It's Your Choice 2016
State of Wisconsin
Group Health Insurance Program
(State Employees, Retirees, Continuants and Graduate Assistants)
The terms below have special meanings in this plan. Defined terms are capitalized when used in the text of this plan.
• Bed And Board: Means all Usual and Customary Hospital charges for: (a) Room and meals; and (b) all general care needed by registered bed patients.
• Benefit Period: Means the total duration of Confinements that are separated from each other by less than 60 days.
• Brand Name Drugs: Are defined by MediSpan (or similar organization). MediSpan is a national organization that determines brand and Generic Drug classifications.
• Comorbidity: Means accompanying but unrelated pathologic or disease process; usually used in epidemiology to indicate the coexistence of two or more disease processes.
• Confinement/Confined: Means (a) the period of time between admission as an inpatient or outpatient to a Hospital, AODA residential center, Skilled Nursing Facility or licensed ambulatory surgical center on the advice of Your physician; and discharge therefrom, or (b) the time spent receiving Emergency Care for Illness or Injury in a Hospital. Hospital swing bed Confinement is considered the same as Confinement in a Skilled Nursing Facility. If the Participant is transferred or discharged to another facility for continued treatment of the same or related condition, it is one Confinement. Charges for Hospital or other institutional Confinements are incurred on the date of admission. The benefit levels that apply on the Hospital admission date apply to the charges for the covered expenses incurred for the entire Confinement regardless of changes in benefit levels during the Confinement.
• Congenital: Means a condition which exists at birth.
• Coinsurance: A specified percentage of the charges that the Participant or family must pay each time those covered services are provided, subject to any limits specified in the Schedule of Benefits.
• Copayment: A specified dollar amount that the Participant or family must pay each time those covered services are provided, subject to any limits specified in the Schedule of Benefits.
• Custodial Care: Provision of room and board, nursing care, personal care or other care designed to assist an individual who, in the opinion of a Plan Provider, has reached the maximum level of recovery. Custodial Care is provided to Participants who need a protected, monitored and/or controlled environment or who need help to support the essentials of daily living. It shall not be considered Custodial Care if the Participant is under active medical, surgical or psychiatric treatment to reduce the disability to the extent necessary for the Participant to function outside of a protected, monitored and/or controlled environment or if it can reasonably be expected, in the opinion of the Plan Provider, that the medical or surgical treatment will enable that person to live outside an institution. Custodial Care also includes rest cures, respite care, and home care provided by family members.
• Deductible: The amount You owe for health care services Your Health Plan covers before Your Health Plan begins to pay. For example, if Your deductible is $1,500, Your plan will not pay anything until You have incurred $1,500 in out-of-pocket expenses for covered health care services subject to the deductible. The deductible may not apply to all services.
• Department: Means, Department of Employee Trust Funds.
• Dependent: Means, as provided herein, the Subscriber’s:
• Domestic Partner: Means an individual that certifies in an affidavit along with his or her partner that they are in a domestic partnership as provided under Wis. Stat. § 40.02 (21d), which is a relationship between two individuals that meets all of the following conditions:
• Effective Date: The date, as certified by the Department and shown on the records of the Health Plan and/or PBM, on which the Participant becomes enrolled and entitled to the benefits specified in the contract.
• Eligible Employee: As defined under Wis. Stat. § 40.02 (25) or 40.02 (46) or Wis. Stat. § 40.19 (4) (a), of an employer as defined under Wis. Stat. § 40.02 (28). Employers, other than the State, must also have acted under Wis. Stat. § 40.51 (7), to make health care coverage available to its employees.
• Emergency: Means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, to lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a lack of medical attention will likely result in any of the following:
Examples of Emergencies are listed in section III., A., 1., e. Emergency services from a Non-Plan Provider may be subject to Usual and Customary Charges. However, the Health Plan must hold the member harmless from any effort(s) by third parties to collect from the member the amount above the Usual and Customary Charges for medical/hospital services.
• Expense Incurred: Means an expense at or after the time the service or supply is actually provided - not before.
• Experimental: The use of any service, treatment, procedure, facility, equipment, drug, device or supply for a Participant’s Illness or Injury that, as determined by the Health Plan and/or PBM: (a) requires the approval by the appropriate federal or other governmental agency that has not been granted at the time it is used; or (b) isn’t yet recognized as acceptable medical practice to treat that Illness or Injury for a Participant’s Illness or Injury. The criteria that the Health Plan and/or PBM uses for determining whether or not a service, treatment, procedure, facility, equipment, drug, device or supply is considered to be Experimental or investigative include, but are not limited to: (a) whether the service, treatment, procedure, facility, equipment, drug, device or supply is commonly performed or used on a widespread geographic basis; (b) whether the service, treatment, procedure, facility, equipment, drug, device or supply is generally accepted to treat that Illness or Injury by the medical profession in the United States; (c) the failure rate and side effects of the service, treatment, procedure, facility, equipment, drug, device or supply; (d) whether other, more conventional methods of treating the Illness or Injury have been exhausted by the Participant; (e) whether the service, treatment, procedure, facility, equipment, drug, device or supply is medically indicated; (f) whether the service, treatment, procedure, facility, equipment, drug, device or supply is recognized for reimbursement by Medicare, Medicaid and other insurers and self-funded plans.
• Formulary: Means a list of prescription drugs, developed by a committee established by the PBM. The committee is made up of physicians and pharmacists. The PBM may require prior authorization for certain Preferred and non-Preferred drugs before coverage applies. Drugs that are not included on the Formulary are not covered by the benefits of this program.
• Generic Drugs: Are defined by MediSpan (or similar organization). MediSpan is a national organization that determines brand and generic classifications.
• Generic Equivalent: Means a prescription drug that contains the same active ingredients, same dosage form, and strength as its Brand Name Drug counterpart.
• Grievance: Means a written complaint filed with the Health Plan and/or PBM concerning some aspect of the Health Plan and/or PBM. Some examples would be a rejection of a claim, denial of a formal Referral, etc.
• Habilitation Services: Means excluded health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
• Health Plan: The Health Maintenance Organization (HMO) or Preferred Provider Plan (PPP) providing health insurance benefits under the Group Insurance Board’s program and which is selected by the Subscriber to provide the uniform benefits during the calendar year.
• High Deductible Health Plan (HDHP): A health plan that, under federal law, has a minimum annual deductible and a maximum annual Out-of-Pocket Limit (OOPL) set by the IRS. An HDHP does not pay any health care costs until the annual deductible has been met (with the exception of preventive services mandated by the Patient Protection and Affordable Care Act). The plan is designed to offer a lower monthly premium in turn for more shared health care costs.
• Hospice Care: Means services provided to a Participant whose life expectancy is six months or less. The care is available on an intermittent basis with on-call services available on a 24-hour basis. It includes services provided in order to ease pain and make the Participant as comfortable as possible. Hospice Care must be provided through a licensed Hospice Care Provider approved by the Health Plan.
• Hospital: Means an institution that:
The term Hospital does not mean an institution that is chiefly: (a) a place for treatment of chemical dependency; (b) a nursing home; or (c) a federal Hospital.
• Hospital Confinement or Confined In A Hospital: Means (a) being registered as a bed patient in a Hospital on the advice of a Plan Provider; or (b) receiving Emergency care for Illness or Injury in a Hospital. Hospital swing bed Confinement is considered the same as Confinement in a Skilled Nursing Facility.
• Illness: Means a bodily disorder, bodily Injury, disease, mental disorder, or pregnancy. It includes Illnesses which exist at the same time, or which occur one after the other but are due to the same or related causes.
• Immediate Family: Means the Dependents, parents, brothers and sisters of the Participant and their spouses or Domestic Partners.
• Injury: Means bodily damage that results directly and independently of all other causes from an accident.
• Level “M” Drug: Means an injectable, prescription medication covered by Medicare Parts B and D when the Medicare Prescription Drug Plan is the primary payer. Level M Drugs are required to be on the Medicare Prescription Drug Plan’s Medicare Part D Formulary but are not included on the commercial coverage Formulary. Claims associated with Level M Drugs, along with the costs to administer the injection, are adjudicated by the PBM, not the Health Plan.
• Maintenance Care: Means ongoing care delivered after an acute episode of an Illness or Injury has passed. It begins when a patient’s recovery has reached a plateau or improvement in his/her condition has slowed or ceased entirely and only minimal rehabilitative gains can be demonstrated. The determination of what constitutes “Maintenance Care” is made by the Health Plan after reviewing an individual’s case history or treatment plan submitted by a Provider.
• Medical Supplies And Durable Medical Equipment: Means items which are, as determined by the Health Plan:
• Medically Necessary: A service, treatment, procedure, equipment, drug, device or supply provided by a Hospital, physician or other health care Provider that is required to identify or treat a Participant’s Illness or Injury and which is, as determined by the Health Plan and/or PBM:
• Medicare: Title XVIII (Health Insurance Act for the Aged) of the United States Social Security Act, as added by the Social Security Amendments of 1965 as now or hereafter amended.
• Medicare Prescription Drug Plan: Means the prescription drug coverage provided by the PBM to Covered Individuals who are enrolled in Medicare Parts A and B, and eligible for Medicare Part D; and who are covered under a Medicare coordinated contract in the State of Wisconsin or Wisconsin Public Employers group health insurance programs.
• Medicaid: Means a program instituted as required by Title XIX (Grants to States for Medical Assistance Program) of the United States Social Security Act, as added by the Social Security Amendments of 1965 as now or hereafter amended.
• Miscellaneous Hospital Expense: Means Usual and Customary Hospital ancillary charges, other than Bed And Board, made on account of the care necessary for an Illness or other condition requiring inpatient or outpatient hospitalization for which Plan Benefits are available under this Health Plan.
• Natural Tooth: Means a tooth that would not have required restoration in the absence of a Participant’s trauma or Injury, or a tooth with restoration limited to composite or amalgam filling, but not a tooth with crowns or root canal therapy.
• Non-Participating Pharmacy: Means a pharmacy who does not have a signed written agreement and is not listed on the most current listing of the PBM’s directory of Participating Pharmacies.
• Non-Plan Provider: Means a Provider who does not have a signed participating Provider agreement and is not listed on the most current edition of the Health Plan’s professional directory of Plan Providers. Care from a Non-Plan Provider requires Prior Authorization from the Health Plan unless it is an Emergency or Urgent Care.
• Non-Preferred Drug: Means a drug the PBM has determined offers less value and/or cost-effectiveness than Preferred Drugs. This would include Non-Preferred Generic Drugs, Non-Preferred Brand Name Drugs and Non-Preferred Specialty Medications included on the Formulary, which are covered by the benefits of this program with a higher Copayment.
• Nutritional Counseling: This counseling consists of the following services:
• Out-of-Area Service: Means any services provided to Participants outside the Plan Service Area.
• Out-of-Pocket Limit (OOPL): The most You pay during a policy period (usually a calendar year) before Your Health Plan begins to pay 100% of the allowed amount. This limit never includes Your premium, balance-billed charges or charges for health care Your Health Plan does not cover. Note: charges for Copayments such as emergency room and Level 3 prescription drugs, payments for out-of-network services or other expenses do not accumulate toward this limit.
• Participant: The Subscriber or any of his/her Dependents who have been specified for enrollment and are entitled to benefits.
• Participating Pharmacy: Means a pharmacy who has agreed in writing to provide the services to Participants that are administered by the PBM and covered under the policy. The pharmacy’s written participation agreement must be in force at the time such services, or other items covered under the policy are provided to a Participant. The PBM agrees to give You lists of Participating Pharmacies.
• PBM: The Pharmacy Benefit Manager (PBM) is a third party administrator that is contracted with the Group Insurance Board to administer the prescription drug benefits under this health insurance program. It is primarily responsible for processing and paying prescription drug claims, developing and maintaining the Formulary, contracting with pharmacies, and negotiating discounts and rebates with drug manufacturers.
• Plan Benefits: Comprehensive prepaid health care services and benefits provided by the Health Plan to Participants in accordance with its contract with the Group Insurance Board. In addition, prescription drugs covered by the PBM under the terms and conditions as outlined in Uniform Benefits are Plan Benefits.
• Plan Dependent: Means a Dependent who becomes a Participant of the Health Plan and/or PBM.
• Plan Provider: A Provider who has agreed in writing by executing a participation agreement to provide, prescribe or direct health care services, supplies or other items covered under the policy to Participants. The Provider’s written participation agreement must be in force at the time such services, supplies or other items covered under the policy are provided to a Participant. The Health Plan agrees to give You lists of affiliated Providers. Some Providers require Prior Authorization by the Health Plan in advance of the services being provided.
• Plan Service Area: Specific ZIP codes in those counties in which the affiliated physicians are approved by the Health Plan to provide professional services to Participants covered by the Health Plan.
• Postoperative Care: Means the medical observation and care of a Participant necessary for recovery from a covered surgical procedure.
• Preferred Drug: Means a drug the PBM has determined offers more value and/or cost-effective treatment options compared to a Non-Preferred Drug. This would include Preferred Generic Drugs, Preferred Brand Name Drugs and Preferred Specialty Medications included on the Formulary, which are covered by the benefits of this program.
• Preferred Specialty Pharmacy: Means a Participating Pharmacy which meets criteria established by the PBM to specifically administer Specialty Medication services, with which the PBM has executed a written contract to provide services to Participants, which are administered by the PBM and covered under the policy. The PBM may execute written contracts with more than one Participating Pharmacy as a Preferred Specialty Pharmacy.
• Preoperative Care: Means the medical evaluation of a Participant prior to a covered surgical procedure. It is the immediate preoperative visit in the Hospital, or elsewhere, necessary for the physical examination of the Participant, the review of the Participant’s medical history and assessment of the laboratory, x-ray and other diagnostic studies. It does not include other procedures done prior to the covered surgical procedure.
• Primary Care Provider: Means a Plan Provider who is a physician named as a Participant’s primary health care contact. He/She provides entry into the Health Plan’s health care system. He/She also (a) evaluates the Participant’s total health needs; and (b) provides personal medical care in one or more medical fields. When medically needed, he/she then preserves continuity of care. He/She is also in charge of coordinating other Provider health services and refers the Participant to other Providers.
• Prior Authorization: Means obtaining approval from Your Health Plan before obtaining the services. Unless otherwise indicated by Your Health Plan, Prior Authorization is required for care from any Non-Plan Providers unless it is an Emergency or Urgent Care. The Prior Authorization must be in writing. Prior Authorizations are at the discretion of the Health Plan and are described in the Health Plan Descriptions section, of the It’s Your Choice Decision Guide. Some prescriptions may also require Prior Authorization, which must be obtained from the PBM and are at its discretion.
• Provider: Means (a) a doctor, Hospital, and clinic; and (b) any other person or entity licensed by the State of Wisconsin, or other applicable jurisdiction, to provide one or more Plan Benefits.
• Referral: When a Participant’s Primary Care Provider sends him/her to another Provider for covered services. In many cases, the Referral must be in writing and on the Health Plan Prior Authorization form and approved by the Health Plan in advance of a Participant’s treatment or service. Referral requirements are determined by each Health Plan and are described in the Health Plan Descriptions section, of the It’s Your Choice Decision Guide. The authorization from the Health Plan will state: a) the type or extent of treatment authorized; and b) the number of Prior Authorized visits and the period of time during which the authorization is valid. In most cases, it is the Participant’s responsibility to ensure a Referral, when required, is approved by the Health Plan before services are rendered.
• Rehabilitation Services: Means health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
• Schedule of Benefits: The document that is issued to accompany this document which details specific benefits for covered services provided to Participants by the Health Plan You elected.
• Self-Administered Injectable: Means an injectable that is administered subcutaneously and can be safely self-administered by the Participant and is obtained by prescription. This does not include those drugs delivered via IM (intramuscular), IV (intravenous) or IA (intra-arterial) injections or any drug administered through infusion.
• Shared Decision Making (SDM): Means a program offered by a Health Plan or health care provider that Participants must complete when considering whether to undergo certain medical or surgical interventions. SDM programs are designed to inform Participants about the range of options, outcomes, probabilities, and scientific uncertainties of available treatment options so that Participants can decide the best possible course of treatment. The Health Plan or health care provider will provide the Participant with written Patient Decisions Aids (PDAs) as part of the SDM program.
• Skilled Care: Means medical services rendered by registered or licensed practical nurses; physical, occupational, and speech therapists. Patients receiving Skilled Care are usually quite ill and often have been recently hospitalized. Examples are patients with complicated diabetes, recent stroke resulting in speech or ambulatory difficulties, fractures of the hip and patients requiring complicated wound care. In the majority of cases, “Skilled Care” is necessary for only a limited period of time. After that, most patients have recuperated enough to be cared for by “non-skilled” persons such as spouses, Domestic Partners, children or other family or relatives. Examples of care provided by “non-skilled” persons include: range of motion exercises; strengthening exercises; wound care; ostomy care; tube and gastrostomy feedings; administration of medications; and maintenance of urinary catheters. Daily care such as assistance with getting out of bed, bathing, dressing, eating, maintenance of bowel and bladder function, preparing special diets or assisting patients with taking their medicines; or 24-hour supervision for potentially unsafe behavior, do not require “Skilled Care” and are considered Custodial.
• Skilled Nursing Facility: Means an institution which is licensed by the State of Wisconsin, or other applicable jurisdiction, as a Skilled Nursing Facility.
• Specialty Medications: Means medications that are used to treat complex chronic and/or life threatening conditions; are more costly to obtain and administer; may not be available from all Participating Pharmacies; require special storage, handling and administration; and involve a significant degree of patient education, monitoring and management.
• State: Means the State of Wisconsin as the policyholder.
• Subscriber: An Eligible Employee who is enrolled for (a) single coverage; or (b) family coverage and whose Dependents are thus eligible for benefits.
• Urgent Care: Means care for an accident or Illness which is needed sooner than a routine doctor’s visit. If the accident or Injury occurs when the Participant is out of the Plan Service Area, this does not include follow-up care unless such care is necessary to prevent his/her health from getting seriously worse before he/she can reach his/her Primary Care Provider. It also does not include care that can be safely postponed until the Participant returns to the Plan Service Area to receive such care from a Plan Provider. Urgent services from a Non-Plan Provider may be subject to Usual and Customary Charges. However, the Health Plan must hold the member harmless from any effort(s) by third parties to collect from the member the amount above the Usual and Customary Charges for medical/hospital services.
• Usual and Customary Charge: An amount for a treatment, service or supply provided by a Non-Plan Provider that is reasonable, as determined by the Health Plan, when taking into consideration, among other factors determined by the Health Plan, amounts charged by health care Providers for similar treatment, services and supplies when provided in the same general area under similar or comparable circumstances and amounts accepted by the health care Provider as full payment for similar treatment, services and supplies. In some cases the amount the Health Plan determines as reasonable may be less than the amount billed. In these situations the Participant is held harmless for the difference between the billed and paid charge(s), other than the Copayments or Coinsurance specified on the Schedule of Benefits, unless he/she accepted financial responsibility, in writing, for specific treatment or services (that is, diagnosis and/or procedure code(s) and related charges) prior to receiving services. Health Plan approved Referrals or Prior Authorizations to Non-Plan Providers are not subject to Usual and Customary Charges. Emergency or urgent services from a Non-Plan Provider may be subject to Usual and Customary Charges, however, the Health Plan must hold the member harmless from any effort(s) by third parties to collect from the member the amount above the Usual and Customary Charges for medical/hospital/dental services.
• You/Your: The Subscriber and his or her covered Dependents.
This page was last modified on: 9/11/2015 7:53:13 PM