Frequently Asked Questions
Below is detailed information regarding enrollment and plan change opportunities during and beyond the annual It’s Your Choice Open Enrollment period, dependent eligibility, benefits and services, Medicare and termination of coverage.
This information is intended to provide understandable explanations of technical provisions of the Uniform Benefits Certificate of Coverage. In the event of any conflict between the terms of the IYC Health Plans Certificate of Coverage and the information contained in the Frequently Asked Questions section, the terms of the Certificate of Coverage shall control.
Information about the Wisconsin Public Employers Group Health Insurance Program in this guide applies to the following individuals whose employer has elected this coverage:
The Marketplace, established under the Patient Protection and Affordable Care Act (ACA), allows individuals to shop for health insurance outside of our program. This may be of interest to annuitants who are paying premiums out-of-pocket. Note, premiums for Marketplace insurance cannot be paid out of sick leave credits or with any employer contribution. After evaluating the benefit levels of the Marketplace, it has been found that only platinum level plans are considered comparable coverage for the purposes of escrowing accumulated sick leave conversion credits. Visit healthcare.gov for more information.
Insurance Complaint Process
Each of the plans and the PBM participating in the Wisconsin Public Employers Group Health Insurance Program is required to have a complaint and grievance resolution procedure in place to help resolve participants' problems. Your plan and the PBM have information on how to initiate this process. You must exhaust all of your appeal rights through the plan or PBM first in order to pursue review through an Independent Review Organization (IRO) or through ETF and the Group Insurance Board. If the plan upholds its denial, it will state in its final decision letter your options if you wish to proceed further.
Depending on the nature of your complaint, you may be given rights to request an independent review through an outside organization approved by the Office of the Commissioner of Insurance. This option becomes available when a plan or PBM has denied services as either not medically necessary or experimental, or due to a preexisting condition exclusion denial or rescission of coverage. Note: If you choose to have an independent review organization (IRO) review the plan's decision, that decision is binding on both you and your plan or PBM except for any decision regarding a preexisting condition exclusion denial or the rescission of coverage. Apart from these two exceptions, you have no further rights to a review through the ETF or the courts once the IRO decision is rendered.
As a member of the Wisconsin Public Employers Group Health Insurance Program, you have the right to request an administrative review through ETF if your health plan or PBM has rendered a decision on your grievance and it is not eligible for IRO review as described above. To initiate an ETF review, you may call or send a letter to ETF and request an Employee Trust Funds Complaint Form (ET-2405). Complete the complaint form and attach all pertinent documentation, including the plan's response to your grievance.
Please note that ETF's review will not be initiated until you have completed the grievance process available to you through the plan or PBM. After your complaint is received, it is acknowledged and information is obtained from the plan or PBM. An ETF ombudsperson will review and investigate your complaint and attempt to resolve your dispute with your plan or PBM. If the ombudsperson is unable to resolve your complaint to your satisfaction, you will be notified of additional administrative review rights available through ETF.
Domestic Partners: The fair market value for insurance coverage provided for a domestic partner and his or her children must be calculated and added to your income, unless the domestic partner and his or her children qualify as your tax dependents.
The fair market value of the health insurance benefits will be calculated and added to your earnings as imputed income. The monthly imputed income amounts vary by health plan and are provided for either one non-tax dependent, or two or more nontax dependents. These dollar amounts will be adjusted annually and are available from your employer. Annuitants who have family coverage may cover non-tax dependents. If the premium is paid directly by the annuitant or through annuity deduction, there will be no imputed income on the value of the non-tax dependent’s coverage. However, if the premium is being paid using accumulated sick leave conversion credits, the value of the non-tax dependent’s coverage will be added to the annuitant’s earnings as imputed income on a W-2 from ETF in January.
Employees who are unsure if a person can be claimed as a dependent should consult IRS Publication 501 or a tax advisor.
Employees may change from single to family coverage to add a newly eligible domestic partner or other dependent who does not qualify as a tax dependent under Internal Revenue Code Section 152 during the plan year. The additional premium attributable to the non-qualified dependent will be taxable.
Adult Children: The Patient Protection and Affordable Care Act (PPACA) and 2011 Wisconsin Act 49 eliminated tax liability for the fair market value of health coverage for these dependents through the month in which they turn 26, if eligible.
If the tax dependent status of your dependent over age 26 changes, please notify your employer (or for annuitants and continuants, ETF).
Imputed income is the non-cash benefit earned for items (e.g., health insurance for certain dependents) that is reported as income to the government on the W-2 and other forms. Employees and annuitants may be taxed on the fair market value of the health care coverage extended to their dependents who do not qualify as dependents for tax purposes.
See Question: What are the tax implications for covering non-tax dependents? to learn when imputed income applies. For more information, employees should contact their employer; annuitants should contact ETF.
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.
Selecting a Health Plan
No, family members are limited to the plan selected by the subscriber.
No. If you elect family coverage for medical, you may only choose family coverage or choose to opt-out of the Uniform Dental Benefit.
Similarly, if you elect single coverage for medical, you may only choose single coverage or choose to opt-out of the Uniform Dental Benefit.
This can be a concern for members who travel and those with covered dependents living elsewhere, such as a college student living away from home. Consider the following when selecting a health plan: If you are covered through an IYC Local Plan, you are required to obtain allowable care only from providers in the IYC Local Plan’s network.
IYC Local Plans will cover emergency care outside of their service areas, but you must get any follow-up care to the emergency from providers in the IYC Local Plan’s network. Do not expect to join an IYC Local Plan HMO and get a referral to a non-HMO physician. An IYC Local Plan generally refers outside its network only if it is unable to provide needed care within the IYC Local Plan.
If you are covered through a Preferred Provider Organization (PPO) such as WEA Trust or the IYC Access Health Plan, you have the flexibility to seek care outside a particular service area. However, out-of-network care is subject to higher deductible and coinsurance amounts.
Annuitants only: If you or your dependents are covered through the Medicare Plus plan, you have the freedom of choice to see any available provider for covered services.
In addition, Humana’s Medicare Advantage-PPO offers coverage for participants with Medicare Parts A and B, with both in- and out-of-network benefits. Note: Non-Medicare members are limited to Humana’s IYC Local Plan HMO network.
Contact the plan directly or follow the instructions provided in the Health Plan Descriptions. ETF and your benefits/payroll/personnel office do not have this information.
Go to the Start Here tab above to see How to Choose Your Health Plan.
New Employee Enrollment
If eligible, you may enroll for single or family coverage in any of the available health plans without restriction or waiting periods for preexisting medical conditions, provided you file an electronic or paper health application with your benefits/payroll/personnel office within the required enrollment period stated below:
There are no interim effective dates except as required by law. However, you may enroll for single coverage within 30 days of your date of hire and change to family coverage if your electronic or paper application is received prior to the date the employer contributions begin.
If you cancel your policy prior to the date that the employer contribution starts, you may re-enroll in health insurance with the new coverage becoming effective on the first day of the month that employer contribution begins.
You cannot assume that the month when your first payroll deduction occurs is the month when your coverage begins. Health premiums are deducted in advance of coverage. For further information on deductions, coverage and effective dates, contact your benefits/payroll/personnel office.
Important Information for Less Than Half-Time Employees:
The initial enrollment opportunity for most employees begins with their participation in the WRS. However, if you are a less than half-time employee, you have another enrollment period if:
If you apply for coverage within 30 days of one of these events, coverage will be effective on the later of the first of the month following the your new hire date, or the effective date of the increase in the employer contribution. Retroactive effective dates are not allowed. This does not provide an opportunity to change from single to family coverage.
You may also enroll during the annual It's Your Choice Open Enrollment period for coverage to be effective January 1 of the following year.
Other Enrollment Opportunities
You may be able to get health insurance coverage if you are otherwise eligible under specific circumstances as described below:
The enrollment period begins on the date the other group health insurance coverage terminates because of loss of eligibility (for example, termination of employment, divorce, etc., but not voluntary cancellation of coverage) or the employer's premium contribution ends.
The It's Your Choice Open Enrollment period is the annual opportunity for eligible employees to select one of the many health plans offered by the Wisconsin Public Employers Group Health Insurance Program. The following list contains some of the most commonly asked questions about the enrollment period. You can also find information about key terms in the definitions section.
The It’s Your Choice Open Enrollment period is an opportunity to change plans, change from family to single coverage, enroll if you had previously deferred coverage, cancel your coverage or cancel the coverage for your adult dependent child. It is offered only to employees, annuitants and surviving spouses and dependents who are eligible under the Wisconsin Public Employers Group Health Insurance Program. Changes made become effective January first of the following year.
Yes, coverage will be effective January 1 of the following year for all eligible dependents. Note that if you are subject to tax liability for dependents such as adult children, and/or a domestic partner and his or her child(ren), you can elect not to cover such individuals. For information about the tax impact of covering non-tax dependents, see Question: Are there other enrollment opportunities available to me after my initial one expires?
Making Changes During It's Your Choice Open Enrollment
If you decide to change to a different plan, you are encouraged
to make changes online using the myETF Benefits website, or you
may submit a paper application using the following instructions:
Note: If you plan to stay with your current plan for next year and you are not changing your coverage, you do not need to take any action.
Refer to the myETF Benefits System Instructions here.
Your changes will not be stored unless you click on the Submit button. You will need to log back in and make the changes again. To view what you submitted, click the myRequests button on the bottom of the myInfo page.
It’s Your Choice coverage changes are effective January 1 of the following year.
You may submit or make changes anytime during the It’s Your Choice Open Enrollment period by filling out a paper application. After that time, you may rescind, that is, withdraw your application (and keep your current coverage) by:
• Active employees should inform their benefits/payroll/personnel office prior to December 31.
Other rules apply when canceling coverage. For more information, see the Cancellation or Termination of Coverage section.
During the annual enrollment period, you can add or drop coverage for yourself and/or your adult dependent children or do a spouse/domestic partner to spouse/domestic partner transfer of your health insurance coverage.
Layoff/Leave of Absence
Reinstatement of Coverage: If your health coverage lapses during your leave or layoff due to non-payment of premiums, you must submit a new application either electronically or via paper within 30 days of returning to payroll to reinstate the lapsed coverage. 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 enrollment opportunity upon your return. (See Question: Are there other enrollment opportunities available to me after my initial one expires?)
Lapsed coverage can also be reinstated for an employee who has been on a leave of absence, who is entitled to and applies for an immediate annuity. Coverage shall be effective the first day of the calendar month that 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 either electronically or via paper.
If you occupy a seasonal or teaching 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.
Termination of Employment
Appealing a Discharge
If you are covered 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. (Those eligible for Medicare and enrolled in the IYC Access Health Plan or SMP will be switched to IYC Medicare Plus.) You must fill out the employer verification form and return it with your retirement application.
Note: If you are eligible for Medicare, you must be enrolled in the hospital (Part A), medical (Part B) and prescription drug (Part D) portions of Medicare at the time of your retirement.
While The Centers for Medicare and Medicaid Services (CMS) considers 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 Wisconsin Public Employers 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 in the Frequently Asked Questions for additional information. Also see the Navitus plan and Navitus MedicareRx description pages in the health plan descriptions section.
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.
If you return to work for a non-WRS participating employer after retirement, your WRS annuity and health benefits will not be affected.
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 an ETF health plan. Check with your employer to make sure you have other health insurance coverage available before you elect WRS participation.
You may also waive or terminate enrollment under Medicare until the first Medicare enrollment period after active WRS employment ceases. Your premium rates, while covered through active employment, will be the active employee contribution rates for your plan, not the Medicare rates.
When you subsequently terminate employment and resume your annuity, your eligibility for Wisconsin Public Employers Group Health Insurance Program coverage is once again dependent on you meeting the requirements for newly retired employees (that is, you must be insured under the Wisconsin Public Employers Group Health Insurance Program, and you must apply for an immediate annuity from the WRS).
Individual coverage covers only you. Family coverage covers those described below. All eligible, listed dependents are covered under a family contract. A subscriber cannot choose to exclude any other eligible dependent from family coverage except as described in the question: When does health coverage terminate for my dependents?
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.
Your employer may determine whether married employees or domestic partners may each elect single or family coverage or if they are eligible only for family coverage through one of the spouses or domestic partners.
Note: If you are an annuitant and cancel your health insurance coverage, you will not be able to re-enroll in this program.
Some things to note:
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. (Note: WPE annuitants who terminate their coverage may not re-enroll).
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 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 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 plan's decision, you must first complete the plan's grievance procedure. If the plan continues to deny disabled dependent status for your child, you may appeal the 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.
Coverage for dependent children who are not physically or mentally disabled terminates on the earliest of the following dates:
You may 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.
See Continuation of Health Coverage for information on continuing coverage after eligibility terminates.
Family Status Changes
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.
You have the responsibility to inform your employer (ETF for annuitants and continuants) of any dependents losing eligibility for coverage under the Wisconsin Public Employers 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.
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 Guide and Question: What if my spouse/domestic partner and I work for the same employer?)
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 effective with the new plan on the first day of the month on or following receipt of the application.
If you were enrolled in family coverage before your domestic partnership, you need to complete an 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 if my spouse/domestic partner and I work for the same employer?)
Birth/Adoption/Legal Guardianship/Dependent Becoming Eligible
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 application.
Single Mother or Father Establishing Paternity
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 the 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 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
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 employees or annuitants, and each party is eligible for this health insurance in his or her own right and is insured under this program at the time of the divorce, each retains the right to continue this health insurance coverage, regardless of the divorce (unless the employer withdraws from this program).
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 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 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: If you fail to enroll within 30 days of the date of divorce, you have no enrollment or continuation rights. (See Question: Are there other enrollment opportunities available to me after my initial one expires?)
Termination of a Domestic Partnership
When both parties in the domestic partnership are employees or annuitants, and each party is eligible for this health insurance in his or her own right and is insured under this program at the time of the termination, each retains the right to continue this health insurance coverage (unless the employer withdraws from this program). Upon 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 plan unless he or she moves out of the service area (e.g., county). The application must be received by his or her benefits/payroll/personnel office within 30 days of ETF receiving 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 the Uniform Benefits (your 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: If you fail to enroll within 30 days of the date of divorce, you have no enrollment or continuation rights. (See Question: Are there other enrollment opportunities available to me after my initial one expires?)
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 coverage will terminate on the last day of the month in which their written request is received by ETF.
If the surviving dependent(s) terminates coverage for any reason he or she may not re-enroll later.
Note: The survivors may not add persons to the policy who were not insured at the time of death.
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.
If your employee premiums are deducted on a pre-tax basis under Internal Revenue Code Section 125, 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. However, you must check this with your employer or your Section 125 plan administrator. 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 premiums are deducted on a post-tax basis, 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.
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 the Frequently Asked 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?" in this FAQ.
Health Plan Information
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 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?):
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 plan you select. If you lose these cards or need additional cards for other family members, you may request them directly from the plan. IYC Health Plans (health plans that offer Uniform Benefits for medical coverage) are not required to provide you with a certificate describing your benefits. The It's Your Choice Uniform Benefits Certificate of Coverage online 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 IYC Health Plans 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 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 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 plan. Outpatient mental health services and treatment of alcohol or drug abuse may be covered. Refer to the It's Your Choice Uniform Benefits. 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. 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 It's Your Choice Uniform Benefits Certificate of Coverage online.) 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.
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. 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.
Most IYC Local Health HMO plans will pay nothing when non-emergency treatment is provided by physicians outside of the plan unless there is an authorized referral. Contact the plans directly regarding their policies on referrals.
For emergency or urgent care, 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 plan may not pay the entire bill and try to negotiate lower fees. However, ultimately the plan must hold you harmless from collection efforts by the provider. (See the Uniform Benefits definition of Emergency Care in the Certificate of Coverage online.)
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 health plan descriptions 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 Local Plan. Confirm this with the IYC Local Plan's provider directory. Even though your current physician may join an IYC Local Plan, he or she may not be available as your primary physician just because you join that IYC Local Plan.
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 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 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 plan's network.
Your provider leaving the plan does not give you an opportunity to change 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.
Premium Contribution Tiering
Employers determine the amount they will contribute toward the premium under one of the two methods described here.
Note: Your employer may contribute any amount toward the premium for retired employees who continue group coverage.
No; all IYC Health Plans 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:
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 and IYC Medicare Plus will continue to offer benefits
that differ from Uniform Benefits for medical, but will be newly eligible for the Uniform Dental Benefit, if offered by the employer.
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.
Active Employees: Premiums are paid in advance. Therefore, initial deductions from your salary probably will occur about one month or more before coverage begins. If the initial deduction cannot occur that far in advance, then double deductions may be required initially so as to make premium payments current.
Retired Employees: 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). The employer may, at its option, pay a portion or all of the premium. If you are paying your entire premium, it will be deducted from your monthly annuity. If the annuity is not sufficient to allow a premium deduction, you will be billed directly from your health plan. Warning: Your coverage will be cancelled if you fail to pay your premium in a timely manner.
If you are retired and have life insurance coverage through the Wisconsin Public Employers Group Life Insurance Program, you may be eligible to convert the present value of your life insurance to pay health insurance premiums. You must be at least age 67, or age 66 if your employer provides post-retirement life insurance coverage at the 50% level. 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.
Here is a chart depicting how these changes affect WPE members, by Program Option:
No, but your employer may offer a similar program.
Each local government employer will choose whether to offer the Uniform Dental Benefit to employees. The benefits are the same for state and local employees who participate in the Uniform Dental Benefit plan. Please check with your employer to determine whether the Uniform Dental Benefit is available to you.
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.
These program options mirror the state employee plan designs. Please refer to the Important Changes tab above, to see What is Changing for 2016.
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.
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 WPE (local government) program has 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 (local government) 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 Group Health Insurance Program, this only applies to Level 3 prescription drugs.
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, it typically negotiates discounts and rebates with drug manufacturers, contracts with pharmacies and develops and maintains the drug formulary. The Wisconsin Public Employers Group Health Insurance Program's PBM uses a fully transparent, full pass-through business model which means they negotiate rebates and discounts on behalf of the Wisconsin Public Employers Group Health Insurance Program and pass the savings directly back to the program.
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 endolled 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 copaymentor 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 3coinsurance 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:
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.
For information about Medicare benefits, eligibility and how to enroll, contact your local Social Security Administration office or call 1-800-772-1213. In addition, the State Health Insurance Assistance Program (SHIP) has counselors in every state and several territories who are available to provide free one-on-one help with your Medicare questions or problems. The Wisconsin SHIP can be reached at 1-800-242-1060. Additional information and assistance can be found at http://www.dhs.wisconsin.gov/benefit-specialists/ship.htm . A list of SHIP programs outside of Wisconsin can be found at www.medicare.gov/contacts/staticpages/ships.aspx.
Because all health plans that participate in the Wisconsin Public Employers Group Health Insurance Program have coverage options that are coordinated with Medicare, you will remain covered by the health plan you have selected even after you enroll in Medicare. Premium rates will decrease if Medicare covers you or a dependent, and you are retired. Medical and prescription drug coverage under the IYC Local Plans (health plans that offer Uniform Benefits for medical coverage) does not change. The health plan will simply not duplicate benefits paid by Medicare. However, if enrolled in the IYC Access Health Plan or SMP, your coverage will change to IYC Medicare Plus when you enroll in Medicare Parts A and B.
If you are not enrolled for all available portions of Medicare (A, B and D) upon retirement, you will be liable for the portion of your claims that Medicare would have paid beginning on the date Medicare coverage would have become effective.
The following questions and answers provide additional information about Medicare as it applies to the Wisconsin Public Employers Group Health Insurance Program.
Important: When you receive your Medicare card, please send a photocopy to ETF immediately or your Medicare coordinated coverage may be delayed.
You and your dependents are not required to enroll in Medicare until you, as 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 Wisconsin Public Employers (WPE) group health insurance program. Additional information about all parts of Medicare can be found in the following questions and answers.
If you become eligible for Medicare, your eligibility for COBRA coverage
ends. Contact ETF for
Medicare Part A
Medicare Part B
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 employed by an employer that does not participate in the WPE group health insurance program, and has coverage as an active employee under that employer's 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 Wisconsin Public Employers 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
Before Navitus can report your enrollment in 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 from the ETF website. If you are retired and cover a Medicare-eligible spouse or disabled dependent on your health plan, please notify ETF and provide your 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 Wisconsin Public Employers (WPE) group health insurance program. If you choose to enroll in a different Medicare Part D plan, your health insurance premium for the WPE plan does not change, but your supplemental, wrap-around pharmacy coverage will be secondary to the other Medicare Part D plan. For more information, 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?
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 Local Medicare Plans (health plans that offer Uniform Benefits
for medical coverage):
IYC Medicare Advantage:
You must be enrolled in Medicare Parts A and B to be eligible for the IYC Local 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 IYC Local 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:
Pharmacy Benefit Manager:
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 the WPE group health insurance program pharmacy benefits, will be considered secondary. You should be prepared to file the secondary claims manually through Navitus. Contact Navitus for more information on filing manual claims. Refer to the Medicare Part D Information section of the FAQs for more details.
Medicare Part B pharmacy claims are covered under the supplemental
wrap benefit. For specific information on Medicare Part B pharmacy
coverage and Part B claims processing, see the plan description
page for Navitus™ Health Solutions.
Since all health plans have coverage options that are coordinated with Medicare, you will remain covered by the health 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 the IYC Access Health Plan or SMP, your coverage will be changed to IYC Medicare Plus. There are some differences in benefits between these health 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 an alternate plan (health plans that offer Uniform Benefits for medical coverage), 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 health plans are 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 your Wisconsin Public Employers Group Health Insurance Program 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 Wisconsin Public Employers 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 Wisconsin Public Employers Group Health Insurance Program. It is not included in your Wisconsin Public Employers 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 Part D Information
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 underwritten by Dean Health Insurance Inc. This affects Medicare-eligible participants covered under an annuitant contract enrolled in the WPE Group Health Insurance Program. As required by Uniform Benefits, a supplemental wrap benefit is also included to mainly provide full coverage to WPE 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 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.
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 Wisconsin Public Employers Group Health Insurance Program, after you become eligible for Medicare Part D, the following will happen:
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.
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 WPE group health insurance program. There is no partial refund of the WPE group health insurance 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 will be automatically disenrolled from your other plan by CMS.
The prescription drug benefit changes do apply to you.The additional benefits (e.g. advance care planning and habilitative therapy services) do apply to you.
Each employer has the option to offer the Uniform Dental Benefit to employees and annuitants. Please contact your employer to see if you have the Uniform Dental Benefit available to you in 2016.
For participating employers, all employees and annuitants who elect medical coverage will be automatically enrolled in the Uniform Dental Benefit for 2016. Employees and annuitants who do not want this coverage must opt-out if they do not want this coverage. Additionally, members of the IYC Access Health Plan, State Maintenance Plan (SMP), and IYC Medicare Plus are newly eligible for the Uniform Dental Benefit plan in 2016, and will also be automatically enrolled in coverage.
If your employer chooses to offer the Uniform Dental Benefit, all employees and annuitants electing medical coverage will be automatically enrolled in the Uniform Dental Benefit. If you do not want this dental coverage, you must choose to opt-out of the Uniform Dental Benefit plan 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 or call Delta Dental directly at 1-844-337-8383.
For additional information, please view the dental section of the Group Health Insurance Changes for 2016 FAQ.
Contact Delta Dental directly at 844-337-8383 or visit their website at deltadentalwi.com/state-of-wi to view the provider directories. You may use a provider in either the "Delta PPO" or the "Delta Premier" network, which are both considered in-network for this plan.
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 can 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 an online 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 a HRA over the telephone
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 you 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, this FAQ or contact your health plan.
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:
See the Life Change Event Guide for more information.
Note: If your premiums are being deducted post-tax, you may cancel coverage at anytime. If your premiums are being deducted on a pre-tax basis, you may cancel coverage midyear only if you become eligible for and enroll in other group coverage.
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.
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. If you are enrolled in the Uniform Dental Benefit, you will continue accumulating to the same benefit maximums as well.
A subscriber who moves out of a service area (for example, out of the county), either permanently or temporarily for 3 months or more, will be permitted to enroll in the IYC Access Health Plan or an available IYC Local Plan 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.
It is important that you submit your 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. See Question: Are there other enrollment opportunities available to me after my initial one expires?
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.
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, 12 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.
Voluntary cancellation (or switching from family to single coverage which is deemed voluntary cancellation for all insured dependents) requires written notification to the employer (annuitants should contact ETF) denoting a cancellation of coverage.
If your premiums are being deducted on a pre-tax basis under Internal Revenue Code Section 125, you may cancel coverage only if:
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 an employee of a participating local employer) 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.
Once an annuitant's coverage is cancelled, neither you nor your surviving dependents may re-enroll in this program. Another insurance opportunity may exist under the Local Annuitant Health Program (LAHP). Contact ETF for more information.
Your coverage can only be terminated because:
Contact your benefits/payroll/personnel office or ETF for the date coverage will end.
When your employer's participation ends in this program, coverage will cease for all participants. This includes retirees, survivors and those who have continuation coverage. If the employer obtains group health insurance from another carrier, ask the employer if the new carrier will provide coverage for retirees, survivors and continuants.
When the employer terminates participation, you will not be eligible for continuation or conversion of health coverage.
Your COBRA continuation rights are described in the State and Federal Notifications. Both you and your dependents should take the time to read that section carefully. This section provides additional information about continuation coverage.
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.
A second qualifying event while on continuation will not serve to extend your period of continuation. Coverage will be limited to the original time period. At the end of the continuation period you will be allowed to enroll in an individual conversion through the health plan.
Employees need to report this change to the benefits/payroll/personnel
office within 60 days of the dependent losing his/her eligibility
to ensure COBRA coverage is offered. Annuitants and continuants
must contact ETF. 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:
It 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.
To cancel continuation coverage, notify ETF in writing. Include your name, 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 608-266-5020 or go online to obtain a 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 Wisconsin Public Employers 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 Wisconsin Public Employers 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 Local Plan 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
This page was last modified on: 3/11/2016 11:35:32 AM