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Wisconsin Department of Employee Trust Funds header image It's Your Choice 2017 Local Traditional Health Plan Insurance Program
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2017 It's Your Choice - Local Traditional Health Plan Insurance for Employees and Retirees
Wisconsin Department Of Employee Trust Funds It's Your Choice 2017


Local Traditional Plan
Insurance for Employees
and Retirees
(PO2, PO12)


Comparison of Medical Benefits 2017

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

Local Program Options 2 and 12

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

 

IYC Local Traditional

IYC Local Access Health Plan

In-Network Out-of-Network

Annual Medical Deductible

No deductible

$100 individual / $200 family

When an individual within a family plan meets the $100 deductible, coinsurance will apply to covered medical services

Medical deductible does not apply to prescription drugs

$500 individual / $1,000 family

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

Medical deductible does not apply to prescription drugs

Annual Medical Coinsurance

Plan pays 100% for most services, except for durable medical equipment, certain hearing aids and cochlear implants

None

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

Annual Medical Maximum
Out-of-Pocket Limit (OOPL)

Only applies to durable medical equipment (see separate OOPL below), certain hearing aids and cochlear implants
$6,850 individual / $13,700 family for federally required essential health benefits

$6,850 individual / $13,700 family for federally required essential health benefits None

Routine, preventive services as required by federal law

Plan pays 100%

For details, visit
healthcare.gov

Plan pays 100%

For details, visit healthcare.gov

After deductible plan pays 80%, you pay 20% coinsurance to OOPL

Illness/injury related services

Plan pays 100% After deductible plan pays 100% After deductible: Plan pays 80%, you pay 20% coinsurance to OOPL

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

You pay $60 copayment per visit You pay $75 copayment, the deductible applies to services after the copayment You pay $75 copayment, the in-network deductible applies to services after the copayment

Vision Exam

Plan pays 100% for one routine exam per year; plan pays 100% for exams related to illness or injury

Routine exam: Plan pays 100% for children only

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

Routine exam: No benefit

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

Hearing Exam

Plan pays 100% After deductible: Plan pays 100% only when exam is for illness or disease After deductible: Plan pays 80% only when exam is for illness or disease; you pay 20% coinsurance to OOPL

Hearing Aid
(per ear)

Every 3 years:
Adults: Plan pays 80% up to $1,000 benefit limit, you pay 20% coinsurance for the first $1,000 and the full cost after

Children: Plan pays 100%

Every 3 years:
Adults: No benefit

Children: After deductible, plan pays 100%

Every 3 years:
Adults: No benefit

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

Cochlear Implants

Adults: Plan pays 80%, you pay 20% coinsurance for device, surgery, follow-up sessions (not to OOPL); plan pays 100% for hospital charge for surgery

Dependents under 18, plan pays 100% for all services

Dependents under 18, After deductible plan pays 100% for device, surgery, follow-up sessions

Dependents under 18, After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL for device, surgery, follow-up sessions

Durable Medical Equipment

Plan pays 80%, you pay 20% coinsurance up to $500 OOPL per person After deductible: Plan pays 100% After deductible: Plan pays 80%, you pay 20% coinsurance to OOPL

Physical/Speech/Occupational Therapy

Plan pays 100% for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type per year After deductible: Plan pays 100% for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type per year After deductible: Plan pays 80% you pay 20% coinsurance to OOPL for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type per year

Skilled Nursing Facility
(non-custodial care)

Plan pays 100% for 120 days per benefit period After deductible: Plan pays 100% for 120 days per benefit period After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL for 120 days per benefit period

Home Health
(Non-custodial)

Plan pays 100% for 50 visits per year

Plan may approve an additional 50 visits

After deductible: Plan pays 100% for 50 visits per plan year

Plan may approve an additional 50 visits

After deductible: Plan pays 80% and you pay 20% coinsurance up to OOPL for 50 visits per plan year

Plan may approve an additional 50 visits

Mental Health/Alcohol & Drug Abuse

Outpatient, inpatient and covered transitional services. Plan pays 100%

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

Outpatient, inpatient and covered transitional services. After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL.

Transplants

Plan pays 100%: Includes bone marrow, parathyroid, musculoskeletal, corneal, kidney, heart, liver, kidney with pancreas, heart with lung, and lung

After deductible: plan pays 100%: Includes bone marrow, musculoskeletal, corneal, and kidney

After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL: Includes bone marrow, musculoskeletal, corneal, and kidney

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

Varies by plan

See plan descriptions and contact your plan

WPS Medical Management Program

WPS Medical Management Program

Referrals

In-network varies by plan

See plan descriptions and contact your plan

Out-of-network: Referral is required

Not required

Not required

Treatment for morbid obesity

Excluded

After deductible: Plan pays 100%. Surgical treatment requires precertification

After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL. Surgical treatment requires precertification

Oral Surgery

Plan pays 100% for 11 procedures

After deductible: Plan pays 100% for 23 procedures

After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL for 23 procedures

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

This page was last modified on: 10/3/2016 1:41:04 PM