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


Local High Deductible Health Plan
Insurance for Employees
and Retirees
(PO7, PO17)


Comparison of Medical Benefits 2017

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

Local Program Options 7 and 17

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 HDHP

IYC Local Access HDHP

In-Network Out-of-Network

Annual Medical Deductible
(includes medical and 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

$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 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: 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: 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 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: 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: You pay 30% coinsurance up to OOPL

Annual Medical Coinsurance

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 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)
(includes medical and prescription drugs)

$2,500 individual / $5,000 family

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

$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

Subject to the deductible and coinsurance

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

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

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 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 OOPL

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

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

Transplants

You pay the full allowed amount of services until 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

You pay the full allowed amount of services until 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 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: after deductible, you pay $15 copayment for primary care office visits. 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

All services apply  to the annual OOPL

Outpatient services: after deductible, you pay $15 copayment for primary care office visits. 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

All services apply  to the annual OOPL

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

Hearing aid (per ear)

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

After deductible: Every three years:

Adults, you pay 20% coinsurance up to plan paid $1,000 (not to OOPL); dependents younger than age 18, 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:

After deductible: For dependents younger than age 18 , 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:

After deductible:For dependents younger than age 18 , plan pays 70%, you pay 30% coinsurance up to OOPL

Cochlear Implants

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

Adults, after deductible, plan pays 80%, you pay 20% coinsurance up to OOPL for device, surgery for implantation, follow-up sessions;

For hospital charge for surgery:

Adults, after deductible 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.

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

Dependents under age 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 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)

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 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)

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

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 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: 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

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

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 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

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

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

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

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: 10/3/2016 2:41:33 PM