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


Local Traditional Plan
Insurance for Employees
and Retirees
(PO2)


Comparison of Medical Benefits 2016

Retirees with Medicare

  IYC Medicare & IYC Medicare Advantage IYC Medicare Plus
Annual Medical Deductible Medicare pays: Allowable services after Part A ($1,260) and Part B ($147) deductibles

Plan pays: Part A inpatient hospital deductible of $1,260 and Part B deductible of $147

You pay: $0
Medicare pays: Allowable services after Part A ($1,260) and Part B ($147) deductibles

Plan pays: Part A inpatient hospital deductible of $1,260 and Part B deductible of $147

You pay: $0
Annual Medical Coinsurance Medicare pays: For Part A, varying coinsurance as listed below for hospital inpatient and skilled nursing facility care. After Part B deductible, 80%

Plan pays: Part B deductible and 20% coinsurance

You pay: $0
Medicare pays: For Part A, varying coinsurance as listed below for hospital inpatient and skilled nursing facility care. After Part B deductible, 80%

Plan pays: Part B deductible and 20% coinsurance

You pay: $0
Annual Medical Out-of-Pocket Limit (OOPL) None None
Outpatient illness/injury related services Medicare pays: After Part B deductible, 80%

Plan pays: Part B deductible and 20% coinsurance

You pay: $0
Medicare pays: After Part B deductible, 80%

Plan pays: Part B deductible and 20% coinsurance

You pay: $0
Emergency Room Copay Medicare pays: After Part B deductible, 80%

Plan pays: Part B deductible and 20% coinsurance

You pay: $60 copayment (Waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer.)
Medicare pays: After Part B deductible, 80%

Plan pays: Part B deductible and 20% coinsurance

You pay: $0
Hospital Semiprivate room and board, and miscellaneous hospital services and supplies such as drugs, X-rays, lab tests and operating room.
“Lifetime reserve” days are a one-time additional 60 days of hospital coverage paid by Medicare.
Medicare pays: After Part A deductible; full cost for the first 60 days 61st to 90th day, all but $315 per day 91st to 150th day, all but $630 per day (if using “lifetime reserve”), if “lifetime reserve” days are exhausted, $0

Plan pays: 100% as medically necessary, plan providers only. No day limit.

You pay: $0
Medicare pays: After Part A deductible; full cost for the first 60 days 61st to 90th day, all but $315 per day 91st to 150th day, all but $630 per day (if using “lifetime reserve), if “lifetime reserve” days are exhausted, $0

Plan pays: Initial Part A deductible of $1,260 for the first 60 days 61st to 90th day, $315 per day 91st to 150th day, $630 per day if under “lifetime reserve” period

You pay: $0 for first 90 days of confinement, and up to 150 under “lifetime reserve.” Once “lifetime reserve” is exhausted, you pay the full cost after 90 days
Licensed Skilled Nursing Facility Medicare covered services in a Medicare approved facility Requires a 3-day period of hospital stay
Medicare pays: 100% for the first 20 days 21st to 100th days, all but $157.50 per day Beyond 100 days, $0

Plan pays: 100% as medically necessary, for the first 120 days per benefit period; plan providers only Beyond 120 days, $0

You pay: $0 for the first 120 days, full cost after 120 days
Requires a 3-day period of hospital stay
Medicare pays: 100% for the first 20 days 21st to 100th days, all but $157.50 per day Beyond 100 days, $0

Plan pays: 21st to 100th days, $157.50 per day 101st to 120th days, all covered services up to a maximum of 120 days per benefit period Beyond 120 days, $0

You pay: $0 for the first 120 days, full cost after 120 days
Licensed Skilled Nursing Facility (Non-Medicare approved facility) If admitted within 24 hours following a hospital stay Medicare pays: $0

Plan pays: 120 days per benefit period for skilled care in a facility licensed in a state

You pay: Full cost after 120 days
Medicare pays: $0

Plan pays: Maximum daily rate for up to 30 days per confinement; covers only the same type of expenses normally covered by Medicare in a Medicare-approved facility

You pay: $0 for eligible expenses for the first 30 days, full cost after 30 days
Medical Supplies, Durable Medical Equipment and Durable Diabetic Equipment and Related Supplies

For Medicare-approved supplies:
Medicare Pays: after Part B deductible, 80%

Plan pays:
If you have not met the Part B deductible, 80%

If you have met the Part B deductible, but you have not met the $500 OOPL, 0%

If you have met the Part B deductible, and also the $500 OOPL, 20%

You pay: 20% up to $500 OOPL per participant, after OOPL, $0

For Medicare-approved supplies:
Medicare Pays: after Part B deductible, 80%

Plan pays: Part B deductible and 20% coinsurance

You pay: $0

For supplies NOT covered by Medicare:
Medicare pays: None

Plan pays:

If you have not met the $500 OOPL, 80%

If you have met the $500 OOPL, 100%

You pay: 20% up to $500 OOPL per participant, after OOPL, $0

For supplies NOT covered by Medicare:
Medicare pays: None

Plan pays: None

You pay: Full cost of supplies

Home Health Care Under an approved plan of care, part-time services of an RN, LPN or home health aide; physical, respiratory, speech or occupational therapy; medical supplies, drugs, lab services and nutritional counseling. Medicare pays: 100% of charges for visits considered medically necessary by Medicare, generally 5 visits per week for 2 to 3 weeks; or 4 or fewer visits per week as long as required

Plan pays: 100% for 50 visits per year, plan may approve an additional 50 visits

You pay: Full costs of visits not covered by Medicare and the plan beyond the 50 (or if approved, 100) visits per year
Medicare pays: 100% of charges for visits considered medically necessary by Medicare, generally 5 visits per week for 2 to 3 weeks; or 4 or fewer visits per week as long as required

Plan pays: 100% for up to 365 visits per year

You pay: Full costs of visits beyond 365 per year
Hearing Exam

For routine exams:
Medicare Pays: None

Plan pays: 100%

You pay: $0

For routine exams:
Medicare pays: None
Plan pays: None

You pay: Full cost of hearing exam
For illness or disease:
Medicare pays: After Part B deductible, 80%

Plan pays: Deductible and 20% coinsurance

You pay: $0
For illness or disease:
Medicare pays: After Part B deductible, 80%

Plan pays: Deductible and 20% coinsurance

You pay: $0
Hearing Aid (per ear) Medicare pays: No coverage for adults

Plan pays: 80% for adults up to plan paid $1,000 every three years (does not count toward OOPL)

You pay: 20% coinsurance and 100% of costs exceeding plan payment of $1,000
Medicare pays: No coverage for adults

Plan pays: None

You pay: Full cost of hearing aid

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

This page was last modified on: 10/16/2015 2:49:30 PM