisconsin Group Health Insurance Program, this only applies to Level 3 prescription drugs.

Q: What are the It’s Your Choice Health Plan medical deductible amounts for 2016?
A: The medical deductible is $250 per individual and $500 per family for the It’s Your Choice Health Plan. Keep in mind that certain preventive services are covered at 100%; office visit copayments and prescription drug costs are not subject to the deductible and do not apply towards meeting the deductible.

Note:  Information about deductible changes for other plan designs can be found in the FAQ sections below. Complete deductible and benefit information will be available at It’s Your Choice 2016 on the ETF website.

Q: When will the new medical deductible apply?
A: Beginning in 2016, all eligible medical charges are subject to the annual deductible. There are two exceptions:

  1. Office visits are subject to a per-visit copayment of $15 for primary care and therapy office visits and $25 for specialty care and urgent care visits.
  2. Emergency room visits are subject to a $75 per-visit copayment.

These visits are not subject to the deductible, but any additional services you receive (e.g., lab work or testing) may be subject to the deductible and any applicable coinsurance. Remember that preventive services are 100% paid for by your health plan.

Q: Does the medical deductible apply to dental services?
A: No. There is no deductible associated with covered services under the Uniform Dental Benefit, including for the high deductible health plan option – this is a change from 2015.

Q: Does the medical deductible have to be met before office visit/emergency room  copayments are applied?
 A: No, but any additional services you receive (e.g., lab work or testing) may be subject to the deductible and any applicable coinsurance.

Q: How much are the office visit copayments?
A:


Office Visit Type

$15 Primary Care Visit

$25 Specialty Visit

Family Practice

 

General Practice

 

Internal Medicine

 

Gynecology/OB

 

Midwives

 

Nurse Practitioners

 

Physician Assistant

 

Pediatrics

 

Urgent Care

 

Chiropractic

 

Home Health Visit

Subject to deductible and coinsurance

Subject to deductible and coinsurance

Palliative Care Visit


For Primary Care Provider Only


For Specialist Only

Vision Exam

 

Pre/Postnatal Visits

✔*

 

Mental Health Visits/Therapy

 

Physical Therapy

 

Occupational Therapy

 

Speech Therapy

 

Other Practitioner

 

* If all prenatal visits are billed as a package at the end of pregnancy, then deductible and 10% coinsurance apply. Check with your doctor’s office for more information.

Q: Do office visit copayments count toward the annual Out-of-Pocket limit (OOPL)?
A: Yes, office visit copayments are applied to the annual OOPL.

Q: Does coinsurance still apply to various services that are now subject to the deductible (e.g., lab tests, diagnostic x-rays)?
A: Yes. After the deductible is met, a 10% coinsurance will be charged for all non-copayment-related services beyond the charge for the office visit. Exception: A 20% coinsurance applies to covered durable and disposable medical equipment, certain hearing aids, and cochlear implants.

Q: How do the medical Out-of-Pocket Limits (OOPL) affect me?
A: The OOPL limits work the same way they do now. However, the amounts have increased for 2016. Here is a summary of the OOPLs for 2015 and 2016 for in-network, covered medical services under the It’s Your Choice Health Plan:


Medical Out-of-Pocket Limits
It’s Your Choice Health Plan

 

Individual

Family

 

2015

2016

2015

2016

Medical OOPL

$500

$1,250

$1,000

$2,500

 


 

The following information about the IYC High Deductible Health Plan/HSA option applies to:

  • State employees and non-Medicare retirees

  • Local employees and non-Medicare retirees with the Local High Deductible Health Plan insurance for employees (Program Options 7 and 17) Note: Only the IYC HDHP information applies to the local program options. Local employers cannot offer the State HSA.

High Deductible Health Plan (HDHP) / Health Savings Account

Q: Are the deductible and out-of-pocket limits (OOPLs) changing for the HDHP for 2016?
A: No, the deductible and OOPL amounts are not changing for the HDHP for 2016.


HDHP

 

Individual

Family

 

2015

2016

2015

2016

Deductible (applies to medical and prescription drug costs)

$1,500

$1,500

$3,000

$3,000

Combined Medical and Pharmacy OOPL

$2,500

$2,500

$5,000

$5,000


Q: How do the changes to the Uniform Dental Benefit affect the IYC HDHP?

A: If you enroll in the IYC HDHP for 2016, you will automatically be enrolled in Uniform Dental Benefits, unless you choose to opt out of this dental benefit during open enrollment. Uniform Dental Benefits will no longer be subject to the combined medical and pharmacy deductible or the OOPL in 2016.

Q: How do the changes to the prescription drug benefit affect the IYC HDHP?

A: The prescription drug copayments and coinsurance amounts will change, as listed in the Prescription Drugs section. However, the deductible and OOPL will not change for the HDHP. All prescription drugs are subject to the deductible unless mandated by federal law.

Q: What are the 2016 HSA employer contribution amounts?
A: The state employer contribution amounts are $750 individual and $1,500 family. Only certain state employees enrolled in one of the HDHP plan designs are eligible for the employer HSA contribution.

 


 

In general, the prescription drug changes apply to all state and local participants:

Prescription Drugs

Q: How can I compare 2015 pharmacy benefits to changes for 2016?
A:

Pharmacy Benefits At a Glance

Benefit Year 2015 2016

Member Costs

Generic – Level 1

$5

$5

Brand – Level 2

$15

20% ($50 maximum)

Brand – Level 3

$351

40% ($150 maximum)1

Brand – Level 4

  • Preferred Pharmacy
  • Non-preferred Pharmacy

 

$152
$50

 

$502
40% ($200 maximum)

Member Out-of-Pocket Limits (OOPL)

Levels 1 & 2

$410 Single / $820 Family

$600 Single / $1,200 Family

Level 4

$1,000 Single / $2,000 Family

$1,200 Single / $2,400 Family

1 Level 3 copays do not apply toward OOPL.
2 Reduced copay applies when Preferred Specialty Medications are obtained from a Preferred Specialty Pharmacy.

Note: This also applies to annuitants who are eligible for and enrolled in Medicare Parts A, B and D


Q: What will my current prescription drugs cost in 2016?
A: It is too early to predict exact prescription drugs costs for 2016 because the cost of prescription drugs charged by pharmacies changes frequently, due to drug manufacturer costs and negotiated discounts. However, follow these steps to estimate your costs for 2016:

  • Find out what level your drug is on the formulary. Visit www.navitus.com (you must log in to the Navi-gate for Members section) and select “Formulary” from the options available. You can also call Navitus at 1-866-333-2757.
  • If you have taken this prescription drug before, you may look at the member portal on Navitus Health Solutions website (Navi-gate for Members) to learn the total negotiated cost of the prescription drug.
  • Find the current cost of your drug on either the paperwork you receive with your prescription, or ask your pharmacist.
  • Calculate the cost based on the chart

Q:  What are the prescription drug copayments and coinsurances for 2016, and which apply to the out-of-pocket limits (OOPLs)?
A: This chart shows the member cost share, the maximum coinsurance amounts for each level of prescription drug, as well as the annual OOPLs. Note: This chart only applies to the It’s Your Choice Health Plan.

2016 Prescription Copays, Coinsurance, and Out-of-Pocket Limits (OOPL)

Prescription Drug Level

Member Costs

Annual OOPL*

Level 1

$5 per fill

$600 individual / $1,200 family

Level 2

20% ($50 maximum per fill)

$600 individual / $1,200 family

Level 3

40% ($150 maximum per fill)

Only federal maximum out-of-pocket limits apply: $6,850 individual / $13,700 family

Level 4 Preferred Specialty Drug

  • Filled at a Preferred Specialty Pharmacy (e.g. Diplomat Specialty Pharmacy)

$50 per fill

$1,200 individual / $2,400 family

  • Filled at any other pharmacy

40% ($200 maximum per fill)

Level 4 Non-preferred Specialty Drug

  • Filled at a Preferred Specialty Pharmacy (e.g. Diplomat Specialty Pharmacy)

$50 per fill

Only federal maximum out-of-pocket limits apply: $6,850 individual / $13,700 family

  • Filled at any other Pharmacy

40%
($200 maximum per fill)

Only federal maximum out-of-pocket limits apply: $6,850 individual / $13,700 family

*The HDHPs have a combined medical and prescription drug OOPL and the OOPLs listed in this chart do not apply. The HDHP OOPLs did not increase from last year.

Q: Where can I find the covered prescription drug formulary?

A: You can view the formulary on the Navitus website. You must log in to the Navi-gate for Members section and then select “Formulary” from the options available.

 


 

Preventive Services

Q: What are preventive services?
A: Preventive services are routine health care that includes check-ups, patient counseling and screenings to prevent illness, disease and other health-related problems. Federal law requires that specific preventive services performed by in-network providers be offered at no cost to you. You can find a list of these preventive services here.

Q: Does the deductible or office visit copayment apply to federally-required preventive services?
A: No. These preventive services are covered at no cost to you, as long as the services are provided by an in-network provider. Therefore, they do not apply to the deductible, including under the It’s Your Choice High Deductible Health Plan. You can find a list of the preventive services here.

Q: Do I have to pay a copayment or coinsurance for preventive services?
A: If the office visit is in-network and is for certain preventive services only, no. These preventive services are covered at no cost to you, therefore there is no copayment or coinsurance. Copayments or coinsurances would apply if the office visit or service is not covered as a preventive service. You can find a list of the preventive services here.

 


 

The following information applies to Medicare enrolled members

Medicare Enrolled Members

Q: How do the 2016 benefit changes affect me if I am retired?
A: If you are retired and not enrolled in Medicare, both the medical benefit and the prescription drug benefit changes apply to you.

If you are retired and enrolled in Medicare A and Medicare B:
1. Cost sharing parts of the medical benefits changes do not apply to you (e.g., deductibles, office visit copayments, out-of-pocket limits).
2. The prescription drug benefit changes do apply to you.
3. The additional benefits (e.g. advance care planning and habilitative therapy services) do apply to you.

 


 

The following information applies to:

  • All state employees and retirees

  • Local government employees whose employer has offered this coverage:

Dental Coverage

Q: Am I required to enroll in the Uniform Dental Benefit through Delta Dental in 2016?
A: It will be the employee’s (or retiree’s) choice whether to continue participating in the Uniform Dental Benefit for routine and preventive care. You will be automatically enrolled if you are enrolled in the medical plan. You will need to file an applicationduring the It's Your Choice open enrollment period to opt out if you do not want Uniform Dental Benefits. Supplemental dental insurance (i.e., Epic, Dental Wisconsin, and Anthem DentalBlue) will remain separate, optional plan offerings.

Q: Will I have to pay a separate premium for the Uniform Dental Benefit coverage in 2016?
A: No -- dental coverage will be rolled into the medical premium, as it always has been. The difference in 2016 is the plan design: the 2016 plans “without” dental coverage have lower medical premiums than those “with” dental coverage. Remember: If you are currently enrolled in a health plan, you will be automatically enrolled in Uniform Dental Benefits and can choose to opt out during the It’s Your Choice open enrollment period, October 5-30.

Q: Can I elect family medical coverage and individual dental coverage?
A: No. If you elect family medical coverage with dental, you will be enrolled in the family dental coverage. Similarly, if you elect individual medical coverage with dental, you will be enrolled in the individual dental coverage.

Q: How will I know if my current dentist is covered by Delta Dental in 2016?
A: The Uniform Dental Benefit will use the Delta Dental PPO and the Delta Dental Premiere networks. You may use a dentist who participates in either network. ETF encourages you to check whether your dental provider is in-network before receiving dental services in 2016. Please visit www.deltadentalwi.com/state-of-wi to search for in-network providers.

Q: Will my dental expenses apply to the medical deductible?
A: No, see the deductible questions for more information.

Q: What dental benefits will be covered in 2016?
A: All covered services, copayments and/or coinsurance will be outlined in the Uniform Dental Benefit Certificate. The benefits for 2016 will be substantially similar to the Uniform Dental Benefit in 2015. Any changes to the covered dental services, copayments and/or coinsurance will be noted in the It’s Your Choice open enrollment materials and in Delta Dental’s benefit materials.

 


 

The following information about IYC Access Health Plan (formerly Standard Plan) apply to:

  • State employees and non-Medicare retirees

  • Local employees and non-Medicare retirees with the Local Health Plan insurance for employees (Program Options 6 and 16):

It’s Your Choice Access Health Plan (formerly Standard Plan)

Q: Which changes affect State It’s Your Choice Access Health Plan (formerly Standard Plan) participants?
A: A summary of the changes to the deductibles and the out-of-pocket limits for the It’s Your Choice Access Health Plan follows below. The office visit copayments (for in-network providers), prescription drug benefit changes, and the additional benefits (e.g., advance care planning and habilitative therapy services) also apply to you.

Note: There are no increases to the It’s Your Choice Access HDHP deductibles or out-of-pocket limits.


It’s Your Choice Access Health Plan Medical Cost Changes

 

Individual

Family

 

2015

2016

2015

2016

In-Network Deductible

$200

$250

$400

$500

Out-of-Network Deductible

$500

$500

$500

$1,000

In-Network  Out-of-Pocket Limit

$800

$1,000

$1,600

$2,000

Out-of-Network Out-of-Pocket Limit

$2,000

$2,000

$4,000

$4,000

It’s Your Choice Access Health Plan
Prescription Drug Cost Changes

Prescription Drug Level

2016 Member Costs

Annual Out-of-Pocket Limits (OOPL)*

Level 1

$5 per fill

$1,000 individual / $2,000 family

Level 2

20%
($50 maximum per fill)

$1,000 individual / $2,000 family

Level 3

40%
($150 maximum per fill)

Only federal maximum out-of-pocket limits apply: $6,850 individual / $13,700 family

Level 4 Preferred Specialty Drug

  • Filled at a Preferred Specialty Pharmacy (e.g. Diplomat Specialty Pharmacy)

$50 per fill

$1,200 individual / $2,400 family

  • Filled at any other pharmacy

40%
($200 maximum per fill)

Level 4 Non-preferred Specialty Drug

  • Filled at a Preferred Specialty Pharmacy (e.g. Diplomat Specialty Pharmacy)

 

$50 per fill

Only federal maximum out-of-pocket limits apply: $6,850 individual / $13,700 family

  • Filled at any other pharmacy

40%
($200 maximum per fill)

*The IYC Access HDHP has a combined medical and prescription drug OOPL and the OOPLs listed in this chart do not apply. The IYC Access HDHP OOPL did not increase from last year.

 


 

Wisconsin Public Employers (WPE) Group Health Insurance Program (local government program)

Q: Do the 2016 changes that were approved for the state employee program affect me?
A: Here is a chart depicting how these changes affect WPE members, by Program Option:


Summary of 2016 Changes for WPE Group Health Insurance Program

WPE Program Option

New Deductibles, Office Visit Copayments,  Out-of-Pocket Limits

Additional Benefits (i.e., Advance Care Planning and Habilitative Therapy)

Prescription Drug Benefit Changes

Uniform Dental Benefits

It’s Your Choice Local Traditional (formerly Traditional Uniform Benefits) Program Option 2

Do not apply, no changes to this area

Do apply

Do apply

If your employer offers Uniform Dental Benefits, you will automatically be enrolled and must opt-out during open enrollment if you do not want the benefit.

It’s Your Choice Local Deductible (formerly Deductible HMO – Standard PPO) Program Option 4

Do not apply, no changes to this area

Do apply

Do apply

If your employer offers Uniform Dental Benefits, you will automatically be enrolled and must opt out during open enrollment if you do not want the benefit.

It’s Your Choice Local Health Plan (formerly Coinsurance HMO – Standard PPO) Program Option 6

Do apply

Do apply

Do apply

If your employer offers Uniform Dental Benefits, you will automatically be enrolled and must opt out during open enrollment if you do not want the benefit.

It’s Your Choice Local High Deductible Health Plan (formerly High Deductible Health Plan – Standard PPO) Program Option 7

No change to deductibles and out-of-pocket limits. Office visit copayments apply after the deductible is met.

Do apply

Do apply

If your employer offers Uniform Dental Benefits, you will automatically be enrolled and must opt-out during open enrollment if you do not want the benefit.


Q: Will the $2,000 opt-out incentive apply to the WPE Group Insurance Program?

A: No, but your employer may offer a similar program.

Q: Will local government employees be offered the same Uniform Dental Benefit plan as state employees?
A: Each local government employer will choose whether to offer the Uniform Dental Benefit to employees. The benefits are the same for state and local employees who participate in the Uniform Dental Benefit plan. Please check with your employer to determine whether the Uniform Dental Benefit is available to you.

 

 

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