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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 Health Plan
Insurance for Employees
and Retirees
(PO6)


Comparison of Medical Benefits 2016

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

Local Program Options 6 and 16

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 Health Plan

IYC Access Health Plan

In-Network Out-of-Network

Annual Medical Deductible

$250 individual / $500 family

Deductible applies to annual OOPL

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

Medical deductible does not apply to prescription drugs

$250 individual / $500 family

Deductible applies to annual OOPL

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

Medical deductible does not apply to prescription drugs

$500 individual / $1,000 family

Deductible applies to annual OOPL

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

Medical deductible does not apply to prescription drugs

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

$15 per visit

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

$15 per visit

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

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

Specialty Office Visit Copayment
Includes:
*  Specialty Providers
*  Urgent Care
*  Vision Exam in an office visit setting.

$25 per visit

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

$25 per visit

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

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

Annual Medical Coinsurance

After deductible: 10% member cost

Applies to medical services except for office visits

Coinsurance applies to the annual OOPL

After deductible: 10% member cost

Applies to medical services except for office visits

Coinsurance applies to the annual OOPL

After deductible: 30% member cost

Applies to medical services

Coinsurance applies to the annual OOPL

Annual Medical Out-of-Pocket Limit (OOPL)

$1,250 individual / $2,500 family

$1,000 individual / $2,000 family

$2,000 individual / $4,000 family

Routine, preventive services as required by federal law

Plan pays 100%

Plan pays 100%

Subject to the deductible, copayments and/or coinsurance

Illness/injury related services beyond the office visit copayment (if applicable)
This includes hospital stay and the cost of an ambulance.

After deductible: 10% member cost up to OOPL

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

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

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

$75 copayment per visit, then the deductible and coinsurance applies to services beyond the copayment up to the OOPL

$75 copayment per visit, then the deductible and coinsurance applies to services beyond the copayment up to the OOPL

$75 copayment per visit, then in-network deductible and coinsurance applies to services beyond the copayment up to the OOPL

Transplants

After deductible: 10% member cost up to OOPL. Includes bone marrow, parathyroid, musculoskeletal, corneal, kidney, heart, liver, kidney with pancreas, heart with lung, and lung

After deductible: 10% member cost up  to OOPL. Includes bone marrow, musculoskeletal, corneal, and kidney

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

Mental Health/Alcohol & Drug Abuse

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

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

All services apply  to the annual OOPL

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

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

All services apply  to the annual OOPL

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

Hearing aid (per ear)

Every three years: Adults, after deductible, 20% member cost up to plan paid $1,000 (not to OOPL); dependents younger than 18 years, after deductible, 10% member cost up to OOPL

For dependents younger than 18 years only every three years—deductible and 10% member cost up  to OOPL

For dependents younger than 18 years only every three years—deductible and 30% member cost up  to OOPL

Cochlear Implants

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

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

Dependents under 18, deductible and 10% member cost up  to OOPL for device, surgery, follow-up sessions

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

Skilled Nursing Facility (non-custodial care)

After deductible, 10% member cost up to OOPL, 120 days per benefit period

Deductible and 10% member cost up to OOPL, as medically necessary, 120 days per benefit period

Deductible and 30% member cost up to OOPL, as medically necessary, 120 days per benefit period

Home Health (non-custodial)

After deductible, 10% member cost up to OOPL, 50 visits per year

Plan may approve an additional 50 visits

Deductible and 10% member cost up to OOPL, 50 visits per plan yea

Plan may approve an additional 50 visits

Deductible and 30% member cost up to OOPL, 50 visits per plan year

Plan may approve an additional 50 visits

Physical/Speech/Occupational Therapy

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

50 combined visits per year

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

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

50 combined visits per year

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

Deductible and 30% member cost up to OOPL

50 visits per plan year

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

Durable Medical Equipment

After deductible, 20% member cost up to OOPL

After deductible: 10% member cost up to OOPL

After deductible: 30% member cost up to OOPL

Precertification for hospitalizations, high-tech radiology and low back surgery

Varies by plan

See plan descriptions and contact your plan

WPS Medical Management Program

WPS Medical Management Program

Referrals

In-network—varies by plan

Out-of-network— referral is required

None

None

Treatment for morbid obesity

Excluded

Deductible and 10% member cost up to OOPL

Surgical treatment requires precertification

Deductible and 30% member cost up to OOPL

Surgical treatment requires precertification

Oral Surgery

After deductible: 10% member cost up to OOPL, 11 procedures

After deductible: 10% member cost up to OOPL, 23 procedures

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

 

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 4:33:14 PM