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Wisconsin Department of Employee Trust Funds header image It's Your Choice 2016 State of Wisconsin Group Health Insurance Program
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Wisconsin Department Of Employee Trust Funds

It's Your Choice 2016


State of Wisconsin
Group Health Insurance Program
(State Employees, Retirees, Continuants and Graduate Assistants)

Comparison of Medical Benefits 2016

Active State Employees and Retirees without Medicare

 

 

IYC Health Plan

IYC HDHP

IYC Access Health Plan
In-Network

IYC Access Health Plan Out-of-Network

IYC Access HDHP
In-Network

IYC Access HDHP
Out-of-Network

Annual Medical Deductible

$250 individual / $500 family

Deductible applies to annual OOPL

After an individual within a family plan meets the $250 deductible, coinsurance will apply to covered medical services except for office visit copayments

Medical deductible does not apply to prescription drugs

$1,500 individual / $3,000 family

The deductible must be met before coverage begins; for family coverage, the full family deductible must be met

The deductible includes prescription drugs and applies to the annual OOPL

$250 individual / $500 family

Deductible applies to annual OOPL

After an individual within a family plan meets the $250 deductible, coinsurance will apply to covered medical services except for office visit copayments

Medical deductible does not apply to prescription drugs

$500 individual / $1,000 family

Deductible applies to annual OOPL

After an individual within a family plan meets the $500 deductible, coinsurance will apply to covered medical services except for office visit copayments

Medical deductible does not apply to prescription drugs

$1,700 individual / $3,400 family

The deductible must be met before coverage begins; for family coverage, the full family deductible must be met

The deductible does apply to prescription drugs and also to the annual OOPL

$2,000 individual / $4,000 family

The deductible must be met before coverage begins; for family coverage, the full family deductible must be met

The deductible includes prescription drugs and applies to OOPL

Primary Care Physician (PCP) Office Visit Copayment
Includes:
Internist
General Physician
Family Practitioner
Pediatrician
Gynecologist / Obstetrician         
Nurse Practitioner
Physician Assistant
Chiropractor
Physical / Occupational / Speech Therapy in an office visit setting.

$15 per visit

Office visit copayments are not subject to the deductible, but do apply to the annual OOPL

After deductible: $15 per visit

Office visit copayments apply to the annual OOPL

$15 per visit

Office visit copayments are not subject to the deductible, but do apply to the annual OOPL

After deductible: 30% member cost up to the annual OOPL

After deductible: $15 per visit

Office visit copayments do apply to the annual OOPL

After deductible: 30% member cost up to the annual OOPL

Specialty Office Visit Copayment
Includes:
Specialty Providers
Urgent Care
Vision Exam

In an office visit setting.

$25 per visit

Office visit copayments are not subject to the deductible, but do apply to the annual OOPL

After deductible: $25 per visit

Office visit copayments apply to the annual OOPL

$25 per visit

Office visit copayments are not subject to the deductible, but do apply to the annual OOPL

After deductible: 30% member cost up to the annual OOPL

After deductible: $25 per visit

Office visit copayments do apply to the annual OOPL

After deductible: 30% member cost up to the annual OOPL

Annual Medical Coinsurance

After deductible: 10% member cost

Applies to medical services except for office visits

Coinsurance applies to the annual OOPL

After deductible: 10% member cost

Applies to medical services except for office visits

Coinsurance applies to the annual OOPL

After deductible: 10% member cost

Applies to medical services except for office visits

Coinsurance applies to the annual OOPL

After deductible: 30% member cost

Applies to medical services

Coinsurance applies to the annual OOPL

After deductible: 10% member cost

Applies to medical services except for office visits

Coinsurance applies to the annual OOPL

After deductible: 30% member cost

Applies to medical services except for office visits

Coinsurance applies to the annual OOPL

Annual Medical Out-of-Pocket Limit (OOPL)

$1,250 individual / $2,500 family $2,500 individual / $5,000 family $1,000 individual / $2,000 family $2,000 individual / $4,000 family $3,500 individual / $6,550 family $3,800 individual / $7,600 family

Routine, preventive services as required by federal law

Plan pays 100% Plan pays 100% Plan pays 100% Subject to the deductible, copayments and/or coinsurance Plan pays 100% Subject to the deductible and coinsurance

Illness/injury related services beyond the office visit copayment (if applicable)

After deductible: 10% member cost up to OOPL After deductible: 10% member cost up to OOPL After deductible: 10% member cost up to the annual OOPL After deductible: 30% member cost up to the annual OOPL After deductible: 10% member cost up to the annual OOPL After deductible: 30% member cost up to the annual OOPL

Emergency Room Copay (Waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer.)

$75 copayment per visit, then the deductible and coinsurance applies to services beyond the copayment up to the OOPL After deductible: $75 copayment per visit, then coinsurance applies to services beyond the copayment up to the OOPL $75 copayment per visit, then the deductible and coinsurance applies to services beyond the copayment up to the OOPL $75 copayment per visit, then in-network deductible and coinsurance applies to services beyond the copayment up to the OOPL After deductible: $75 copayment per visit, then the deductible and coinsurance applies to services beyond the copayment up to the OOPL After deductible: $75 copayment per visit, then in-network deductible and coinsurance applies to services beyond the copayment up to the OOPL
Transplants After deductible: 10% member cost up to OOPL. Includes bone marrow, parathyroid, musculoskeletal, corneal, kidney, heart, liver, kidney with pancreas, heart with lung, and lung After deductible: 10% member cost up to OOPL. Includes bone marrow, parathyroid, musculoskeletal, corneal, kidney, heart, liver, kidney with pancreas, heart with lung, and lung After deductible: 10% member cost up to OOPL. Includes bone marrow, musculoskeletal, corneal, and kidney After deductible: 30% member cost up to OOPL. Includes bone marrow, musculoskeletal, corneal, and kidney After deductible: 10% member cost up to OOPL. Includes bone marrow, musculoskeletal, corneal, and kidney After deductible: 30% member cost up to OOPL. Includes bone marrow, musculoskeletal, corneal, and kidney
Mental Health/Alcohol & Drug Abuse

Outpatient services: primary care office visit copayment ($15), you also pay your deductible and a 10% coinsurance for any costs beyond the office visit

Inpatient and covered transitional services: after deductible 10% member cost

All services apply  to the annual OOPL

Outpatient services: after deductible, primary care office visit copayment ($15), you also pay your deductible and a 10% coinsurance for any costs beyond the office visit

Inpatient and covered transitional services: after deductible 10% member cost 

All services apply  to the annual OOPL

Outpatient services: primary care office visit copayment ($15), you also pay your deductible and a 10% coinsurance for any costs beyond the office visit

Inpatient and covered transitional services: after deductible 10% member cost 

All services apply  to the annual OOPL
Outpatient, inpatient and covered transitional services: after deductible 30% member cost up to the annual OOPL

Outpatient services: after deductible, primary care office visit copayment ($15), you also pay your deductible and a 10% coinsurance for any costs beyond the office visit.
Inpatient and covered transitional services: after deductible 10% member cost 

All services apply  to the annual OOPL
Outpatient, inpatient and covered transitional services: after deductible 30% member cost up to the annual OOPL
Hearing aid (per ear) Every three years: Adults, after dedutible, 20% member cost up to plan paid $1,000 (not to OOPL); dependents younger than 18 years, after dedutible, 10% member cost up to OOPL After deductible: Every three years: Adults, member cost 20% up to plan paid $1,000 (20% member cost to OOPL); dependents younger than 18 years, 10% member cost up to OOPL For dependents younger than 18 years only every three years—deductible and 10% member cost up  to OOPL For dependents younger than 18 years only every three years—deductible and 30% member cost up  to OOPL For dependents younger than 18 years only every three years—deductible and 10% member cost up  to OOPL For dependents younger than 18 years only every three years—deductible and 30% member cost up  to OOPL
Cochlear Implants

Adults, after deductible, 20% member cost for device, surgery for implantation, follow-up sessions (not to OOPL); for hospital charge for surgery, after deductible, 10% member cost to OOPL

Dependents under 18, 10% member cost up to OOPL for all services

After deductible: Adults, 20% member cost to OOPL for device, surgery for implantation, follow-up sessions; For hospital charge for surgery, after deductible 10% member cost to OOPL

Dependents under 18, 10% member cost up to OOPL for all services
Dependents under 18, deductible and 10% member cost up  to OOPL for device, surgery, follow-up sessions Dependents under 18, deductible and 30% member cost up  to OOPL for device, surgery, follow-up sessions Dependents under 18, deductible and 10% member cost up  to OOPL for device, surgery, follow-up sessions Dependents under 18, deductible and 30% member cost up  to OOPL for device, surgery, follow-up sessions
Skilled Nursing Facility (non-custodial care) After deductible, 10% member cost up to OOPL, 120 days per benefit period After deductible: 10% member cost up to OOPL, 120 days per benefit period Deductible and 10% member cost up to OOPL, as medically necessary, 120 days per benefit period Deductible and 30% member cost up to OOPL, as medically necessary, 120 days per benefit period Deductible and 10% member cost up to OOPL, as medically necessary, 120 days per benefit period Deductible and 30% member cost up to OOPL, as medically necessary, 120 days per benefit period
Home Health (non-custodial) After deductible, 10% member cost up to OOPL, 50 visits per year. Plan may approve an additional 50 visits After deductible: 10% member cost up to OOPL, 50 visits per year. Plan may approve an additional 50 visits Deductible and 10% member cost up to OOPL, 50 visits per plan year. Plan may approve an additional 50 visits Deductible and 30% member cost up to OOPL, 50 visits per plan year. Plan may approve an additional 50 visits Deductible and 10% member cost up to OOPL, 50 visits per plan year. Plan may approve an additional 50 visits Deductible and 30% member cost up to OOPL, 50 visits per plan year. Plan may approve an additional 50 visits
Physical / Speech / Occupational Therapy

Office visit copayment ($15), you also pay your deductible and a 10% coinsurance for any medical services beyond the office visit to OOPL

50 combined visits per year. Plan may approve an additional 50 visits per therapy type per year

After deductible: Office visit copayment ($15), you also pay your deductible and a 10% coinsurance for any medical services beyond the office visit to OOPL

50 combined visits per year. Plan may approve an additional 50 visits per therapy type per year

Office visit copayment ($15), you also pay your deductible and a 10% coinsurance for any medical services beyond the office visit to OOPL

50 combined visits per year. Plan may approve an additional 50 visits per therapy type per year
Deductible and 30% member cost up to OOPL. 50 combined visits per plan year. Plan may approve an additional 50 visits per therapy type per year

After deductible: Office visit copayment ($15), you also pay your deductible and a 10% coinsurance for any medical services beyond the office visit to OOPL

50 combined visits per year. Plan may approve an additional 50 visits per therapy type per year
Deductible and 30% member cost up to OOPL. 50 combined visits per plan year. Plan may approve an additional 50 visits per therapy type per year
Durable Medical Equipment After deductible, 20% member cost up to OOPL After deductible: 20% member cost up to OOPL After deductible: 10% member cost up to OOPL After deductible: 30% member cost up to OOPL After deductible: 10% member cost up to OOPL After deductible: 30% member cost up to OOPL
Precertification for hospitalizations, high-tech radiology and low back surgery Varies by plan.  See plan descriptions and contact your plan Varies by plan. See plan descriptions and contact your plan WPS Medical Management Program WPS Medical Management Program WPS Medical Management Program WPS Medical Management Program
Referrals

In-network—varies by plan

Out-of-network— referral is required

In-network—varies by plan

Out-of-network— referral is required
None None None None
Treatment for morbid obesity Excluded Excluded Deductible and 10% member cost up to OOPL. Surgical treatment requires precertification Deductible and 30% member cost up to OOPL. Surgical treatment requires precertification Deductible and 10% member cost up to OOPL. Surgical treatment requires precertification Deductible and 30% member cost up to OOPL. Surgical treatment requires precertification
Oral Surgery After deductible: 10% member cost up to OOPL, 11 procedures After deductible: 10% member cost up to OOPL, 11 procedures After deductible: 10% member cost up to OOPL, 23 procedures After deductible: 30% member cost up to OOPL, 23 procedures After deductible: 10% member cost up to OOPL, 23 procedures After deductible: 30% member cost up to OOPL, 23 procedures

Disclaimer:
Every effort has been made to ensure that this information is accurate, but may be subject to change. Please note revision dates located at the bottom of each page. In the event of conflicting information, federal law, state statute, state health contracts and/or policies and provisions established by the State of Wisconsin Group Insurance Board shall be followed.

This page was last modified on: 8/17/2016 9:00:54 AM