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Wisconsin Department of Employee Trust Funds header image It's Your Choice 2017 State of Wisconsin Group Health Insurance Program
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2017 It's Your Choice - State of Wisconsin Group Health Insurance for Employees and Retirees

Wisconsin Department Of Employee Trust FundsIt's Your Choice 2017


State of Wisconsin
Group Health Insurance Program
(State Employees, Retirees, Continuants and Graduate Assistants)

Comparison of Medical Benefits 2017

Active State Employees and Retirees without Medicare

 

 

IYC Health Plan

IYC HDHP

IYC Access Health Plan
In-Network

IYC Access Health Plan Out-of-Network

IYC Access HDHP
In-Network

IYC Access HDHP
Out-of-Network

Annual Medical Deductible

$250 individual / $500 family

After an individual within a family plan meets the $250 deductible, benefits apply as described below.

Deductible applies to annual out-of-pocket limit (OOPL)

Medical deductible does not apply to office visit copayments, preventive services* or prescription drugs

$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 OOPL

$250 individual / $500 family

After an individual within a family plan meets the $250 deductible, coinsurance will apply as described
below

Deductible applies to annual OOPL

Medical deductible does not apply to prescription drugs

$500 individual / $1,000 family

After an individual within a family plan meets the $500 deductible, coinsurance will apply as described
below

Deductible applies to annual OOPL

Medical deductible does not apply to prescription drugs

$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 includes prescription drugs and applies to 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.

You pay $15 copayment per visit up to OOPL

Office visit copayments are not subject to the deductible

Additional services such as lab work, X-rays, etc., are subject to the deductible and coinsurance

You pay the full allowed amount of an office visit until deductible is met

After deductible: You pay $15 copayment per office visit up to OOPL

Coinsurance will apply to additional services such as lab work, X-rays, etc.

You pay $15 copayment per visit up to OOPL

Office visit copayments are not subject to the deductible

Additional services such as lab work, X-rays, etc., are subject to the deductible and coinsurance

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

You pay the full allowed amount of an office visit until deductible is met

After deductible: You pay $15 copayment per office visit up to OOPL

Coinsurance will apply to additional services such as lab work, X-rays, etc.

You pay the full allowed amount of an office visit until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

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

You pay $25 copayment per visit up to OOPL

Office visit copayments are not subject to the deductible

Additional services such as lab work, X-rays, etc., are subject to the deductible and coinsurance

You pay the full allowed amount of an office visit until deductible is met

After deductible: You pay $25 copayment per office visit up to OOPL

Coinsurance will apply to additional services such as lab work, X-rays, etc.

You pay $25 copayment per visit up to OOPL

Office visit copayments are not subject to the deductible

Additional services such as lab work, X-rays, etc., are subject to the deductible and coinsurance

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

You pay the full allowed amount of an office visit until deductible is met

After deductible: You pay $25 copayment per office visit up to OOPL

Coinsurance will apply to additional services such as lab work, X-rays, etc.

You pay the full allowed amount of an office visit until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Annual Medical Coinsurance

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Applies to medical services except for office visit or emergency room copayments and preventive services*

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Applies to medical services except for office visit or emergency room copayments and preventive services*

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Applies to medical services except for office visit or emergency room copayments and preventive services*

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Applies to medical services except for emergency room copayments

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Applies to medical services except for office visit or emergency room copayments and preventive services*

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Applies to medical services except for emergency room copayments

Annual Medical Out-of-Pocket Limit (OOPL)

$1,250 individual / $2,500 family

$2,500 individual / $5,000 family

For family coverage, you must meet the full family OOPL before your plan pays 100%

$1,250 individual / $2,500 family $2,000 individual / $4,000 family

$3,500 individual / $6,550 family

For family coverage, you must meet the full family OOPL before your plan pays 100%

$3,800 individual / $7,600 family

For family coverage, you must meet the full family OOPL before your plan pays 100%

Routine, preventive services as required by federal law

Plan pays 100%, not subject to deductible

For details, visit
healthcare.gov

Plan pays 100%, not subject to deductible

For details, visit
healthcare.gov

Plan pays 100%, not subject to deductible

For details, visit
healthcare.gov

Subject to the deductible and coinsurance

Plan pays 100%, not subject to deductible

For details, visit
healthcare.gov

Subject to the deductible and coinsurance

Illness/injury related services beyond the office visit copayment (if applicable)

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Applies to medical services except for office visit or emergency room copayments

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Applies to medical services except for office visit or emergency room copayments

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Applies to medical services except for office visit or emergency room copayments

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Applies to medical services except for emergency room copayments

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Applies to medical services except for office visit or emergency room copayments

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Applies to medical services except for emergency room copayments

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

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

You pay the full allowed amount of services until deductible is met

After deductible: You pay $75 copayment per visit, then coinsurance applies to services beyond the copayment up to the OOPL

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

You pay the full allowed amount of services until deductible is met

After deductible: You pay $75 copayment per visit, then coinsurance applies to services beyond the copayment up to the OOPL

You pay the full allowed amount of services until deductible is met

After deductible: You pay $75 copayment per visit, then in-network coinsurance applies to services beyond the copayment up to the OOPL

Transplants

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Includes bone marrow, parathyroid, musculoskeletal, corneal, kidney, heart, liver, kidney with pancreas, heart with lung, and lung

You pay the full allowed amount of services until the deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Includes bone marrow, parathyroid, musculoskeletal, corneal, kidney, heart, liver, kidney with pancreas, heart with lung, and lung

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Includes bone marrow, musculoskeletal, corneal, and kidney

After deductible: Plan pays 70%, you pay 30% coinsurance cost up to OOPL

Includes bone marrow, musculoskeletal, corneal, and kidney

You pay the full allowed amount of services until the deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Includes bone marrow, musculoskeletal, corneal, and kidney

You pay the full allowed amount of services
until the deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Includes bone marrow, musculoskeletal, corneal, and kidney

Mental Health/Alcohol & Drug Abuse

Outpatient services: You pay $15 primary care office visit copayment. Additional services such as lab work, assessments, etc., are subject to deductible and coinsurance

Inpatient and covered transitional services: after deductible plan pays 90%, you pay 10% coinsurance up to OOPL

Outpatient services: After deductible, you pay $15 primary care office visit copayment. Additional services such as lab
work, assessments, etc., are subject to coinsurance

Inpatient and covered transitional services: after deductible plan pays 90%, you pay 10% coinsurance up to OOPL

Outpatient services: You pay $15 primary care office visit copayment. Additional services such as lab work, assessments, etc., are subject to deductible and coinsurance

Inpatient and covered transitional services: after deductible plan pays 90%, you pay 10% coinsurance up to OOPL

Outpatient, inpatient and covered transitional services: after deductible plan pays 70%, you pay 30% coinsurance up to OOPL

Outpatient services: after deductible, you pay $15 primary care office visit copayment. Additional services such as lab work, assessments, etc., are subject to coinsurance

Inpatient and covered transitional services: after deductible plan pays 90%, you pay 10% coinsurance up to OOPL

Outpatient, inpatient and covered transitional services: after deductible plan pays 70%, you pay 30% coinsurance up to OOPL
Hearing aid
(per ear)

Every three years:

Adults, after deductible you pay 20% up to plan paid $1,000 (not to OOPL); dependents younger than 18 years, after deductible, plan pays 90%, you pay 10% coinsurance up to OOPL

You pay the full allowed amount of services until deductible is met

Every three years:

Adults pay 20% up to plan paid $1,000 (not to OOPL); dependents younger than 18 years, plan pays 90%, you pay 10% coinsurance up to OOPL

Every three years:

For dependents younger than 18 years, after deductible plan pays 90%, you pay 10% coinsurance up to OOPL

Every three years:

For dependents younger than 18 years plan pays 70%, you pay 30% coinsurance up  to OOPL

You pay the full allowed amount of services until deductible is met

Every three years:

For dependents younger than 18 years plan pays 90%, you pay 10% coinsurance up to OOPL

You pay the full allowed amount of services until deductible is met

Every three years:

For dependents younger than 18 years plan pays 70%, you pay 30% coinsurance up to OOPL

Cochlear Implants

Adults: After deductible plan pays 80%, you pay 20% coinsurance for device, surgery for implantation, follow-up sessions (not to OOPL); for hospital charge for surgery, plan pays 90%, you pay 10% coinsurance to OOPL

Dependents (under age 18): After deductible, plan pays 90%, you pay 10% coinsurance up to OOPL for all services

You pay the full allowed amount of services until deductible is met

Adults: After deductible, plan pays 80%, you pay 20% coinsurance to OOPL for device, surgery for implantation, follow-up sessions. For hospital charge for surgery, plan pays 90%, you pay 10% coinsurance to OOPL

Dependents (under age 18): After deductible, plan pays 90%, you pay 10% coinsurance up to OOPL for all services
Dependents under 18: After deductible, plan pays 90%, you pay 10% coinsurance to OOPL for device, surgery, follow-up sessions Dependents under 18: After deductible, plan pays 70%, you pay 30% coinsurance up to OOPL for device, surgery, follow-up sessions

You pay the full allowed amount of services until deductible is met

Dependents under 18, : After deductible, plan pays 90%, you pay 10% coinsurance up to OOPL for device, surgery, follow-up sessions

You pay the full allowed amount of services until deductible is met

Dependents under 18: After deductible, plan pays 70%, you pay 30% coinsurance up to OOPL for device, surgery, follow-up sessions

Skilled Nursing Facility (non-custodial care) After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 120 days per benefit period

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 120 days per benefit period

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 120 days per benefit period After deductible : Plan pays 70%, you pay 30% coinsurance up to OOPL, 120 days per benefit period

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 120 days per benefit period

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL, 120 days per benefit period

Home Health (non-custodial) After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 50 visits per year. Plan may approve an additional 50 visits

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 50 visits per year. Plan may approve an additional 50 visits

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 50 visits per plan year. Plan may approve an additional 50 visits After deductible: Plan pays 70%, you pay 30% coinsuranceup to OOPL, 50 visits per plan year. Plan may approve an additional 50 visits

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 50 visits per plan year. Plan may approve an additional 50 visits

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL, 50 visits per plan year. Plan may approve an additional 50 visits

Physical / Speech / Occupational Therapy

You pay $15 copayment for office visits. Additional services such as lab
work, X-rays, etc. are subject to deductible and coinsurance up to OOPL

50 combined visits per year

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

You pay the full allowed amount of services until deductible is met

After deductible: You pay $15 copayment for office visits. Additional services such as lab work, X-rays, etc. are subject to coinsurance up to OOPL

50 combined visits per year

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

You pay $15 copayment for office visits. Additional services such as lab work, X-rays, etc. are subject to deductible and coinsurance up to OOPL

50 combined visits per year

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

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

50 combined visits per plan year

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

You pay the full allowed amount of services until deductible is met

After deductible: You pay $15 copayment for office visits. Additional services such as lab work, X-rays, etc. are subject to coinsurance up to OOPL

50 combined visits per year

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

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance 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: Plan pays 80%, you pay 20% coinsurance up to OOPL

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Precertification for hospitalizations, high-tech radiology and low back surgery Varies by plan.  See plan descriptions and contact your plan Varies by plan. See plan descriptions and contact your plan WPS Medical Management Program WPS Medical Management Program WPS Medical Management Program WPS Medical Management Program
Referrals

In-network—varies by plan. See plan descriptions and contact your plan

Out-of-network— referral is required

In-network—varies by plan. See plan descriptions and contact your plan

Out-of-network— referral is required
None None None None
Treatment for morbid obesity Excluded Excluded

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Surgical treatment requires precertification

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Surgical treatment requires precertification

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Surgical treatment requires precertification

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Surgical treatment requires precertification

Oral Surgery After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 11 procedures

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 11 procedures

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 23 procedures After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL, 23 procedures

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 23 procedures

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL, 23 procedures

*Routine, preventive services as required by federal law

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: 11/1/2016 2:08:27 PM