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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 Deductible Plan
Insurance for Employees
and Retirees
(PO4)


Comparison of Medical Benefits 2016

It’s Your Choice Local Health Program For Actives and Retirees without Medicare

Local Program Options 4 and 14

This chart compares your medical benefit options. This is not a complete description of coverage, you can find that in the Certificates of Coverage.

 

IYC Local Deductible

IYC Local Access Health Plan

In-Network Out-of-Network

Annual Medical Deductible

$500 individual / $1,000 family

When an individual within a family plan meets the $500 deductible, coinsurance will apply to certain covered medical services

Medical deductible does not apply to prescription drugs

$500 individual / $1,000 family

When an individual within a family plan meets the $500 deductible, coinsurance will apply to covered medical services

Medical deductible does not apply to prescription drugs

$1,000 individual / $2,000 family

When an individual within a family plan meets the $1,000 deductible, coinsurance will apply to covered medical services

Medical deductible does not apply to prescription drugs

Annual Medical Coinsurance &
Out-of-Pocket-Limit (OOPL)

After deductible: plan pays 100% for most services, except for durable medical equipment, certain hearing aids and cochlear implants. See below.

After deductible: 20% member cost

Applies to medical services

Coinsurance applies to Out-of-Pocket-Limit (OOPL)

After deductible: plan pays 70%, you pay 30% cost

Applies to medical services

Coinsurance applies to Out-of-Pocket-Limit (OOPL)

Annual Federal Medical Maximum
Out-of-Pocket Limit (MOOP)

For durable medical equipment, certain hearing aids and cochlear implants. See below. $6,850 Individual / $13,700 Family for federally required essential health benefits

$2,000 individual / $4,000 family (includes deductible)

$4,000 individual $8,000 family (includes deductible)

Routine, preventive services as required by federal law

Plan pays 100%

Plan pays 100%

After deductible plan pays 70%, you pay 30% cost to OOPL

Illness/injury related services

After deductible plan pays 100%

After deductible: plan pays 80% you pay 20% cost to OOPL

After deductible plan pays 70%, you pay 30% cost to OOPL

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

$60 copay per visit

$75, after copay subject to deductible and 20% member cost to OOPL

$75, after copay In-Network deductible and coinsurance applies

Vision Exam

Routine exam: After deductible plan pays 100% for one routine eye exam per year; exam for children is not subject to the deductible and plan pays 100%

Illness or injury: After deductible plan pays 100% for adults or children

Routine exam: Plan pays 100% for children only

Illness or injury: After deductible plan pays 80% for adults or children; you pay 20% cost to OOPL

Routine exam: No benefit

Illness or injury: After deductible plan pays 70% for adults or children; you pay 30% cost to OOPL

Hearing Exam

After deductible plan pays 100%

After deductible plan pays 80% only when exam is for illness or disease; you pay 20% cost to OOPL

After deductible plan pays 70% only when exam is for illness or disease; you pay 30% cost to OOPL

Hearing Aid
(per ear)

Every 3 years:

Adults: After deductible plan pays 80% up to $1,000 benefit limit, you pay 20% for the first $1,000 and the full cost after

Children: Plan pays 100%

Every 3 years:

Adults: No benefit

Children: After deductible, plan pays 80%; you pay 20% cost to OOPL

Every 3 years:

Adults: No benefit

Children: After deductible, plan pays 70%; you pay 30% cost to OOPL

Cochlear Implants

Adults:  After deductible 20% member cost for device, surgery, follow-up sessions (not to OOPL); plan pays 100% for hospital charge for surgery

Dependents under 18, plan pays 100% for all services

Dependents under 18, after deductible 20% member cost up to OOPL for device, surgery, follow-up sessions

Dependents under 18, after deductible 30% member cost up to OOPL for device, surgery, follow-up sessions

Durable Medical Equipment

After deductible plan pays 80%, you pay 20% up to $500 OOPL

After deductible plan pays 80%; you pay 20% cost to OOPL

After deductible plan pays 70%; you pay 30% cost to OOPL

Physical/Speech/Occupational Therapy

After deductible plan pays 100% for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type
per year

After deductible plan pays 80% for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type per year

After deductible plan pays 70% for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type per year

Skilled Nursing Facility
(non-custodial care)

After deductible plan pays 100% for 120 days
per benefit period

After deductible plan pays 80% for 120 days per benefit period; you pay 20% cost to OOPL

After deductible plan pays 70% for 120 days per benefit period; you pay 30% cost to OOPL

Home Health
(Non-custodial)

After deductible: plan pays 100% for 50 visits per year. Plan may approve an additional 50 visits

After deductible: 20% member cost up to OOPL for 50 visits per plan year. Plan may approve an additional 50 visits

After deductible: and 30% member cost up to OOPL for 50 visits per plan year. Plan may approve an additional 50 visits

Mental Health/Alcohol & Drug Abuse

Outpatient, inpatient and covered transitional services: After deductible: plan pays 100%

Outpatient, inpatient and covered transitional services: after deductible: plan 20% member cost up to OOPL

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

Transplants

After deductible: plan pays 100%: Bone marrow, parathyroid, musculoskeletal, corneal, kidney, heart, liver, kidney with pancreas, heart with lung, and lung

After deductible: 20% member cost up to OOPL: Bone marrow, musculoskeletal, corneal, and kidney

After deductible: 30% member cost up  to OOPL: Bone marrow, musculoskeletal, corneal, and kidney

Pre certification for hospitalizations, high-tech radiology and low back surgery

Varies by plan. See plan descriptions and contact your plan

WPS Medical Management Program

WPS Medical Management Program

Referrals

In-network: varies by plan

Out-of-network: referral is required

Not required

Not required

Treatment for morbid obesity

Excluded

After deductible: 20% member cost up to OOPL: Surgical treatment requires pre certification

After deductible: 30% member cost up to OOPL: Surgical treatment requires pre certification

Oral Surgery

After deductible: plan pays 100% for 11 procedures

After deductible: 20% member cost up to OOPL for 23 procedures

After deductible: 30% member cost up to OOPL for 23 procedures

 

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

This page was last modified on: 10/1/2015 4:33:13 PM