Frequently Asked Questions

Temporary Layoff
(State only) State share toward premium will continue for the first three months after your leave begins. You can elect coverage for 36 months (or beyond 36 months if you are using sick leave to pay premium). Arrangements for premium payment must be made with your benefits/payroll/personnel office prior to the time your leave of absence begins.

If you occupy a seasonal position and do not receive pay between the end of one term of service and the beginning of another, your coverage may continue if you authorize a payroll deduction before your earnings are interrupted or make other provisions to pay premiums in advance. Accumulated sick leave credits may be used to pay premium for up to five years. A written request to use sick leave credit must be submitted to your benefits/payroll/personnel office before the date of layoff.

Accumulated sick leave credits may be used to pay premium for up to five years. A written request to use sick leave credit must be submitted to your benefits/payroll/personnel office before the date of layoff.

Permanent Layoff
(State only) State contributions toward premium will be three months of state contribution in addition to any premium prepaid prior to the time of layoff. Arrangements for employee share of premium payment must be made with your benefits/payroll/personnel office prior to the date of layoff.

Accumulated sick leave credits may be used to pay premium for up to five years. A written request to use sick leave credit must be submitted to your benefits/payroll/personnel office before the date of layoff.

After sick leave credits are exhausted, or if you have no sick leave credits and state share of premium is no longer available, COBRA continuation will be offered, which will allow you to purchase, at your own expense, an additional 36 months of coverage.

If you have 20 years of WRS service at the time of the layoff but were not eligible for an immediate annuity at the time of layoff, any sick leave remaining after paying premium during layoff is available upon retirement. You cannot use your sick leave after five years from the layoff date until you retire. If you had 20 years of WRS service and were eligible for an immediate annuity at the time of layoff, you may continue to use it after five years or begin using the sick leave at anytime.

Unpaid Leave of Absence
(State and Grad only) State share toward premium will be three months of state contribution and any premium prepaid at the time your leave of absence begins. You can elect coverage for 36 months (or beyond 36 months if the leave is military or union service). Arrangements for premium payment must be made with your benefits/payroll/personnel office prior to the time your leave of absence begins. If coverage is not continued during leave of absence, there are no continuation rights if employment terminates.

Note: If your health coverage lapses in whole or only for your dependents during your leave due to nonpayment of premiums, you must submit a new application either electronically or via paper within 30 days of returning to work to reinstate prospectively the coverage that lapsed. Coverage will be effective the first of the month after the application is received by your payroll office. If an It's Your Choice Open Enrollment period has occurred while you were on leave, you will be offered an It's Your Choice enrollment opportunity upon your return.

A leave of absence is not considered ended until you have terminated employment or have resumed employment for at least 50% of what is considered your normal work time for that employer for 30 consecutive calendar days.

(State only) Lapsed coverage can also be reinstated for an employee who has been on a leave of absence and who is entitled to, and applies for, an immediate annuity. Coverage shall be effective the first day of the calendar month which occurs on or after the date the annuity application is approved by ETF, provided an application for health insurance has been received by that date.

Military Leave of Absence
(State only) Under Wisconsin state law § 40.05 (4g), Wis. Stat., health insurance coverage may be continued under our program with employer contribution, as long as you are on active duty, your employee premium contribution continues to be paid and you elect coverage within 60 days of military activation. For more information on this option and the steps you need to take, contact your benefits/payroll/personnel office.

Transfer
(State only) If you transfer from one employing state department to another, you are required to file a new enrollment application either electronically or via paper within 30 days of the date you transfer to maintain continuous coverage. If an application is not filed within 30 days, coverage may be reinstated retroactively by submitting an application and paying back premiums. However, an employee in active pay status whose employee portion of premiums has not been deducted from salary by the employer for a period of 12 months, shall be deemed to have waived coverage. Waived coverage cannot be reinstated retroactively.

You may not select a new health plan when you submit your insurance application due to a transfer, unless it coincides with one of the other designated enrollment opportunities.

(Grad only) If you transfer from one employing state department to another, contact your benefits/payroll/personnel office for information on how to maintain continuous coverage.

Termination of Employment
(State and Grad only) Coverage will end at the end of the month in which the employee terminates employment. (See Continuation of Health Coverage.)

Appealing a Discharge
(State and Grad only) Coverage may be continued if you have been terminated from employment and are appealing discharge. The first premium payment and the appeal must both be filed within 30 days of discharge. Premium payments must be made through your employing agency and be received at least 30 days prior to the end of the period for which premiums were previously paid. You must pay the gross amount of premium due until the appeal is resolved. If the appeal is resolved in your favor, the amount normally considered state contribution will be refunded to you.

Retirement
(State only) If you are covered under our health insurance when you retire, the health benefit plan will automatically continue if your retirement annuity from the WRS begins within 30 days after employment ends. If you are eligible for Medicare, effective dates must be provided before coverage continues. If you do not want your health plan to continue because you are covered under a comparable non-state health plan at the time of retirement, you may escrow your sick leave credits to pay health premiums for use later. Contact ETF for further information.

You may be eligible for supplemental sick leave credits if you have at least 15 full years of adjusted continuous service with the state of Wisconsin at the time of retirement. (Continuous service means the number of full years the employee has worked for the state without a break in service. Local service does not apply.) Your employer will determine whether you are eligible for supplemental sick leave credits and submit the certification to ETF. If you have questions regarding your eligibility for supplemental sick leave credits, contact your payroll office.

If you are an employee who deferred coverage and who wants to preserve your sick leave credits for later use, you may enroll for coverage in the Standard Plan 30 days prior to retirement.

Medicare Part D
While The Centers for Medicare and Medicaid Services (CMS) considers Medicare Part D voluntary, Medicare enrolled retirees will be automatically enrolled in the Navitus MedicareRx (PDP) plan, which is underwritten by Dean Health Insurance Inc., a federally-qualified Medicare contracting prescription drug plan. This is Medicare Part D coverage through an employer group waiver plan (EGWP) administered by Navitus Health Solutions, the State group health insurance program's pharmacy benefit manager. This replaces the commercial creditable coverage provided by Navitus prior to the retiree being enrolled in Medicare. Supplemental wrap coverage is also included to ensure your prescription drugs are covered when you reach the Medicare Part D coverage gap, commonly referred to as the "donut hole." Please see the Medicare Information section for additional information. Also see the Navitus plan and Navitus MedicareRx description pages.

If you do not enroll for all available portions of Medicare (A, B and D) upon retirement, you may be liable for the portion of your claims that Medicare would have paid on the date Medicare coverage would have become effective. (See the Medicare Information provided later in this section.)

Premium rates for retired employees are the same as for the active employees (except that your premium will decrease when you or a dependent becomes covered by Medicare). The employer may, at its option, pay all or a portion of the premium. If any portion of the premium is employer paid, you must remit your portion of the premium directly to the former employer.

If/when your employer does not pay any portion of the premium, the premium will be deducted from your monthly annuity. If the annuity is not sufficient to allow a premium deduction, you will be billed directly.

(Annuitants only) If you return to work for a non-WRS participating employer after retirement, your WRS annuity and health benefits will not be affected.

(Annuitants only) If you return to work for a WRS-participating employer, you may be eligible to once again become an active WRS employee. If you make this election and become an active WRS employee, your annuity will be cancelled and you will no longer be eligible for health insurance as a retiree/annuitant. You will be eligible for health insurance as an active WRS employee through your WRS participating employer if the employer is participating in the ETF health insurance program. If you work for a state employer, the state (non-Graduate Assistant) premium rates will apply. Check with your employer to make sure you have other health insurance coverage available before you elect WRS participation.

As a state annuitant, if you were paying for your health insurance from your converted sick leave credit account, your account will be inactivated if you return to work for a state government employer. Your sick leave credit account will be activated when you retire again. Any sick leave credit you accumulate during re-employment with a state government employer will be added to the balance in your account when you re-retire. If your re-employment is with a local government employer, and you have comparable health insurance coverage, you may escrow your sick leave account balance. Contact ETF or visit the ETF website for a Sick Leave Credit Escrow Application (ET-4305). Your sick leave credit account balance will be available to you when you re-retire.

You may also waive or terminate enrollment under Medicare until the first Medicare enrollment period after active WRS employment ceases. While covered through active employment, your premium rates will be the active employee rates, not the Medicare rates.

When you subsequently terminate employment, eligibility for state group health coverage is once again dependent on your meeting the requirements for newly retired employees (that is, you must be insured, and you must apply for an immediate annuity from the WRS).

(Annuitants only) If you are a disability annuitant under § 40.63(1) who is under normal retirement age and return to any employment, you are subject to a flat rate earnings limit. If you exceed your earnings limit, your disability annuity is suspended, but you will remain eligible for health insurance as an annuitant.

If you are receiving a disability annuity, you may not actively participate in the WRS until it is determined that you are no longer eligible for a disability annuity because of medical certification. If your disability annuity is terminated, and you are employed by a WRS participating employer, you will become eligible for the health insurance offered by your employer.

• If you return to state employment, you must file a new health application either electronically or via paper within 30 days after the date you resume active status under WRS.
• If you return to local public employment, you lose eligibility to remain in the State of Wisconsin Group Health Insurance Program. You may enroll in your public employer's health program (if one is offered), or you may elect continuation coverage of the State of Wisconsin Group Health Insurance Program for up to 36 months by applying within 60 days of being notified by ETF of your right to continue.

Important Caution: Continuation coverage will end after a maximum of 36 months. It does not make you eligible to re-enroll in the state health plan when you terminate. You will only be eligible for the health insurance your employer offers its retirees, subject to its rules and requirements.

• Your spouse.
• Your domestic partner if elected.
• Your children who include:
  1. Your natural children.
  2. Stepchildren or children of your domestic partner insured on the policy.
  3. Adopted children and pre-adoption placements. Coverage will be effective on the date that a court makes a final order granting adoption by the subscriber or on the date the child is placed in the custody of the subscriber, whichever occurs first. These dates are defined by Wis. Stat. § 632.896. If the adoption of a child is not finalized, the insurer may terminate coverage of the child when the adoptive placement ends.
  4. Legal wards that become your permanent ward before age 19. Coverage will be effective on the date that a court awards permanent guardianship to you (the subscriber or your spouse or domestic partner).

  Note:

  1. Dependents may only be covered once under both the State Group Health Insurance Program and the Wisconsin Public Employers Group Insurance Program. In the event it is determined that a DEPENDENT is covered by two separate SUBSCRIBERS, the SUBSCRIBERS will be notified and will have 30 days to determine which SUBSCRIBER will remove coverage of the DEPENDENT and submit an application to remove the DEPENDENT. The effective date will be the first of the month following receipt of the application. The health plan(s) will be notified.
  2. Children may be covered until the end of the month in which they turn 26. His/her spouse and dependents are not eligible. Upon losing eligibility, they may be eligible for COBRA continuation. (See Question: Who is eligible for continuation?)
  
  Coverage may continue beyond turning 26 when children:
  1. Have a disability of long standing duration, are unmarried, dependent on you or the other parent for at least 50% of support and maintenance and are incapable of self-support; or
  2. Are full-time students and were called to federal active duty when they were under the age of 27 years and while they were attending, on a full-time basis, an institution of higher education. Note: The adult child must apply to an institution of higher education as a full-time student within 12 months from the date the adult child fulfilled his or her active duty obligation.
• Your grandchildren born to your insured dependent children may be covered until the end of the month in which your insured dependent (your grandchild's parent) turns age 18. Your child's eligibility as a dependent is unaffected by the birth of the grandchild.

Important Note: There are state and/or federal tax consequences to you when you provide coverage for dependents that do not meet the support test for federal income tax purposes. An example of such a dependent is a domestic partner who is not dependent on you for at least 50% of their support and maintenance.

You have the following options:

• You may each elect single coverage with your current health plan(s)
• If your spouse/domestic partner is also an eligible state employee or annuitant, one of you may select family coverage that will cover all of your eligible tax dependents and any eligible non-tax dependents you choose to cover. Note: Dependents may only be covered once under both the State Group Health Insurance Program and the Wisconsin Public Employers Group Insurance Program. In the event it is determined that a DEPENDENT is covered by two separate SUBSCRIBERS, the SUBSCRIBERS will be notified and will have 30 days to determine which SUBSCRIBER will remove coverage of the DEPENDENT and submit an application to remove the DEPENDENT. The effective date will be the first of the month following receipt of the application. The health plan(s) will be notified.
• If both spouses or domestic partners are each enrolled for single coverage and premiums are being deducted on a pre-tax basis, family coverage may only be elected effective at the beginning of the calendar year or when the employees have gained a dependent that necessitates family coverage.
• If premiums are being deducted on a post-tax basis, one of the single contracts may be changed to a family plan at anytime without restriction and the other single contract will be cancelled. Family coverage will be effective on the beginning of the month following receipt of an electronic or paper application, or a later date specified on the application.
• If premiums for family coverage are being deducted on a pre-tax basis, coverage may only be changed to single coverage effective at the beginning of the calendar year or when the last dependent becomes ineligible for coverage or becomes eligible for and enrolled in other group coverage.
• If premiums are being deducted post-tax, one family policy can be split into two single plans with the same carrier effective on the beginning of the month following receipt of an electronic or paper application, or a later date specified on the application from both spouses or domestic partners.

Note: A subscriber who has family coverage that covers only a domestic partner and/or other non-tax dependents such as a domestic partner's children can change to single coverage at anytime. This is also true for a change from single to family coverage and is because the non-tax dependent's coverage is taxed as imputed income and not subject to the federal regulations governing pre-tax deductions.

Some things to note:

1. (State and Annuitants only) If you and your spouse/domestic partner each have single coverage, no dependents are covered and if one of you should die, that individual's sick leave credits will not be available for use by the surviving dependents. Under a family plan, sick leave credits are preserved for the surviving dependents regardless of who should die first.
2. If you or your spouse/domestic partner have family coverage and want to change the named subscriber for the family coverage to the other spouse/domestic partner and the premium for coverage is being deducted on a pre-tax basis, coverage may only be changed to the other spouse/domestic partner:
   • effective at the beginning of the calendar year;
   • when the subscriber carrying the coverage terminates employment or goes on an unpaid leave of absence; or
   • the premium contribution increases because of reduced work hours.
   For subscribers whose premiums are being deducted on a post-tax basis, coverage can be changed at anytime. Coverage will be effective on the beginning of the month following receipt of an electronic or paper application, or a later date specified on the application.
3. If at the time of marriage, the employees and/or annuitants each have family coverage or one has family coverage and the other has single coverage, coverage must be changed to one of the options listed above within 30 days of marriage to be effective as of the date of marriage. Failure to comply with this requirement may result in denial of claims for eligible dependents. Note: Change from single to family coverage due to marriage is effective the date of marriage if an electronic or paper application is received by your employer (or for annuitants/continuants, by ETF) within 30 days of the marriage.
4. If at the time a domestic partnership is formed (effective on the date that ETF receives a completed Affidavit of Domestic Partnership (ET-2371)), and the employees and/or annuitants each have family coverage, or one has family coverage and the other has single coverage, coverage must be changed to one of the options listed above within 30 days of the effective date. Failure to comply with this requirement may result in denial of claims for eligible dependents. Note: A copy of the Affidavit of Domestic Partnership (ET-2371) and an electronic or paper application must be received by your employer (or for annuitants/continuants by ETF) within 30 days of the beginning of the domestic partnership. Further information is available at etf.wi.gov.
   

If your unmarried child has a physical or mental disability that is expected to be of long-continued or indefinite duration and is incapable of self-support, he or she may be eligible to be covered under your health insurance through our program.

You must work with your health plan to determine if your child meets the disabled dependent eligibility criteria. If disabled dependent status is approved by the health plan, you will be contacted annually to verify the adult dependent's continued eligibility.

If your child loses eligibility for coverage due to age or loss of student status, but you are now indicating that the child meets the disabled dependent definition, eligibility as a disabled dependent must be established before coverage can be continued. If you are providing at least 50% support you must file an electronic or paper application with your employer to initiate the disability review process by the health plan. Your dependent will be offered COBRA continuation*.

If your disabled dependent child, who has been covered due to disability, is determined by the health plan to no longer meet their disability criteria, the health plan will notify you in writing of their decision. They will inform you of the effective date of cancellation, usually the first of the month following notification, and your dependent will be offered COBRA continuation*. If you would like to appeal the health plan's decision, you must first complete the health plan's grievance procedure. If the health plan continues to deny disabled dependent status for your child, you may appeal the health plan's grievance decision to ETF by filing an ETF Insurance Complaint Form (ET-2405). Note: If you are changing health plans, see also the Changing Health Plans section.

*Electing COBRA continuation coverage should be considered while his or her eligibility is being verified. If it is determined that the individual is not eligible as a disabled dependent, there will not be another opportunity to elect COBRA. If it is later determined that the child was eligible for coverage as a disabled dependent, coverage will be retroactive to the date they were last covered, and premiums paid for COBRA continuation coverage will be refunded.

Even though custody of your children may have been transferred to the other parent, you may still insure the children if the other dependency requirements are met. Note: Dependents may only be covered once under both the State Group Health Insurance Program and the Wisconsin Public Employers Group Insurance Program. In the event it is determined that a DEPENDENT is covered by two separate SUBSCRIBERS, the SUBSCRIBERS will be notified and will have 30 days to determine which SUBSCRIBER will remove coverage of the DEPENDENT and submit an application to remove the DEPENDENT. The effective date will be the first of the month following receipt of the application. The health plan(s) will be notified.

Coverage for dependent children who are not physically or mentally disabled terminates on the earliest of the following dates:

• The date eligibility for coverage ends for the subscriber.
• The end of the month in which:
  1. The child turns age 26.
  2. Coverage for the grandchild ends when your child (parent of grandchild) ceases to be an eligible dependent or becomes age 18, whichever occurs first. The grandchild is then eligible for continuation coverage.
  3. Coverage for a spouse and stepchildren under your health plan terminates when there is an entry of judgment of divorce.
  4. Coverage for a domestic partner and children of your domestic partner terminates when the ETF Affidavit of Termination of Domestic Partnership (ET-2372) is filed.
  5. The child was covered per Wis. Stats. 632.885 (2) (b) and ceases to be a full-time student.
  6. The child becomes insured as an employee of a state agency, or an employer who participates in the State of Wisconsin Group Health Insurance Program.
  7. You terminate coverage for your adult dependent within 30 days of their eligibility for and enrollment in another group health insurance program. Termination will be effective the first of the month following receipt of an electronic or paper application. You may also terminate coverage for your adult dependent during the annual It's Your Choice enrollment period to be effective January 1 of the following year.
  8. Note: If it is determined that a DEPENDENT is covered by two separate SUBSCRIBERS, the SUBSCRIBERS will be notified and will have 30 days to determine which SUBSCRIBER will remove coverage of the DEPENDENT and submit an application to remove the DEPENDENT. The effective date will be the first of the month following receipt of the application. The health plan(s) will be notified.

See Continuation of Health Coverage for information on continuing coverage after eligibility terminates.

You need to file an electronic or paper application as notification for the following changes to your benefits/payroll/personnel office within 30 days of the change. Annuitants and continuants will need to contact ETF. Additional information may be required. Failure to report changes on time may result in loss of benefits or delay payment of claims.

• Change of name, address, telephone number and Social Security number, etc.
• Obtaining or losing other health insurance coverage, including any part of Medicare
• Addition of a dependent (within 60 days of birth, adoption or date legal guardianship is granted)
• Loss of dependent's eligibility, including Medicare eligibility
• Marriage/domestic partnership
• Divorce/termination of a domestic partnership
• Death (Contact ETF if dependent is your named survivor.)
• (State and Annuitants only) Eligibility/Enrollment for Medicare

You have the responsibility to inform your employer (ETF, for annuitants and continuants) of any dependents losing eligibility for coverage under the State of Wisconsin Group Health Insurance Program. Under federal law, if notification is not made within 60 days of the later of (1) the event that caused the loss of coverage, or (2) the end of the period of coverage, the right to continuation coverage is lost. A voluntary change in coverage from a family plan to a single plan does not create a continuation opportunity.

If your last dependent is losing eligibility, you must file an application to change to single coverage.

There are other limited opportunities for coverage to be changed from single to family coverage without restrictions as described below:

If an electronic or paper application is received by your benefits/payroll/personnel office for active employees (or ETF for annuitants/continuants) within 30 days of the following events, coverage becomes effective on the date of the following event:

• Marriage.
• The date ETF receives the completed Affidavit of Domestic Partnership (ET-2371).
• You or any of your eligible dependents involuntarily lose eligibility for other medical coverage or lose the employer contribution for the other coverage.
• An unmarried parent whose only eligible child becomes disabled and thus is again an eligible dependent. Coverage will be effective the date eligibility was regained.

If an application is received by your benefits/payroll/personnel office for active employees or ETF for annuitants/continuants, within 60 days of the following events, coverage becomes effective on the date of the following event:

• Birth or adoption of a child or placement for adoption (timely application prevents claim payment delays).
• Legal guardianship is granted.
• A single father declaring paternity. Children born outside of marriage become dependents of the father on the date of the court order declaring paternity, on the date the acknowledgement of paternity is filed with the Department of Health Services (or equivalent if the birth was outside of the state of Wisconsin) or on the date of birth with a birth certificate listing the father's name. The effective date of coverage will be the birth date, if a statement of paternity is filed within 60 days of the birth. If filed more than 60 days after the birth, coverage will be effective on the first of the month following receipt of application.

If an application is received by your benefits/payroll/personnel office for active employees or ETF for annuitants/continuants, upon order of a federal court under a National Medical Support Notice, coverage will be effective on either:

• The first of the month following receipt of application by the employer; or
• The date specified on the Medical Support Notice.

Note: This can occur when a parent has been ordered to insure one or more children who are not currently covered.

Marriage
You can change from single to family coverage to include your spouse (and stepchildren if applicable) without restriction, provided your electronic or paper application is received within 30 days after your marriage, with family coverage being effective on the date of your marriage. If you were enrolled in family coverage before your marriage, you need to complete an electronic or paper application as soon as possible to report your change in marital status, add your new spouse (and stepchildren) to the coverage and, if applicable, change your name. In most cases, coverage for the newly added dependent(s) will be effective as of the date of marriage. (See the Life Change Event Chart and Question: What are my coverage options if my spouse/domestic partner is also a state of Wisconsin or participating Wisconsin Public Employer (WPE) employee or state annuitant?)

Note: You may also change health plans when adding a dependent due to marriage. The subscriber will need to file an application within 30 days of the marriage with coverage with the new health plan effective on the first day of the month on or following receipt of the application.

Domestic Partnership
You can change from single to family coverage to include your eligible domestic partner (and his/her eligible children if applicable) when you submit an Affidavit of Domestic Partnership (ET-2371) to ETF. Active employees should submit either an electronic or paper application to your employer, annuitants should submit it to ETF within 30 days of the date ETF receives a completed Affidavit of Domestic Partnership (ET-2371). Coverage will be effective on the day ETF receives the completed Affidavit of Domestic Partnership (ET-2371). Check etf.wi.gov for tax implications.

If you were enrolled in family coverage before your domestic partnership, you need to complete an ETF Affidavit of Domestic Partnership (ET-2371) and an electronic or paper application as soon as possible to report your change in status and add your new domestic partner (and his/her eligible children) to the coverage. (See Question What are my coverage options if my spouse/domestic partner is also a state of Wisconsin or participating Wisconsin Public Employer (WPE) employee or state annuitant?)

Birth/Adoption/Legal Guardianship/Dependent Becoming Eligible
If you already have family coverage, you need to submit a timely electronic or paper application to add the new dependent. Coverage is effective from the date of birth, adoption, when legal guardianship is granted, or when a dependent becomes eligible and otherwise satisfies the dependency requirements. Be prepared to submit documentation of guardianship, paternity or other information as requested by your employer.

If you have single coverage, you can change to family coverage with your current health plan by submitting an application within 30 days of the date a dependent becomes eligible, or within 60 days of birth, adoption or the date legal guardianship is granted. Note: You may also change health plans if you, the subscriber file an application within 30 days of a birth or adoption with coverage effective on the first day of the month on or following receipt of the electronic or paper application.

Single Mother or Father Establishing Paternity
A subscriber may cover his or her dependent child, effective with the child's birth or adoption, by submitting a timely electronic or paper application changing from single to family coverage.

Children born outside of marriage become dependents of the father on the date of the court order declaring paternity or on the date the "Voluntary Paternity Acknowledgment" (form DPH 5024) is filed with the Department of Health Services (or equivalent if the birth was outside the state of Wisconsin) or on date of birth with a birth certificate listing the father's name. The effective date of coverage will be the date of birth if a statement of paternity is filed within 60 days of the birth. If more than 60 days after the birth, coverage is effective on the first of the month following receipt of the electronic or paper application.

A single mother may cover the child under her health plan effective with the birth by submitting an application changing from single to family coverage.

Upon Order of a Federal Court Under a National Medical Support Notice
This can occur when a parent has been ordered to insure his/her eligible child(ren) who are not currently covered. You will need to submit an electronic or paper application to your benefits/payroll/personnel office (annuitants and continuants will notify ETF) with coverage becoming effective on either:

• The first of the month following receipt of application by the employer, or
• The date specified on the National Medical Support Notice.

Divorce
Your ex-spouse (and stepchildren) can remain covered under your family plan only until the end of the month in which the marriage is terminated by divorce or annulment, or to the end of the month in which the Continuation-Conversion Notice (ET-2311) is provided to the divorced spouse if family premium continued to be paid, whichever is later. (In Wisconsin, a legal separation is unlike divorce in that it does not affect coverage under the State of Wisconsin Group Health Insurance Program.) The entry of judgment of divorce is usually when the judge signs the divorce papers and the clerk of courts date stamps them. You should notify your payroll office prior to the divorce hearing date and once the entry of judgment of divorce has occurred. You will need to contact the clerk of courts to learn the date of entry of judgment of divorce. If you fail to provide timely notice of divorce, you may be responsible for premiums paid in error which covered your ineligible ex-spouse and stepchildren. Your ex-spouse and stepchildren are then eligible to continue coverage under a separate contract with the group plan for up to 36 additional months. Conversion coverage would then be available. You can keep your dependent children and adopted stepchildren on your family plan for as long as they are eligible (age, student status, etc.). (See the Continuation of Health Coverage section for further information.)

You must file an electronic or paper health application with your employer to change from family to single coverage or to remove ineligible dependents from a family contract.

When both parties in the divorce are state or university employees or annuitants, and each party is eligible for state health insurance in his or her own right and is insured under the state health plan at the time of the divorce, each retains the right to continue state health insurance coverage regardless of the divorce.

The participant who is the subscriber of the insurance coverage at the time of the divorce must submit an electronic or paper health application to remove the ex-spouse from his or her coverage and may also elect to change to single coverage.

The participant insured as a dependent under his or her ex-spouse's insurance must submit a health application to establish coverage in his or her own name. The ex-spouse must continue coverage with the same health plan unless he or she moves out of the service area (e.g., county). The electronic or paper application must be received by the employee's benefits/payroll/personnel office (or ETF, for annuitants) within 30 days of the date of the divorce.

Each participant may cover any eligible dependent children (not former stepchildren) under a family contract. Coverage of the same dependents by both parents would be subject to Coordination of Benefits provisions. Refer to the Uniform Benefits (your health plan Certificate of Coverage) or contact your health plan directly for information on Coordination of Benefits policies and procedures.

Note for active employees: Failure to apply in a timely manner will limit enrollment to the annual It's Your Choice Open Enrollment period for coverage effective January 1.

Note for annuitants and continuants: Failure to apply in a timely manner will delay the effective date of coverage.

Termination of a Domestic Partnership
Your former domestic partner (and eligible children of a domestic partnership) can remain covered under your family plan only until the end of the month in which ETF receives your Affidavit of Termination of Domestic Partnership (ET-2372). If you fail to provide timely notice of termination of the domestic partnership, you may be responsible for premiums paid in error that covered your former domestic partner and children of a domestic partnership. After termination, your ex-domestic partner and ineligible children of the domestic partnership are then eligible to continue coverage under a separate contract with the group plan for up to 36 additional months. Conversion coverage would then be available. You can keep your dependent children and adopted children/stepchildren on your family plan for as long as they are eligible (age, student status, etc.). (See the Continuation of Health Coverage section for further information.)

When both parties in the domestic partnership are state or university employees or annuitants, and each party is eligible for state health insurance in his or her own right, and is insured under the state health plan at the time of the termination, each retains the right to continue state health insurance coverage. Upon a termination of a domestic partnership, an affidavit must also be filed, in addition to an electronic or paper application.

The participant insured as a dependent under his or her former domestic partner's insurance must submit an electronic or paper application to establish coverage in his or her own name. The former domestic partner must continue coverage with the same health plan unless he or she moves out of the service area (e.g., county). The application must be received by the employee's benefits/payroll/personnel office, or for annuitants by ETF, within 30 days of receipt by ETF of the Affidavit of Termination of the Domestic Partnership (ET-2372).

Each participant may cover any eligible dependent children (not former dependents who lost coverage due to a terminated domestic partnership) under a family contract. Coverage of the same dependents by both parents would be subject to Coordination of Benefits provisions. Refer to your health plan's Certificate of Coverage or contact your health plan directly for information on Coordination of Benefits policies and procedures.

Note for active employees: Failure to apply in a timely manner will limit enrollment to the annual It's Your Choice Open Enrollment period for January 1 coverage.

Note for annuitants and continuants: Failure to apply in a timely manner will delay the effective date of coverage.

Medicare Eligibility: Please refer to the Medicare information in this FAQ for details regarding Medicare eligibility and enrollment requirements.

Death: (State and Annuitants only) Surviving Dependents: If an active or retired employee with family coverage dies, the surviving insured dependents shall have the right to continue coverage for life under the State of Wisconsin Group Health Insurance Program at group rates. The dependent children may continue coverage until eligibility ceases if they:

• Were enrolled at the time of death,
• Were previously insured and regain eligibility, or
• Are a child of the employee and born after the death of the employee.

Health insurance coverage will automatically continue for your covered surviving dependents. Continued coverage will be effective on the first of the month after your date of death. Surviving dependents may voluntarily terminate coverage by providing written notification to ETF, and it will terminate on the last day of the month in which their written request is received by ETF.

Note: Survivors may not add persons to the policy who were not insured at the time of death unless the survivor is also a state employee and eligible for the insurance in his or her own right.

If family coverage was in force at the time of death, any unused sick leave credits in the deceased employee's account are available to the surviving dependents for premium payments. If sick leave credits are escrowed, the surviving dependents may continue to escrow the credits or may apply to convert the credits to pay health insurance premiums.

Note: If single coverage was in force at the time of death, the monthly premiums collected for coverage months following the date of death will be refunded. No partial month's premium is refunded for the month of coverage in which the death occurred. Surviving dependents are not eligible for coverage.

(Grad only) If family coverage was in force at the time of death, the covered surviving dependents are then eligible for COBRA Continuation. (See Question: Who is eligible for continuation?).

If your employee premiums are deducted on a pre-tax basis under Internal Revenue Code Section 125 rules, switching from family to single coverage is not allowable unless there is an IRS qualified family status change such as divorce, marriage, birth or adoption. For example, all covered family members lose eligibility for health coverage or become eligible for and enroll in another group plan. If any covered dependents remain eligible for coverage, a change from family to single coverage is allowed only during the It's Your Choice Open Enrollment period.

If your employee premiums are deducted on a post-tax basis or you are an annuitant, you may change from family to single coverage at anytime. The change will be effective on the first day of the month on or following receipt of your electronic or paper application by your benefits/payroll/personnel office (ETF for annuitants and continuants). Switching from family to single coverage when you still have eligible dependents is deemed a voluntary cancellation of coverage for all covered dependents and is not considered a "qualifying event" for continuation coverage.

(State only) Please Note: If you have single coverage and you should die, your sick leave credits will not be available for use by your surviving dependents.

Changing from single to family coverage, regardless of whether your premiums are deducted on a pre- or post-tax basis, is only allowed during the It's Your Choice enrollment period, or when you or an eligible dependent has a qualifying event that allows for family coverage. See Question: If I do not change from single to family coverage during the It's Your Choice Open Enrollment period, will I have other opportunities to do so?

All changes in coverage are accomplished by completing an approved electronic or paper application within 30 days after the change occurs. Employees should file an application through your benefits/payroll/personnel office to notify your health plan of changes. Annuitants and continuants should file with ETF. Failure to report changes on time may result in loss of benefits or delay payment of claims. (See Question: Which family changes need to be reported?):

• Change in health plan (for example, from IYC Health Plan to IYC Access Health Plan)
• Change in plan coverage (for example, from single to family)
• Name change
• Change of address or telephone number
• Addition/deletion of a dependent to an existing family plan

Exception: Some health plans require you to notify them if you change your primary care physician. Contact your health plan for details.

You will receive identification cards from the health plan you select. If you lose these cards or need additional cards for other family members, you may request them directly from the health plan. Health plans that offer the IYC Health Plan or the IYC HDHP are not required to provide you with a certificate describing your benefits. The IYC Health Plans Certificate of Coverage provides this information.

Present your identification card to the hospital or physician who is providing the service. Identification numbers are necessary for any claim to be processed or service provided.

Most of the health plans that offer the IYC Health Plan or the IYC HDHP also require that non-emergency hospitalizations be prior authorized and contact be made if there is an emergency admission. Prior authorizations are required for high-tech radiology (for example, MRI, PET, CT scans) and for low back surgeries. Check with your health plan, and make sure you understand any requirements.

For the IYC Access Health Plan and SMP, it is recommended or required that you or your physician contact the health plan before you are admitted to a hospital unless it is an emergency. In an emergency, it is in your best interest to notify the health plan as soon as reasonably possible.

Only if the IYC Health Plan HMO has providers in the community in which the child resides. Emergency or urgent care services are covered wherever they occur. However, non-emergency treatment must be received at a facility approved by the health plan. Outpatient mental health services and treatment of alcohol or drug abuse may be covered. Refer to the IYC Health Plans Certificate of Coverage. Contact your health plan for more information.

Most of the services provided by health plans do not require filing of claim forms. However, you may be required to file claims for some items or services. The IYC Access Health Plan, IYC Medicare Plus and SMP require claims incurred in any calendar year to be received by the administrator no later than the end of the next calendar year. All other health plans require claims be filed within 12 months of the date of service or, if later, as soon as reasonably possible.

When you are covered under two or more group health insurance policies at the same time and both contain coordination of benefit provisions, insurance regulations require the primary carrier be determined by an established sequence. This means that the primary carrier will pay its full benefits first; then the secondary carrier would consider the remaining expenses. (See the Coordination of Benefits Provision found in the IYC Health Plans Certificate of Coverage.) Note that with coordination of benefits, the secondary carrier may not always cover all of your expenses that were not covered by the primary carrier.

Once you reach your OOPL, you no longer have to pay most copays. You will continue to pay copays for certain level 3 and level 4 prescription drugs, and any other essential health benefit services that do not accumulate to the OOPL. If you are enrolled in the high deductible health plan (HDHP), you do not have to pay for any copays once you reach your OOPL. There is a federal maximum out-of-pocket (MOOP) of $6,850/$13,700 for 2016 which is the maximum you will pay for essential health benefits, including services that do not apply to the OOPL.

Most IYC Health Plans will pay nothing when non-emergency treatment is provided by physicians outside of the health plan unless there is an authorized referral. Contact the health plans directly regarding their policies on referrals.

For emergency or urgent care, health plans are required to pay for care received outside of the network, but it may be subject to usual and customary charges. This means the health plan may not pay the entire bill and try to negotiate lower fees. However, ultimately the health plan must hold you harmless from collection efforts by the provider. (See the definition of Emergency Care in the IYC Health Plans Certificate of Coverage.)

If you're not sure a provider holds the same beliefs as you do, call the clinic or pharmacy and ask about your concerns. For example, you may want to ask about the provider's opinion about dispensing a prescription for oral contraceptives.

See the plan description pages for more information on how to access or receive a provider directory. You may also contact the health plan to receive a printed copy of the provider directory. Neither ETF nor your employer maintain a current list of this information.

Contact your health plan to find out their requirements to make this change and when your change will become effective.

If you want to continue seeing a particular physician (or psychologist, dentist, optometrist, etc.), contact that physician to see if he or she will be available to you under your IYC Health Plan or IYC HDHP HMO. Confirm this with the IYC Health Plan or IYC HDHP HMO's provider directory. Even though your current physician may join an IYC Health Plan or IYC HDHP HMO, he or she may not be available as your primary physician just because you join that IYC Health Plan or IYC HDHP HMO.

Health care providers appearing in any published health plan provider listing or directory remain available for the entire calendar year except in cases of normal attrition (that is, death, retirement or relocation) or termination due to formal disciplinary action. A participant who is in her second or third trimester of pregnancy may continue to have access to her provider until the completion of postpartum care for herself and the infant.

If a provider contract terminates during the year (excluding normal attrition or formal disciplinary action), the health plan is required to pay charges for covered services from these providers on a fee-for-service basis. Fee-for-service means the usual and customary charges the health plan is able to negotiate with the provider while the member is held harmless. Health plans will individually notify members of terminating providers (prior to the It's Your Choice Open Enrollment period) and will allow them an opportunity to select another provider within the health plan's network.

Your provider leaving the plan does not give you an opportunity to change health plans midyear.

You are strongly recommended to designate a primary physician or clinic. Your primary physician is responsible for managing your health care. Under most circumstances, he or she may refer you to other medical specialists within the health plan's provider network as he or she feels is appropriate. However, referrals outside of the network are strictly regulated for most health plans. Check with your health plan for their referral requirements and procedures.

In case of an injury that may fall under workers' compensation, you should utilize only providers in your health plan, in case workers' compensation denies your claim.

(State and Grad only) For eligible employees, the employer contribution is determined either through collective bargaining or through the applicable compensation plan.

The three-tier health insurance program was implemented as an innovative approach that holds costs down as it creates incentives for health plans to reduce their costs to the state, and encourages employees in the state to choose the health plans that are most efficient in providing quality health care. Each health plan is rated and placed in a tier based on providing the most cost-effective, quality care (as determined by ETF). Health plans in the same tier have been determined to be within certain thresholds in their level of providing cost-effective, quality care.

(State and Grad only) No, all IYC Health Plans or IYC HDHPs are required to offer the Uniform Medical Benefits (this includes WEA Trust and SMP). Premium rates and tier placement may vary because of many factors:

• how efficiently the health plan is able to provide services and process benefit payments;
• the fees charged in the area in which service is being rendered;
• the manner in which the health care providers deliver care and are compensated within the service area; and
• how frequently individuals covered by the plan use the health plan.

Also, members who enroll in the Uniform Dental Benefit plan will have a slightly higher premium than members who opt-out of the plan. The IYC Access Health Plan will continue to offer benefits that differ from Uniform Benefits for medical, but will be newly eligible for the Uniform Dental Benefit.

All group premium rates change at the same time, January 1 of each year. The monthly cost of all health plans will be announced during the It's Your Choice Open Enrollment period.

(State and Grad only) No. The Group Insurance Board will not allow such a plan into the program. This is verified by our collection of data from the Consumer Assessment of Health Plans (CAHPS) survey, the Health Plan Employer Data and Information Set (HEDIS) and other quality measures. Health plans that do not make Tier 1 placement are those that are less cost effective in managing care, costs and quality.

(State and Grad only) Premiums are deducted from your paycheck. If you have questions, contact your employer. Note: If eligible, your premiums will automatically be deducted from your payroll check on a pre-tax basis unless you choose otherwise.

(Annuitants only) Premium rates for retired employees are the same as for active employees (except that your premium will decrease when you or a dependent becomes covered by Medicare). However, the state does not pay any portion.

Your monthly premiums will be paid in one of the following ways:

• From your Accumulated Sick Leave Conversion Credits until those credits are exhausted. If you have accumulated sick leave at the time of your retirement or death (and your applicable compensation plan or collective bargaining agreement provides for sick leave conversion), the credits can be converted to a dollar amount to pay your health premiums for the State of Wisconsin Group Health Insurance Program. (Sick leave credits can only be converted for payment of State of Wisconsin Group Health Insurance Program premiums; they cannot be used for other insurance; they have no cash value and accrue no interest.) If you choose to escrow (preserve) your sick leave, this can be done at the time of retirement or a later date. Contact ETF for the escrow form. Note: If you qualify for a WRS disability benefit, you have the option of being paid your sick leave hours or having them converted to pay your health premiums while you are receiving your disability annuity.
  
  
• If you have no sick leave credits available or your credits are exhausted, then monthly premiums will be paid from deductions from your monthly retirement, disability or beneficiary annuity payment. Premiums will be automatically deducted a month in advance of coverage. If there is no annuity or your annuity is not large enough to take premiums, then they will be paid:
• From direct billings to you. Your health plan will bill you directly for premiums on a monthly basis. Warning: Your coverage will be cancelled if you fail to pay your premium in a timely manner. If you re-enroll, coverage will be effective January 1 following enrollment during the It's Your Choice Open Enrollment period. If you are a surviving dependent, you are not eligible for re-enrollment.
• From your converted life insurance. If you are retired and have life insurance coverage through the state of Wisconsin, are at least 66 and have used up all your sick leave credits, you may elect to convert your life insurance to pay health insurance premiums. If you make this election, your life insurance coverage will cease and you will receive credits in a conversion account equal to the present value of your life insurance. The present value ranges from about 44% to 80% of the amount, depending on your age. The life insurance company, Securian Financial Group, will pay health insurance premiums on your behalf from your conversion account until the account is exhausted. You will not receive any direct cash payment. You may file the election at anytime, and it will be effective no earlier than 61 days after ETF receives it. For more information and an election form, contact ETF.

(Annuitants only) You do not have to use your sick leave credits to pay your health premiums if:

• You escrow your sick leave. If you are insured in the state program on your termination date, are eligible to use sick leave credits and are covered under comparable health coverage, you may escrow your sick leave credits. You may also elect to escrow later if you become covered by a comparable health coverage when you are insured in the state program. You may escrow indefinitely as long as you have comparable health coverage continuously during the escrow period. You may elect coverage under any health plan in the state program without waiting periods or exclusions for preexisting conditions when timely re-enrolled, or
• You are covered under your spouse/domestic partner's State of Wisconsin Group Health Insurance Program plan. If you retire and are also a dependent on your spouse/domestic partner's State of Wisconsin Group Health Insurance Program plan, you will have your sick leave credits inactivated until your spouse/domestic partner retires and depletes his or her own sick leave credits.

Note: You can unescrow your sick leave once a year during the It's Your Choice Open Enrollment period. (See Sick Leave Conversion Credit Program (ET-4132) brochure for detailed information.)

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.

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.

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).

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) 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 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 and Non-Preferred Level 4 prescription drugs.

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: You can find complete deductible and benefit information for your plan online.

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.

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.

No, but any additional services you receive (e.g., lab work or testing) may be subject to the deductible and any applicable coinsurance.

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	•* For family practice with obstetrics or OB/GYN	•* For maternal/fetal specialist
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.

Yes, office visit copayments are applied to the annual OOPL.

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.

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 (OOPL) It's Your Choice Health Plan	Individual		Family
	2015	2016	2015	2016
Medical OOPL	$500	$1,250	$1,000	$2,500

More information can be found in the comparison of medical benefit charts.

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.

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 these preventive services here.

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 these preventive services here.

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

Also see 2016 prescription drug costs, under the Benefits tab above.

Note: 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.

A PBM is a third-party administrator of a prescription drug program that is primarily responsible for processing and paying prescription drug claims. In addition, they typically negotiate discounts and rebates with drug manufacturers, contract with pharmacies and develop and maintain the drug formulary. The state's PBM uses a fully transparent, full pass-through business model which means they negotiate rebates and discounts on behalf of the state and pass the savings directly back to the state.

A formulary, which is established by a committee of physicians and pharmacists, is a list of prescription drugs that are determined to be both medically effective and cost-effective. The formulary is developed by the PBM's Pharmacy and Therapeutics Committee, which is made up of a group of physicians and pharmacists, a majority of whom practice throughout Wisconsin.. Drugs are evaluated on the basis of effectiveness, side-effects, drug interactions and then cost. New drugs are reviewed on a continuous basis to make sure the formulary is kept up-to-date and that patient needs are being met.

The complete formulary can be found on Navitus' website, www.navitus.com. At the WELCOME page just click on the MEMBERS option on the left side of the screen, then click on the "Member Login" link. You must be registered on the Navitus web site, using your 8-digit member ID found on your Navitus ID card.

You may also call Navitus Customer Care toll free at 1-866-333-2757 with questions about the formulary. If you are enrolled in the Navitus MedicareRx plan (Medicare Part D) you can access the formulary through the "Members" section on the Navitus MedicareRx web site, medicarerx.navitus.com. See more on using Navi-gate.

 

Under a four-level prescription drug benefit, you have four different copayment or coinsurance amounts for covered prescription drugs. By having to pay a lower copayment or coinsurance for Level 1 and Level 2 drugs, you are encouraged to use the preferred formulary drugs. Drugs that are listed on the formulary at the Level 3 coinsurance are considered non-preferred drugs but are still covered if you wish to use them and pay the higher coinsurance. This gives you more freedom of choice with the drugs that you are prescribed. Level 4 drugs are Specialty Medications that have the highest copayment or coinsurance and are also classified as either preferred or non-preferred drugs. Specialty Medications may have a reduced coinsurance if the prescription is filled at the preferred participating pharmacy for Specialty Medications (currently Diplomat Specialty Pharmacy). The copayments or coinsurance for Level 1 and Level 2 (preferred) drugs are applied to your annual Level 1/Level 2 out-of-pocket limit (OOPL). The copayments for preferred Specialty Medications are applied to your Level 4 OOPL, which is separate from the Level 1/Level 2 OOPL. The coinsurance for Level 3 drugs and non-preferred Specialty Medications do not count towards any OOPL.

Under the four-level prescription drug benefit, it may still be necessary to get a prior authorization before some preferred and non-preferred drugs will be covered.

Preferred and non-preferred prescription drugs that are classified by Navitus as specialty medications have a Level 4 coinsurance of 40% (up to a maximum of $200) when they are filled at a participating network pharmacy. The coinsurance for preferred specialty drugs counts toward your $1,200/$2,400 Level 4 out-of-pocket limit (OOPL). Coinsurance for non-preferred specialty drugs do not count toward the Level 4 OOPL.

We strongly encourage you to participate in the Navitus SpecialtyRx, specialty pharmacy program. If you have your prescriptions for preferred specialty drugs filled at the preferred participating pharmacy for specialty medications, which is currently Diplomat Specialty Pharmacy, you will have a reduced copayment of $50 for preferred specialty drugs (which also counts toward the Level 4 OOPL). These drugs will be marked with "ESP" on the formulary. This also allows you to take advantage of the additional, personalized services available with the Navitus SpecialtyRx, specialty pharmacy program. Non-preferred specialty and certain other drugs are not eligible for the reduced copayment, and the coinsurance does not count toward the Level 4 OOPL.

To enroll in the Navitus SpecialtyRx, specialty pharmacy program or to obtain additional information, call 1-877-651-4943 or visit diplomatpharmacy.com.

Yes. You will have two identification cards: one from your health plan and one from either (a) Navitus Health Solutions or (b) the Navitus MedicareRx (PDP) plan (for eligible retirees enrolled in Medicare) for pharmacy benefits. Your member identification number will be different on each card, so it is important that you show the correct card when getting services. When filling prescriptions, you must present your pharmacy benefits ID card to the pharmacist.

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:

1. 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.
2. 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.
3. Find the current cost of your drug on either the paperwork you receive with your prescription, or ask your pharmacist.
4. Calculate the cost based on the chart.

Find the member cost share, the maximum coinsurance amounts for each level of prescription drug, as well as the annual OOPLs on the Pharmacy Benefits table, under the Benefits section, above.

Note: The HDHPs have a combined medical and prescription drug OOPL. The HDHP OOPLs did not increase from last year.

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.

Important! When you receive your Medicare card, please send a photocopy to the ETF immediately or your Medicare coordinated coverage may be delayed.

If you become eligible for Medicare, your eligibility for COBRA coverage ends. Contact ETF for more information.

(State and Annuitants only) You and your dependents are not required to enroll in Medicare until you, the subscriber, terminate employment or health insurance coverage as an active employee ceases. At the time of your retirement, you and your dependents who are eligible for Medicare must enroll for the Part A (hospital) portion and Part B (medical) portion of Medicare. When you and/or your dependents enroll in Medicare Parts A and B, your group health insurance coverage will be integrated with Medicare and the monthly premium will be reduced.

In general, enrollment in Medicare Part D (prescription drug coverage) is voluntary; however, you may pay a penalty if you do not enroll when you are first eligible or are not covered by what Medicare considers creditable coverage. Regardless, Medicare Part D coverage is provided by the State of Wisconsin Group Health Insurance Program. Additional information about all parts of Medicare can be found in the following questions and answers.

(Grad only) There is no Medicare reduced rate available to those enrolled in the Graduate Assistant program.

(State and Annuitants only)
Medicare Part A
Most people become eligible for Medicare upon reaching age 65. Individuals who have been determined to be disabled by the Social Security Administration (SSA) become eligible after a 24-month waiting period.

If you or your spouse/domestic partner are actively working when you become eligible, you may want to consider enrolling in Medicare Part A as it may cover hospital services if your health plan denies them. There is no premium for Medicare Part A.

Medicare Part B
The requirement to enroll in Medicare Part B coverage is deferred for active employees and their dependents until the subscriber's termination of their WRS-covered employment, through which active employee health insurance coverage is provided. If you have terminated employment, or are a surviving dependent, or a continuant and are eligible for coverage under the federal Medicare program, you must immediately enroll in both Part A and Part B of Medicare unless you are otherwise employed and have health insurance coverage through that employment. If you do not enroll for all available portions of Medicare upon retirement, you may be liable for the portions of your claims that Medicare would have paid beginning on the date Medicare coverage would have become effective.

If you or your insured spouse/domestic partner is insured as an active employee under a non-state group plan, enrollment in Medicare may be deferred until retirement from that job. However, if you insure a domestic partner, that individual may be subject to a Medicare late enrollment penalty if they do not enroll in Medicare Part B when first eligible. Health insurance premiums will not be reduced until the employee retires and Medicare pays as primary.

For subscribers and their dependents with End Stage Renal Disease (ESRD): You will want to contact your local Social Security office, health plan, provider and Medicare to make sure you enroll in Medicare Part A and Part B at the appropriate time. The State of Wisconsin Group Health Insurance Program will provide primary coverage during the 30-month coordination period for members with ESRD. You will want to decide if it would be beneficial to enroll in Part B during your initial or general enrollment opportunities to avoid later delayed Medicare enrollment and potential premium penalties after your 30-month coordination period ends.

Medicare Part D
U.S. residents, retired members and their spouses, domestic partners and/ or dependents that participate in the State of Wisconsin Group Health Insurance Program who are Medicare enrolled, will be automatically enrolled in the Navitus MedicareRx (PDP) plan, which is offered by Navitus Health Solutions and underwritten by Dean Health Insurance Inc., a federally-qualified Medicare contracting prescription drug plan. The prescription drug coverage under this program is Medicare Part D coverage. Your monthly health insurance premium includes a portion that applies to this program's coverage.

Before Navitus can report your enrollment in Medicare Part D to Medicare, they need to have your Medicare Health Insurance Claim (HIC) number and Parts A and B effective dates. In most cases, ETF will request this information from you two to three months in advance of your 65th birthday by sending you a Medicare Eligibility Statement (ET-4307). ETF will then provide the information to Navitus. Please complete and return this form as soon as possible to ensure you receive the benefits you are eligible for and your claims are paid properly.

If you do not receive the Medicare Eligibility Statement (ET-4307) at least one month before your 65th birthday, please contact ETF. The form is also available here.

If you are retired and cover a Medicare-eligible spouse or disabled dependent on your plan, please notify ETF and provide your spouse's or dependent's Medicare information.

Individuals may choose to enroll in another Medicare Part D prescription drug plan; however, it is not recommended or required for your continued coverage under the State of Wisconsin Group Health Insurance Program.

If you choose to enroll in a different Medicare Part D plan, your health insurance premium for the state plan does not change, but your supplemental, wrap-around pharmacy coverage will be secondary to the other Medicare Part D plan. (See Question: Does Medicare Part D affect my prescription drug coverage? Should I enroll? and Question: Will my health insurance premium go down if I enroll in a Medicare Part D prescription drug plan?

(Annuitants only) If Medicare is the primary insurance, your provider must submit claims to Medicare first. Once Medicare processes the claim(s), Medicare will send you a quarterly Medicare Summary Notice (MSN).

IYC Health Plan Medicare:
Many of the health plans have an automated procedure after Medicare processes the claim, through which the provider then submits it to the health plan for processing. However, some health plans require members to submit a copy of the MSN and, in certain circumstances, a copy of the provider's bill. You should discuss with your provider if they will bill Medicare and your health plan on your behalf. Contact your health plan for additional information.

IYC Medicare Advantage:
It’s Your Choice Medicare Advantage–formerly Traditional Uniform Benefits Medicare Advantage Preferred Provider Organization offered by Humana–allows members to use any health care provider in the United States. However, you will have greater out-of-pocket expenses when you use out-of-network providers. When you visit your provider, you must show your health plan's card. Your provider will submit your claims directly to the health plan. To request reimbursement for a covered service charge that you paid, send your receipt (noting on it your name and your member ID) and a copy of your card to the address on the back of that card.

You must be enrolled in Medicare Parts A and B to be eligible for the IYC Medicare Advantage plan. You should keep your Medicare card in a safe place, but you should not show it when you receive health care services, as the the IYC Medicare Advantage plan will be primary for your service. See Question: If I have Medicare as my primary coverage, how are my benefits coordinated?

IYC Medicare Plus:
Your responsibilities in the claims process will depend on the policies and practices of the medical facility from which you receive care. You may be required to submit the claims to Medicare and then submit the proper forms to WPS Health Insurance for supplemental payments. Refer to the State Medicare Plus (ET-4113) guide available from WPS or ETF for more information, and contact your health care provider or facility regarding their particular Medicare claims procedures.

Pharmacy Benefit Manager:
As long as you maintain the Navitus MedicareRx (PDP) plan, as your Medicare Part D plan, Navitus will process your claims for both Part D and the supplemental wrap coverage that is included.

However, if you choose to enroll in a Medicare Part D plan other than the Navitus MedicareRx (PDP) plan, your supplemental wrap coverage, which is part of your State of Wisconsin Group Health Insurance Program pharmacy benefits will be considered secondary. You should be prepared to file the secondary claims manually through Navitus. Contact Navitus or visit their website for more information on filing manual claims. Refer to the Medicare Part D Information section for more details.

Medicare Part B pharmacy claims are covered under the supplemental wrap coverage benefit. For specific information on Medicare Part B pharmacy coverage and Part B claims processing, see the plan description page for Navitus™ Health Solutions.

(Annuitants only) Medicare Cross-over is designed to eliminate some of the paperwork involved in filing medical claims. Some plans have an agreement with Medicare to crossover claims for any services that Medicare processed as primary. Medicare will automatically forward your Medicare Summary Notice (MSN) to those plans for services you receive throughout the United States. Claim forwarding is automatic for each person covered under Medicare when a plan participates in Medicare Cross-over. You do not need to complete a form or contact a plan to take advantage of crossover. Please contact your health plan for further information.

(Annuitants only) Since all state health plans have coverage options that are coordinated with Medicare, you will remain covered by the plan you selected after you are enrolled in Medicare, even though Medicare is the primary payor of your claims.

Exception: if you are enrolled in one of the IYC Access Health Plans or SMP, your coverage will be changed to the IYC Medicare Plus plan. There are some differences in benefits between these plans. IYC Medicare Plus is designed to supplement the benefits you receive under Medicare. For purposes of paying benefits, Medicare is the primary plan and IYC Medicare Plus is the secondary plan. This means Medicare reviews claims first and determines what, if anything, should be paid and then the IYC Medicare Plus plan reviews the claims to determine if there is anything else that is payable.

If you are enrolled in one of the IYC Health Plans, your health coverage will remain substantially the same as before Medicare coverage became effective. For purposes of paying benefits, Medicare is the primary plan and the State of Wisconsin Group Health Insurance Program is the secondary plan. This means Medicare reviews claims first and determines what, if anything, should be paid and then the state health plans review the claims to determine if there is anything else that is payable. Because of this coordination with Medicare, your monthly premiums for state health insurance will be less.

Note: For some benefits under Uniform Benefits, such as durable medical equipment, Medicare Part B and the health plan both have a 20% coinsurance that you are responsible to pay.

If you are enrolled in Medicare and your modified adjusted gross income exceeds certain limits established by federal law, you may be required to pay an adjustment to your monthly Medicare Part B (medical) and Medicare Part D (prescription drug; i.e. Navitus MedicareRx (PDP) plan) coverage premiums. The additional premium amount you will pay for Medicare Part B and Medicare prescription drug coverage is called the income-related monthly adjustment amount or IRMAA. Since Medicare beneficiaries enrolled in the State of Wisconsin Group Health Insurance Program are required to have Medicare Parts A, B and D, the IRMAA may impact you if you have higher income.

To determine if you will pay the additional premiums, Social Security uses the most recent federal tax return that the IRS provides and reviews your modified adjusted gross income. Your modified adjusted gross income is the total of your adjusted gross income and tax-exempt interest income.

Social Security notifies you in November about any additional premium amounts that will be due for coverage in the next year because of the IRMAA. You must pay the additional premium amount, which will be deducted from your Social Security check if it's large enough. Failure to pay may result in Medicare terminating your coverage. The IRMAA is paid to Social Security, not the State of Wisconsin Group Health Insurance Program. It is not included in your State of Wisconsin Group Health Insurance Program premium.

Additional information can be found in SSA Publication No. 05-10536 or by calling the SSA toll-free at 1-800-772-1213.

Medicare related prescription drug coverage will be provided by Navitus Health Solutions (Navitus) through a self-funded, Medicare Part D Employer Group Waiver Plan (EGWP) called the Navitus MedicareRx (PDP) plan. This plan is underwritten by Dean Health Insurance Inc., a federally-qualified Medicare contracting prescription drug plan. This affects Medicare-eligible participants covered under an annuitant contract enrolled in the State of Wisconsin Group Health Insurance Program. As required by Uniform Benefits, a supplemental wrap benefit is also included to mainly provide full coverage to State members when they reach the Medicare coverage gap, also known as the "donut hole." But the supplemental wrap benefit will also provide coverage at other times when the EGWP does not, such as during the Medicare Part D deductible and the initial coverage phases. Dean has been contracted with the Centers for Medicare and Medicaid Services (CMS) since 2006, when Medicare Part D was first implemented, to offer Medicare Part D prescription drug plans to employer groups.

Your group health insurance premium already includes the cost of this benefit. There is no separate premium that needs to be paid for this Medicare Part D coverage. It is important that you read and understand the information presented on the Navitus MedicareRx plan description page included in the It's Your Choice Decision Guide.

(Annuitants only) A Medicare Part D prescription drug plan (PDP) provides primary coverage of prescription benefits through Medicare. While enrollment in a PDP is voluntary, if you do not enroll when you are first eligible and do not have what Medicare considers creditable coverage, you may have to pay a penalty in the form of a higher PDP premium once you do enroll.

Under the State group health insurance program, after you become eligible for Medicare Part D the following will happen:

• You will be automatically enrolled in the Navitus MedicareRx (PDP) plan. Medicare eligible spouses, domestic partners and/or dependents will also be enrolled. This is Medicare Part D coverage. Your group health insurance premium already includes the cost of this Medicare Part D coverage.
• You will also be automatically enrolled for supplemental wrap coverage to ensure your prescription drugs are covered when you reach the Medicare Part D coverage gap, commonly referred to as the "donut hole." Your group health insurance premium already includes the cost of this supplemental wrap coverage.

When you are enrolled in the Navitus MedicareRx (PDP) plan, you will be issued a new ID card that you will be required to use.

If you would like to maintain your current level of prescription drug benefits under our program, it is not necessary to enroll in another Medicare Part D plan. Nevertheless, participation in a Medicare Part D prescription drug plan is voluntary and you should carefully consider all options before making any kind of decision to enroll in a different Medicare Part D plan.

Also, if you are enrolled in Medicare and your modified adjusted gross income exceeds certain limits established by federal law, you may be required to pay an additional amount for your Medicare Part D coverage under the Navitus MedicareRx (PDP) plan. Please refer to the Question: What is the Social Security Income-Related Monthly Adjusted Amount (IRMAA) and does it affect me? Please note that IRMAA is not unique to the Navitus medicareRx (PDP) plan. If you are required to pay the IRMAA, you would have to do so under any Medicare Part D plan.

(Annuitants only) No. Your health insurance premium includes both medical and prescription drug coverage. If you choose to enroll in a different Medicare Part D plan, you will be dropped from the Navitus MedicareRx (PDP) plan and you will have to pay an additional premium to the other plan you enroll in. However, you will still have secondary coverage with the supplemental wrap benefits under the State of Wisconsin Group Health Insurance Program. There is no partial refund of the State of Wisconsin Group Health Insurance Program premium if you choose to enroll in a different PDP. Navitus will coordinate coverage with Medicare and pay secondary claims after Medicare processes your prescription claims from the other Medicare Part D plan, minus the applicable copayments and coinsurance that are your responsibility. If you enroll in another Medicare Part D plan, and you intend to stay in that program, notify ETF immediately. If ETF enrolls you in Navitus MedicareRx, you may be automatically disenrolled from your other plan by CMS.

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.

All state employees and annuitants who elect medical coverage through the State of Wisconsin Group Health Insurance Program are eligible, and will be automatically enrolled in the Uniform Dental Benefit plan for 2016. Employees and annuitants who do not want this coverage must opt-out during open enrollment if they do not want this coverage.

Members of the IYC Access Health Plans, the State Maintenance Plan and IYC Medicare Plus are newly eligible for the Uniform Dental Benefit plan in 2016 and will also be automatically enrolled in coverage.

All state employees and annuitants electing medical coverage through the State of Wisconsin Group Health Insurance Program will be automatically enrolled in the Uniform Dental Benefit for 2016. If you do not want the Uniform Dental Benefit Plan, you must opt-out during open enrollment.

The 2016 Uniform Dental Benefit plan is substantially similar to the 2015 benefit plan. For specific benefit details, you may visit Delta Dental's website at www.deltadentalwi.com/state-of-wi.

Contact Delta Dental directly at 1-844-337-8383 or visit their website at www.deltadentalwi.com/state-of-wi to view the provider directories. You may use a provider in either the "Delta PPO" or "Delta Premier" network, which are both considered in-network for this plan.

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 application 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.

Dental coverage is currently included in the health insurance premium. However, beginning in 2016, employees and retirees will be able to optout of dental coverage, which will result in a lower medical premium contribution.

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.

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.

No, see the deductible questions for more information.

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.

A biometric screening is a test that measures your blood pressure, body mass index, cholesterol and glucose levels. A HRA is a questionnaire that asks about your health history and lifestyle choices. These tools help you and your doctor identify potential health risks for certain diseases and chronic conditions. The information can also help you make well-informed decisions concerning your lifestyle and healthcare options.

A biometric screening may be done either at your annual physical with your Primary Care Provider (PCP) or at an onsite wellness event offered by your employer. For a schedule of onsite events, visit the Well Wisconsin website.

A HRA is available online through your health plan's website. Contact your health plan if you need help locating the webpage that contains an online HRA and biometric form. If you are unable to complete the online version of an HRA, you may request that your health plan provide you with a paper version or that a representative from your health plan contact you to administer an HRA over the telephone.

Active State Employees Only: When prior-arranged with your supervisor, you are allowed to use paid work time to complete your biometric screening and HRA at an onsite wellness event that is offered by your employer.

You are eligible to receive a $150 incentive paid directly to you by your health plan when the health plan receives all the required documentation to show that you have completed both a biometric screening and HRA. Your enrolled spouse/domestic partner is also eligible for the incentive.

Effective January 1, 2016, adult children will no longer be eligible for the Well Wisconsin Incentive program. This is the result of the Equal Employment Opportunity Commission’s (EEOC) recent ruling on the applicability of Genetic Information Nondiscrimination Act (GINA) to employee wellness programs and the proposed rule amending GINA to only allow spouse participation. At this time, retirees also enrolled in Humana Medicare Advantage are not eligible to receive incentives.

Health plans will pay incentives by the end of the quarter in which you complete both a biometric screening and HRA, or within four weeks of the quarter ending. The $150 incentive is paid either by cash, check or gift card, depending on your health plan. If you have questions about the status of your payment, contact your health plan.

No. HRAs and biometric screenings have no out-of-pocket costs when performed as preventive screenings under federal law.

Yes. All of the results from your biometric screening and HRA will be kept strictly confidential. Results will not be shared with your employer. Some health plans automatically send results to your PCP as part of your electronic health record; other health plans require you to request that your results be sent to your PCP. Contact your health plan for more information on how your results are sent to your PCP.

Depending on your health plan, many plans will continue to offer discounts or reimbursement for fitness club memberships, community supported agriculture, and health education courses for tobacco cessation, weight loss and nutrition.

Yes, the Internal Revenue Service considers all incentives issued to your or your enrolled adult members to be a fringe benefit of employment. Incentives are therefore subject to payroll tax. Incentive payment information will be provided to your employer at year end. The incentive will be reported as income and applicable deductions will be applied.

Go to www.wellwisconsin.wi.gov to find more information on your health plan's wellness offerings, to get biometric screening and HRA forms, and to find a calendar of onsite wellness events offered by your employer.

For more information on disease management and wellness programs, see the Health Plan Features.

Yes, but only if you, the subscriber, file an electronic or paper application within 30 days for the following events with coverage effective on the first day of the month on or following receipt of the application:

• Move from your plan's service area (for example, out of the county) for a period of at least three months. Your new coverage will be effective subsequent to your move. You may again change plans when you return for three months by submitting another application within 30 days after your return. (See Question: What if I have a temporary or permanent move from the service area?)
• You involuntarily lose eligibility for other coverage or lose the employer contribution for it.
• You add one or more dependents due to marriage, domestic partnership, birth, adoption or placement for adoption.
• (State and Grad only) If your premiums are being deducted on a pre-tax basis, you may cancel coverage mid-year only if you are cancelling because you have become eligible for and enroll in other group coverage or terminate employment. Otherwise, you can only change health plans without restriction during each It's Your Choice Open Enrollment period and coverage will be effective the following January 1. If your premiums are being deducted post-tax, you may cancel coverage at anytime.
  

See the Life Change Event Guide for more information.

When you change plans for any reason (for example, during an It's Your Choice Open Enrollment period or for a move from a plan's service area), any annual health insurance benefit maximums under Uniform Benefits (such as durable medical equipment) will start over at $0 with your new plan, even if you change plans mid-year with the exception of the prescription annual out-of-pocket maximum. You will continue accumulating to the same benefit maximums under the Uniform Dental Benefit plan as well.

A subscriber who moves out of a service area (for example, out of the county), either permanently or temporarily for three months or more, will be permitted to enroll in the IYC Access Health Plan or an available alternate plan offered under the IYC Health Plans (health plans that offer Uniform Benefits for medical coverage) that offers in-network providers near you, provided an electronic or paper application for such plan is submitted within 30 days after relocation. You will be required to document the fact that your application is being submitted due to a change of residence out of a service area.

If your relocation is temporary, you may again change plans by submitting an application within 30 days after your return. The change will be effective on the first of the month on or after your application is received by your employer or by ETF, but not prior to your return.

(State and Grad only) It is important that you submit your electronic or paper application to change coverage as soon as possible and no later than 30 days after the change of residence to maintain coverage for non-emergency services. The change in plans will be effective on the first day of the month on or after your application is received by your employer but not prior to the date of your move. If your application is received after the 30-day deadline, you will not be allowed to change plans until the following It's Your Choice Open Enrollment period or in certain situations.

If you are confined as an inpatient (in a hospital, a skilled nursing facility or, in some cases, an Alcohol and Other Drug Abuse (AODA) residential center) or require 24-hour home care on the effective date of coverage with the new plan, you will begin to receive benefits from your new plan unless the facility you are confined in is not in your new plan's network. If you are confined in such a facility, your claims will continue to be processed by your prior plan as provided by contract until that confinement ends and you are discharged from the non-network hospital or other facility, twelve months have passed or the contract maximum is reached. If you are transferred or discharged to another facility for continued treatment of the same or related condition, it is considered one confinement.

In all other instances, the new plan assumes liability immediately on the effective date of your coverage, such as January 1.

Each health plan has the responsibility to determine whether or not a newly enrolled disabled dependent continues to meet the contractual definition of disabled dependent. (See the Dependent Information section of this FAQ.)

Voluntary cancellation (or switching from family to single coverage which is deemed voluntary cancellation for all insured dependents) requires written notification to the employer denoting a cancellation of coverage.

If your premiums are being deducted on a pre-tax basis, you may cancel coverage only if:

• you experience a qualifying change or life event and submit an application to cancel coverage within 30 days of the event;
• you terminate employment;
• you become eligible for and enroll in another group health insurance plan; or
• you cancel your coverage during the annual It's Your Choice open enrollment period.

If your adult dependent child becomes eligible for and enrolled in other group health insurance coverage, and you want to drop coverage for him/her, you must submit an application electronically or via paper to your employer (to ETF for annuitants) within 30 days of the effective date of other coverage. In addition, you must submit proof of enrollment such as an ID card from that coverage. If this is your last dependent and you want to change to single coverage, you must note that on your application.

If your spouse/domestic partner becomes eligible for and enrolled in other group health insurance coverage, and you want to change to single coverage or cancel your family coverage, you must submit an application electronically or via paper to your employer (to ETF for annuitants) within 30 days of the effective date of other coverage. In addition, you must submit proof of enrollment such as an ID card that lists all individuals covered under that plan.

If your premiums are being deducted post-tax, you may cancel at anytime.

Be aware that voluntary cancellation of coverage does not provide an opportunity to continue coverage for previously covered dependents as described in the Continuation of Health Coverage section. Cancellation affects both medical and prescription drug coverage.

No refunds are made for premiums paid in advance unless your employer (or ETF, if you are no longer a state employee) receives your written request on or before the last day of the month preceding the month for which you request the refund. Under no circumstances are partial month's premiums refunded. Once coverage terminates, you will be responsible for any claims inadvertently paid beyond your coverage effective dates.

Your coverage can only be terminated because:

• Premiums are not paid by the due date. Coverage is also waived (known as "constructive waiver") when the employee portion of the premium is not deducted for 12 consecutive months.
• Coverage is voluntarily cancelled.
• Death of the subscriber.
• Fraud is committed in obtaining benefits or there is an inability to establish a physician/patient relationship. Termination of coverage for this reason requires Group Insurance Board approval.

(State and Grad only) Your coverage can be terminated because your eligibility for coverage ceases (for example, termination of employment).

(Annuitants only) Your coverage can be terminated because you:

• Failed to apply for both Medicare Part A and B when first eligible. The Medicare enrollment requirement is deferred while you or your spouse/domestic partner are employed and covered under a group health insurance plan from that employment. (See Question: When must I apply for Medicare?)
• Became ineligible for coverage as an annuitant because of becoming an active WRS employee. (See Question: How are my health benefits affected by my return to work for an employer who is under the WRS?)

Active employees should contact their benefits/payroll/personnel office (annuitants and continuants should contact ETF) for the date coverage will end.

(State and Annuitants only) If you terminate state employment and you are not enrolled for health insurance or subsequently terminate coverage, you may enroll for single or family coverage if you are:

1. A retired employee of the state who is receiving a retirement annuity or has received a lump sum payment under Wis. Stat. § 40.25 (1); or
2. An employee of the state who terminates service after attaining 20 years of creditable service, remains a WRS participant and is not eligible for an immediate annuity.

If you are eligible, you must submit an electronic or paper application to enroll during the It's Your Choice Open Enrollment period and may select any offered health plan. Surviving dependents are not eligible for this enrollment.

(State only) Yes. Under certain circumstances, your accumulated unused sick leave can be converted to credits to pay for health insurance premium if you are:

• Retiring,
• Terminating after accumulating 20 years of creditable WRS service, or
• Surviving dependents who are insured under our program at the time of the active subscriber's death.

The rules governing eligibility are described in ETF publications Group Health Insurance (ET-4112), Information for Retirees (ET-4116) and Your Benefit Handbook (ET-2119).

Your COBRA continuation rights are described in the State and Federal Notification Section. Both you and your dependents should take the time to read that section carefully. This section provides additional information about continuation coverage.

(State and Grad only)

• You do not have to provide evidence of insurability to enroll in continuation coverage. However, coverage is limited to the plan you had as an active employee or covered dependent. (For example, if you change plans January 1 and your dependent loses eligibility December 31, that dependent would be eligible for COBRA from the plan you were enrolled in on December 31. An exception is made when the participant resides in a county that does not include a primary physician for the subscriber's plan at the time continuation is elected. In that case, the participant may elect a different plan that is offered in the county where the participant resides.) You may select another plan during the It's Your Choice Open Enrollment period or if you move from the service area. If family coverage is in effect when continuation is first offered, each dependent may independently elect single continuation coverage. A family of two may select two single contracts at a lower cost than the premium for a family contract. The health plan will bill you directly. There can be no lapse in coverage, so multiple premiums may be required.
• If you terminate employment and have less than 20 years of creditable service, you will be offered an 18-month continuation coverage period. A second qualifying event while on continuation will not serve to extend your period of continuation. Coverage will be limited to the original 18 months. At the end of the continuation period, you will be allowed to enroll in an individual conversion through the health plan.

Note: Continuation coverage time limits do not apply to state and university employees who terminate with 20 years of WRS-creditable service and remain a WRS participant. They can continue the group health insurance for life even if they don't take an immediate annuity. To continue, an application must be received before coverage lapses.

You will need to report this change to your benefits/payroll/personnel office (or ETF for annuitants and continuants) within 60 days of your dependent losing his/her eligibility to ensure COBRA coverage is offered. Your dependent will be entitled to 36 months of continuation coverage.

No, continuation coverage is identical to the active employee coverage. In most cases, you are eligible to maintain continuation coverage for 18 months from the month of the qualifying event. These events are termination of employment or reduction in work hours. Events such as death of employee, divorce or the loss of eligibility for a dependent child entitles the dependent to 36 months of coverage. You are allowed to change plans during the annual It's Your Choice Open Enrollment period or if the subscriber moves from the service area. However, your continuation coverage may be cut short for any of the following reasons:

• The premium for your continuation coverage is not paid when due.
• You or a covered family member become covered under another group health plan that does not have a preexisting conditions
  clause that applies to you or your covered family member.
• You were divorced from an insured employee, subsequently remarry and are insured through your new spouse's group health plan.
• You or a covered family member become entitled to Medicare benefits.

If you or your covered dependent becomes eligible for Medicare, you may need to enroll in Medicare as soon as you are eligible. (See Question: When Must I Apply for Medicare?)

If you are an active employee, your premium may change as you will pay the total premium amount which includes both the employee and employer share. Contact your benefits/payroll/personnel office to obtain the total amount.

If you are an annuitant or continuant, you will want to refer to the full premium rates.

To cancel continuation coverage, notify ETF in writing. Include your name, ETF member ID or Social Security number, date of birth and address. ETF will forward your request to the health plan. Your coverage will be cancelled at the end of the month in which ETF receives the request to cancel coverage.

If you move out of the service area (either permanently or temporarily for three months or more), you are eligible to change plans. (See Question: What if I have a temporary or permanent move from the service area?).

Your electronic or paper application to change plans must be postmarked within 30 days after your move. Because you are on continuation coverage, call the ETF Employer Communication Center at (608) 264-7900 to obtain a Group Health Insurance Application/Change Form (ET-2301). Complete and submit the application to: Department of Employee Trust Funds, P. O. Box 7931, Madison, WI 53707-7931.

As required by law, you are eligible to apply for conversion coverage when group continuation coverage terminates. Contact the plan directly to make application for conversion coverage. Conversion coverage is available without providing evidence of insurability and with no waiting period for preexisting conditions, provided the State of Wisconsin Group Health Insurance Program coverage has been in effect for at least three months prior to termination.

If the health plan automatically bills you for conversion coverage that you do not want, simply do not pay the premium for the coverage. The coverage offered will be the conversion contract (not the State of Wisconsin plan) available at the time, subject to the rates and regulations then in effect. The coverage and premium amount may vary greatly from plan to plan.

If you reside outside of the IYC Health Plan HMO service area at the time you apply for conversion coverage, you may only be eligible for an out-of-area conversion policy through another insurance carrier. The benefits and rates of the out-of-area conversion plan are subject to the regulations in effect in the state in which you reside.

The conversion privilege is also available to dependents when they cease to be eligible under the subscriber's family contract. The request for conversion must be received by the plan within 30 days after termination of group coverage. If you have questions regarding conversion, write or call the plan in which you are enrolled

It is a health plan that, under federal law, has a minimum annual deductible and a maximum annual out-of-pocket limit 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 by the member.

A deductible is the fixed amount that you must pay before your insurance begins to make payments for covered medical services. For example, if you have a $1500 deductible, you must incur $1500 in covered medical expenses (for which you are responsible for paying) before your insurance pays anything (with the exception of preventive services mandated by the Patient Protection and Affordable Care Act).

Health plans will provide you with periodic explanation of benefit statements that will provide this information. While it’s always a good idea to keep track of your out-of-pocket medical expenses, you can check with your health plan to determine where you are in meeting your deductible.

Yes, the prescription benefits remain the same, with the exception of an added deductible. Certain prescription drugs that are considered preventive medications are provided with "first-dollar" coverage under the HDHP, meaning that your benefits pay for these drugs before you meet your deductible. In other words, your deductible does not apply to these certain preventive drugs and you will not have to pay for the full cost of the drug. You will still have to pay the copayment on these preventive medications in most cases; however, there are also some drugs which are covered at 100% by federal law, meaning you will not have to pay the copayment on these specific drugs. You can find the lists of preventive prescription drugs that are paid with "first-dollar" coverage and those that require no copayment under federal law on the website.

An HDHP must meet certain requirements, including the minimum amount of the deductible and maximum out-of-pocket limit, as set by the IRS.

Yes, examples of covered services before the deductible is met include: in-network preventive medical services and certain preventive prescription drugs. See a list of preventive medical services. See question 4 for more information about preventive prescription drugs.

No, the amount you pay for medical claims submitted to your health plan and prescription drug claims submitted to the Pharmacy Benefit Manager (PBM), which is currently Navitus Health Solutions, LLC, both count towards a single deductible.

Your health plan and the PBM, share your claims data in order to account for all the costs you pay. The combined amount is applied to your deductible. However, be aware that claims processing for prescription drugs is nearly instantaneous when you receive your prescriptions, but medical claims processing takes more time. As such, there may be times when you have actually met your deductible but your health plan and the PBM are not aware of it. Retroactive adjustments and refunds for costs you paid after reaching your deductible will occur.

No, you only have to incur the claims. You are still responsible for payment, but your deductible is considered to be met once you receive the service and it is billed to the health plan.

Yes, you will have an insurance ID card the same as you would under any of the other health plan options.

To be eligible to open and contribute to an HSA, an individual must be covered by a federally qualified HDHP and must not be covered by other health insurance (including Medicare and Health Care Flexible Spending Accounts) that is not a federally qualified HDHP. Certain types of insurance are not considered "health insurance" and will not jeopardize an individual’s eligibility for an HSA. Auto, dental, vision, disability, and long-term care insurance are allowed. Individuals may also have coverage for a specific disease or illness, known as an indemnity plan, as long as it pays a specific dollar amount when the policy is triggered. Wellness programs offered by employers are also permitted if they don’t pay significant medical benefits.

You can use your sick leave credits to pay for your premium only. These credits cannot be transferred to your HSA.

No, the Uniform Dental Benefit is now separate from the medical and prescription drug benefits. There is no deductible associated with the Uniform Dental Benefit plan.

No, the deductible and OOPL amounts are not changing for the HDHP for 2016.

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.

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.

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.

An HSA is an account established by an individual to pay for health care. To set up an HSA, the individual must be covered by a federally qualified HDHP. HSAs are owned by the individual, balances roll over from year to year, and the funds are portable, meaning the employee keeps them if they leave the HDHP plan or state service. The funds in an HSA can be used to pay for qualified medical expenses that are not covered by your health plan, and can be saved for future expenses on a pre-tax basis. The funds can also be invested. Contact TASC for investment options. See question #12 for more information.

A participant is only eligible for an HSA if they are enrolled in a federally qualified HDHP. A participant may not enroll in both an HSA and a health care FSA at the same time. Both types of accounts allow a participant to set aside money pre-tax to pay for healthcare expenses, however, there are some key differences shown in the table below:

HSA and Medical FSA Key Differences
	HSA	FSA
Type of health insurance plan it works with	HDHP only	Any type
Account owner	Individual participant	Employer
Who contributes?	Can be anyone: employer, employee, or other. See page 8 of the It’s Your Choice State Decision Guide for state employer contribution amounts.	Usually only the employee contributes. State employers do not contribute.
Do the funds roll-over from year to year?	Yes	Up to $500 will rollover to the next plan year.
What if the participant leaves state service?	The HSA is portable because it is owned by the participant. HSAs are not subject to COBRA continuation, when you leave state employment you keep the funds in your account, but you become responsible for paying any HSA associated fees and there will be no future employer contribution to your account.	FSAs are subject to COBRA continuation and a participant can choose to keep their FSA open and active. Otherwise, expenses can only be incurred for reimbursement through the last day of the month of the participant’s last paycheck.

 

No, you choose how you pay for your deductible.

Check out this list of eligible expenses.

Yes, some of the expenses include: cosmetic surgery, over-the-counter medications, insurance premiums, and family or marriage counseling. This a list of qualified expenses.

Yes, you cannot enroll in a state sponsored HSA through your employer unless you are enrolled in the High Deductible Health Plan.

Anyone can contribute money to your HSA. Your employer can make pre-tax contributions to your HSA. You can also choose to contribute tax-free dollars through your payroll. Any others who choose to contribute to your account would do so on an after-tax basis, although you would be able to deduct the contribution from your gross income on your tax return.

Yes, Contributions made to an HSA by a family member on behalf of an eligible individual are deductible by the eligible individual in computing adjusted gross income. The contributions are deductible whether or not the eligible individual itemizes deductions.

Yes, you can arrange this through your payroll office. When you complete the HSA enrollment process, you will have the option to choose a pre-tax paycheck deduction amount. Note: LTEs are not able to contribute to an HSA through payroll deduction.

Yes, the limits are available online in the IYC HSA Information section. The IRS updates the annual limits each year, so the limit in future years may be different. All contributions, including those made by your employer or another person, are combined when applying the contribution limit.

No, your HSA balance will roll over from year to year.

Yes, your HSA balance earns interest. You can also choose to invest a portion of your HSA balance once you have a $2,000 balance in your account. More information is available at www.tasconline.com.

Yes, the contributions made by your employer are not taxable income. This money is yours, tax-free, as long as you spend it on qualified medical expenses. You can also make pre-tax contributions to your HSA, contact your payroll office to arrange.

Yes, as long as you use the funds to pay for qualified medical expenses, you can pay for any family member who is a tax dependent on your tax return. You may also use the funds for medical expenses incurred by your child who is claimed as a tax dependent by his/her other parent.

The IRS views spouses as one tax unit, even if filing as "married filing separately", so if either spouse is eligible for a family contribution limit, that is intended to cover both spouses. The IRS suggests that the family limit be split evenly between the spouses, unless a separate allocation is desired.

The money in the HSA belongs to you. You can continue to use the money in your HSA to pay for qualified medical expenses, but you can no longer make contributions to the account unless you are enrolled in another HSA eligible HDHP.

You can withdraw money at any time if it’s used for qualified medical expenses. However, if you withdraw money for other purposes, your withdrawal will be subject to income tax (if the contribution was pre-tax) and a 20% penalty.

You can keep your HSA open as long as you choose. This is your account. Your new employer may or may not contribute to this HSA. Once you leave state service you are responsible for any account maintenance fees.

You can continue to use your account tax-free for qualified medical expenses. Once you turn age 65, you can also use your account to pay for things other than medical expenses. If used for other expenses, the amount withdrawn will be taxable as income but will not be subject to any other penalties. Individuals under age 65 who use their accounts for non-qualified medical expenses must pay income tax and a 20% penalty on the non-qualified withdrawal.

The HSA is an asset that is treated like any other.

Yes.

No, only expenses incurred after establishing your HSA.

Yes, you can use your HSA to pay for any qualified medical expenses from any provider.

Yes, as long as you are not currently eligible for or enrolled in Medicare.

It depends. You can have a limited-purpose Health Care FSA, which only allows you to pay for qualified vision, dental and post-deductible expenses. However, the IRS prohibits you from having a general-purpose Health Care FSA and an HSA at the same time because they have almost identical qualified medical expenses, and because the IRS considers a Health Care FSA to be “other health insurance coverage”. It is permissible to still have a dependent day care FSA when you have an HSA.

You can enroll in the HDHP for the next plan year if you are enrolling during It’s Your Choice (open enrollment period). You will be required to spend out any remaining FSA funds before the HDHP can take effect and before you are eligible to open an HSA. In some cases your FSA funds may be converted to a limited-purposed FSA, check with your employer on this.

Your HSA would transfer to your beneficiary tax-free.

It is recommended that you keep your receipts. If you are audited by the IRS, you may need to explain any funds you used from your HSA.

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 cannot 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.

No, incentive payments will be spread out over all applicable pay periods in the year.

No, not as the law is currently written.

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.

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. You are eligible, as a state employee, as long as you meet the other eligibility requirements.

No.

Yes, as long as you meet the other eligibility requirements, you can receive the $2,000 opt-out incentive for each year that you opt out.

Yes.

• 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.

Yes, and it will appear on employees’ W-2 statements. The incentive payment is not considered WRS earnings.

The eligibility criteria for sick leave conversion for state employees remains the same. You must be in the health insurance program to be able to convert unused sick leave time to credits that can be used to purchase health insurance at retirement. Keep in mind, if you opt-out of the health insurance program and unfortunately pass away, your unused sick leave time will not be eligible to be converted to sick leave credits by your dependent like it would if you passed away and had family health insurance coverage. Please see ET-4132, Sick Leave Conversion Credit Program brochure for more information on eligibility requirements related to retirement and death benefits for spouse and dependents.