Your browser does not support JavaScript!
calculators
Member Education
forms and publications
news
about etf
frequently asked questions
contact etf
site map
related links
home
top of page
Wisconsin Department of Employee Trust Funds header image It's Your Choice 2016 State of Wisconsin Group Health Insurance Program
members retirees employers governing boards careers at etf
Wisconsin Department Of Employee Trust Funds It's Your Choice 2016


Local High Deductible Health Plan
Insurance for Employees
and Retirees
(PO7)


Comparison of Medical Benefits 2016

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

Local Program Options 7 and 17

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 HDHP

IYC Access HDHP

In-Network Out-of-Network

Annual Medical Deductible

$1,500 individual / $3,000 family

The deductible must be met before coverage begins; for family coverage, the full family deductible must be met

The deductible includes prescription drugs and applies to the annual OOPL

$1,700 individual / $3,400 family

The deductible must be met before coverage begins; for family coverage, the full family deductible must be met

The deductible does apply to prescription drugs and also to the annual OOPL

$2,000 individual / $4,000 family

The deductible must be met before coverage begins; for family coverage, the full family deductible must be met

The deductible includes prescription drugs and applies to OOPL

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.

After deductible: $15 per visit

Office visit copayments apply to the annual OOPL

After deductible: $15 per visit

Office visit copayments 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.

After deductible: $25 per visit

Office visit copayments apply to the annual OOPL

After deductible: $25 per visit

Office visit copayments 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 except for office visits

Coinsurance applies to the annual OOPL

Annual Medical Out-of-Pocket Limit (OOPL)

$2,500 individual / $5,000 family $3,500 individual / $6,550 family $3,800 individual / $7,600 family

Routine, preventive services as required by federal law

Plan pays 100% Plan pays 100% Subject to the deductible and 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.)

After deductible: $75 copayment per visit, then coinsurance applies to services beyond the copayment up to the OOPL After deductible: $75 copayment per visit, then the deductible and coinsurance applies to services beyond the copayment up to the OOPL After deductible: $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: after deductible, primary care office visit copayment ($15), you also pay a 10% member cost 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: after deductible, primary care office visit copayment ($15), you also pay a 10% member cost 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)

After deductible: Every three years: Adults, member cost 20% up to plan paid $1,000 (20% member cost to OOPL); dependents younger than 18 years, 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

After deductible: Adults, 20% member cost to OOPL for device, surgery for implantation, follow-up sessions;

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 year

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

After deductible: Office visit copayment ($15), you also pay a 10% member cost 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

After deductible: Office visit copayment ($15), you also pay a 10% member cost 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 combined visits per plan year

Plan may approve an additional 50 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: 8/17/2016 9:01:32 AM