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


Local Health Plan
Insurance for Employees
and Retirees
(PO6, PO16)


Comparison of Medical Benefits 2017

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

Local Program Options 6 and 16

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 Health Plan

IYC Local Access Health Plan

In-Network 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 (OOPL)

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

$250 individual / $500 family

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

Deductible applies to annual OOPL

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

$500 individual / $1,000 family

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

Deductible applies to annual OOPL

Medical deductible does not apply to prescription drugs

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 $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

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 $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

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*

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

Annual Medical Out-of-Pocket Limit (OOPL)

$1,250 individual / $2,500 family

$1,250 individual / $2,500 family

$2,000 individual / $4,000 family

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

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

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

Emergency Room Copayment (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 $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

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

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 up  to OOPL

Includes bone marrow, musculoskeletal, corneal, and kidney

Mental Health/Alcohol & Drug Abuse

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

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

Outpatient services: primary care office visit copayment ($15). Additional services such as lab work, assessments, etc., are subject to the 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

Hearing aid (per ear)

Every three years:

Adults, after deductible, plan pays 80%, you pay 20% coinsurance up to plan paid $1,000 (not to OOPL); dependents younger than age 18, after deductible, plan pays 90%, you pay 10% coinsurance up to OOPL

Every three years:

Adults, no benefit. For dependents younger than age 18, after deductible plan pays 90%, you pay 10% coinsurance up to OOPL

Every three years:

Adults, no benefit. For dependents younger than age 18, after deductible 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 up to OOPL

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

Dependents under age 18: After deductible plan pays 90%, you pay 10% 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

Skilled Nursing Facility (non-custodial care)

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

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

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% 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 $15 copayment per office visit . 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 visits per plan year

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

Durable Medical Equipment

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

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

None

None

Treatment for morbid obesity

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

Oral Surgery

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

*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: 10/3/2016 2:34:07 PM