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


Local Deductible Plan
Insurance for Employees
and Retirees
(PO4, PO14)


Comparison of Medical Benefits 2017

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

Local Program Options 4 and 14

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 Deductible

IYC Local Access Health Plan

In-Network Out-of-Network

Annual Medical Deductible

$500 individual / $1,000 family

When an individual within a family plan meets the $500 deductible, benefits apply as described below

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

Medical deductible does not apply to prescription drugs

$500 individual / $1,000 family

When an individual within a family plan meets the $500 deductible, benefits apply as described below

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

Medical deductible does not apply to prescription drugs

$1,000 individual / $2,000 family

When an individual within a family plan meets the $1,000 deductible, benefits apply as described below

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

Medical deductible does not apply to prescription drugs

Annual Medical Coinsurance

After deductible: Plan pays 100% for most services, except for durable medical equipment, certain hearing aids and cochlear implants. See below.

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

Applies to medical services

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

Applies to medical services

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

$2,000 individual / $4,000 family (includes deductible)

$4,000 individual $8,000 family (includes deductible)

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 70%, you pay 30% coinsurance up to OOPL

Illness/injury related services

After deductible: Plan pays 100%

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

After deductible: Plan pays 70%, you pay 30% coinsurance up 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, after copayment subject to deductible and 20% coinsurance up to OOPL

You pay $75 copayment, after copayment in-network deductible and 30% coinsurance up to OOPL

Vision Exam

Routine exam: After deductible plan pays 100% for one routine eye exam per year; exam for children is not subject to the deductible and plan pays 100%

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

Routine exam: Plan pays 100% for children under 5 years of age only

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

Routine exam: No benefit

Illness or injury: After deductible plan pays 70% for adults or children; you pay 30% coinsurance up to OOPL

Hearing Exam

After deductible: Plan pays 100%

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

After deductible: Plan pays 70% only when exam is for illness or disease; you pay 30% coinsurance up to OOPL

Hearing Aid
(per ear)

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

Children: After deductible, plan pays 100%

Every 3 years:
Adults: No benefit

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

Every 3 years:
Adults: No benefit

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

Cochlear Implants

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

Dependents under age 18: Plan pays 100% for all services

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

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

Durable Medical Equipment

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

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

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

Physical/Speech/Occupational Therapy

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 up to OOPL 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 70%, you pay 30% coinsurance up 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)

After deductible: Plan pays 100% for 120 days per benefit period

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

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

Home Health
(Non-custodial)

After deductible: Plan pays 100% for 50 visits per year. Plan may approve an additional 50 visits

After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL for 50 visits per plan year. Plan may approve an additional 50 visits

After deductible: Plan pays 70%, you pay 30% 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: After deductible: plan pays 100%

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

Outpatient, inpatient and covered transitional services: After deductible: Plan pays 70%, you pay 30% member cost up to OOPL

Transplants

After deductible: plan pays 100%: Bone marrow, parathyroid, musculoskeletal, corneal, kidney, heart, liver, kidney with pancreas, heart with lung, and lung

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

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

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL: Surgical treatment requires precertification

Oral Surgery

After deductible: plan pays 100% for 11 procedures

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

After deductible: Plan pays 70%, you pay 30% 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 2:41:13 PM