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Wisconsin Department of Employee Trust Funds header image It's Your Choice 2018 Local High Deductible Health Plan Insurance Program
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2018 It's Your Choice - Local High Deductible Health Plan Insurance for Employees and Retirees
Wisconsin Department Of Employee Trust Funds It's Your Choice 2018


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


Frequently Asked Questions

Below is detailed information regarding enrollment and plan change opportunities during and beyond the annual It’s Your Choice (IYC) open enrollment period, dependent eligibility, benefits and services, Medicare and termination of coverage.

This information is intended to provide understandable explanations of the Uniform Benefits Certificate of Coverage. In the event of any conflict between the terms of the IYC Health Plans Certificate of Coverage and the information contained in the Frequently Asked Questions section, the terms of the Certificate of Coverage shall control.

Question Topics

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General Information
General Information

Each year ETF and the Group Insurance Board conducts an annual renewal process with health plans. The Board sets the requirements for the program and health plans decide whether they will participate. Some plans chose not to participate in 2018. You may also want to see Frequently Asked Question 6 under the section Enrolling for Coverage that reads: Someone on my health plan is in the middle of medical treatment and we have to change health plans. What do I need to do?

Information about the Wisconsin Public Employers Group Health Insurance Program in this guide applies to the following individuals whose employer has elected this coverage:

  • Active employees participating in the Wisconsin Retirement System.
  • Retired employees who receive an annuity from the WRS (including a lump sum or disability annuity) and who are participants in the employer's group health plan.
  • Insured employees who terminate employment after age 55 (age 50 for protectives) and who have 20 years of creditable service.
  • The surviving insured spouse of an insured employee or an insured retiree.
  • Employees of a Wisconsin Public Employer who do not participate in the WRS and who is a separate Social Security entity.

The Marketplace, established under the Affordable Care Act (ACA), allows individuals to shop for health insurance outside of our program. This may be of interest to retirees who are paying premiums out-of-pocket. Note, premiums for Marketplace insurance cannot be paid out of sick leave credits or with any employer contribution. After evaluating the benefit levels of the Marketplace, it has been found that only platinum level plans are considered comparable coverage for the purposes of escrowing accumulated sick leave conversion credits. Visit healthcare.gov for more information.

Insurance Complaint Process

Each of the plans and the PBM participating in the Wisconsin Public Employers Group Health Insurance Program is required to have a complaint and grievance resolution procedure in place to help resolve participants' problems. Your plan and the PBM have information on how to initiate this process. You must exhaust all of your appeal rights through the plan or PBM first in order to pursue review through an External Review/Independent Review Organization (IRO) or through ETF and the Group Insurance Board. If the plan upholds its denial, it will state in its final decision letter your options if you wish to proceed further.

Depending on the nature of your complaint, you may be given rights to request an external or independent review through an outside organization. This option becomes available when a plan or PBM has denied services as either not medically necessary or experimental, or due to a preexisting condition exclusion denial or rescission of coverage. Note: If you choose to have an independent review organization (IRO) review the plan or PBM's decision, that decision is binding on both you and your plan or PBM except for any decision regarding a preexisting condition exclusion denial or the rescission of coverage. Apart from these two exceptions, you have no further rights to a review through the ETF or the courts once the IRO decision is rendered.

As a member of the Wisconsin Public Employers Group Health Insurance Program, you have the right to request an administrative review through ETF if your health plan or PBM has rendered a decision on your grievance and it is not eligible for IRO review as described above. To initiate an ETF review, you may call or send a letter to ETF and request an ETF Insurance Complaint (ET-2405) form. Complete the complaint form and attach all pertinent documentation, including the plan's response to your grievance.

Please note that ETF's review will not be initiated until you have completed the grievance process available to you through the plan or PBM. After your complaint is received, it will be acknowledged and information may be obtained from the plan or PBM. An ETF ombudsperson will review and investigate your complaint and attempt to resolve your dispute with your plan or PBM. If the ombudsperson is unable to resolve your complaint to your satisfaction, you will be notified of additional administrative review rights available through ETF.

Tax Implications

Adult Children: The Affordable Care Act (ACA) and 2011 Wisconsin Act 49 eliminated tax liability for the fair market value of health coverage for these dependents through the month in which they turn age 26, if eligible.

If the tax dependent status of your dependent over age 26 changes, please notify your employer (or for retirees and continuants, ETF).

No. Note, program benefits meet the minimum value standard for minimum essential health coverage under the ACA.

This opt-out incentive is available only to eligible State of Wisconsin employees. However, WPE employers may choose to offer a similar program.

Enrolling For Coverage
Selecting a Health Plan

No, family members are limited to the plan selected by the subscriber.

No. If you elect family coverage for medical, you may only choose family coverage or choose to decline the Uniform Dental Benefit.

Similarly, if you elect individual coverage for medical, you may only choose individual coverage or choose to decline the Uniform Dental Benefit.

This can be a concern for members who travel and those with covered dependents living elsewhere, such as a college student living away from home. Consider the following when selecting a health plan:

If you are covered through an IYC Local Plan HMO, you are required to obtain allowable care only from providers in the IYC Local Plan HMO’s network. IYC Local Plan HMOs will cover emergency care outside of their service areas, but you must get any follow-up care to the emergency from providers in the IYC Local Plan HMO’s network. Do not expect to join an IYC Local Plan HMO and get a referral to a non-HMO physician. An IYC Local Plan HMO generally refers outside its network only if it is unable to provide needed care within the HMO.

If you are covered through a Preferred Provider Organization (PPO) such as WEA Trust or the IYC Access Plan, you have the flexibility to seek care outside a particular service area. However, out-of-network care is subject to higher deductible and coinsurance amounts.

Retirees only: If you or your dependents are covered through the IYC Medicare Plus plan, you have the freedom of choice to see any provider Medicare Assignment. For more information see: https://www.medicare.gov/your-medicare-costs/part-a-costs/assignment/costs-and-assignment.html.

Contact the plan directly or follow the instructions found through the Available Plans page, by clicking on the health plan name. ETF and your benefits/payroll/personnel office do not have this information.

  • Determine which plans have providers in your area.
  • Contact the health plans directly for information regarding available physicians, medical facilities and services.
  • Review the health plan rates, report card information and the Available Plans pages.

If you or someone in your family is in the middle of medical treatment when you need to change health plans or has complex healthcare needs, you should keep a few things in mind when you make your health plan choice. Check the provider directories of the health plans you are considering, and try to find one with your doctor in network.

Next, contact the plan you have selected and ask what their process is for transitioning your care. They may ask you to submit a form or to speak with someone in their care management team.

New Employee Enrollment

If eligible, you may enroll for individual or family coverage in any of the available health plans without restriction or waiting periods for preexisting medical conditions, provided you file an electronic or paper health application with your benefits/payroll/personnel office within the required enrollment period stated below:

  1. Within 30 days of your date of hire in an eligible position. Coverage will be effective the first day of the month on or following your hire date. You will have to pay the entire premium prior to becoming eligible for the employer share of the contribution. Check with your benefits person to see when your employer contribution begins. Or,
  2. Within 30 days prior to the date that the employer contributes to the premium, with coverage becoming effective when you become eligible for the employer contribution.
  3. You may also enroll during the annual It's Your Choice open enrollment period for coverage to be effective January 1 of the following year.

There are no interim effective dates except as required by law. However, you may enroll for individual coverage within 30 days of your date of hire and change to family coverage if your electronic or paper application is received prior to the date the employer contributions begin.

If you cancel your policy prior to the date that the employer contribution starts, you may re-enroll in health insurance with the new coverage becoming effective on the first day of the month that employer contribution begins.

You cannot assume that the month when your first payroll deduction occurs is the month when your coverage begins. For further information on deductions, coverage and effective dates, contact your benefits/payroll/personnel office.

Important Information for Less Than Half-Time Employees:

The initial enrollment opportunity for most employees begins with their participation in the Wisconsin Retirement System. However, if you are a less than half-time employee, you have another enrollment period if:

  1. There has been a 30-day termination of employment break; or
  2. Your hours of employment increase due to a change in your appointment and you qualify for a higher share of employer contribution toward health insurance premiums; or
  3. You are appointed to a permanent position and now qualify for the full share of employer contribution.

If you apply for coverage within 30 days of one of these events, coverage will be effective on the later of the first of the month following the your new hire date, or the effective date of the increase in the employer contribution. Retroactive effective dates are not allowed. This does not provide an opportunity to change from individual to family coverage.

You may also enroll during the annual It's Your Choice open enrollment period for coverage to be effective January 1 of the following year.

Other Enrollment Opportunities

You may be able to get health insurance coverage if you are otherwise eligible under specific circumstances as described below:

  • If you are an active employee and you and/or your dependent(s) are not insured under the Wisconsin Public Employers Group Health Insurance Program because of being insured under a group health insurance plan elsewhere, you may take advantage of a special 30-day enrollment period to become insured in this program if:
  1. Your eligibility for that other coverage is lost involuntarily, or the employer's premium contribution for the other plan ends, or
  2. You and/or your dependents lose medical coverage:
    • Under medical assistance (Medicaid); or
    • Upon return from active military service with the armed forces. Employees must return to employment within 180 days of release from active duty. You are entitled to enroll regardless of the coverage in effect. Coverage is effective on the date of your re-employment, or
    • As a citizen of a country with national health care coverage comparable to the IYC Access Health Plan.

The enrollment period begins on the date the other group health insurance coverage terminates because of loss of eligibility (for example, termination of employment, divorce, etc., but not voluntary cancellation of coverage) or the employer's premium contribution ends.

  • If you are currently enrolled in the Wisconsin Public Employers Group Health Insurance Program with individual coverage, because your dependents are insured under a group health insurance plan elsewhere, and eligibility for that coverage is lost or the employer's premium contribution for the other plan ends, you may take advantage of a special 30-day enrollment period to change from individual to family coverage. Coverage will be effective on the date the other coverage or the employer's premium contribution ends.
  • If you are currently enrolled in the Wisconsin Public Employers Group Health Insurance Program with family coverage, you may request to provide coverage for your eligible adult child who is not currently insured. You do this during the It's Your Choice open enrollment period. Coverage for your child will be effective the following January 1.
  • If you are not insured under the Wisconsin Public Employers Group Health Insurance Program and have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may enroll if coverage is elected within 30 days of marriage or 60 days of the other events. Coverage is effective on the date of marriage, birth, adoption or placement for adoption.
  • If you and/or your dependents lose medical coverage under the Children's Health Insurance Program (CHIP) or become eligible to participate in a premium assistance program, you will have an opportunity to enroll in the Wisconsin Public Employers Group Health Insurance Program without waiting periods for preexisting conditions by filing an application either electronically or via paper within 60 days of the loss of eligibility or the date you become eligible for premium assistance and by providing evidence satisfactory to ETF.
  • If you do not enroll during a designated enrollment period, you may enroll for health insurance coverage, if you are otherwise eligible, during the annual It's Your Choice open enrollment period.
Open Enrollment

The It's Your Choice open enrollment period is the annual opportunity for eligible employees to select one of the many health plans offered by the Wisconsin Public Employers Group Health Insurance Program. The following list contains some of the most commonly asked questions about the enrollment period. You can also find information about key terms in the definitions section.

The It’s Your Choice open enrollment period is an opportunity to change plans, change from family to individual coverage, enroll if you had previously deferred coverage, cancel your coverage or cancel the coverage for your adult dependent child. It is offered only to employees, surviving spouses and dependents and currently insured retirees and continuants who are eligible under the Wisconsin Public Employers Group Health Insurance Program. Changes made become effective January 1 of the following year.

Yes, coverage will be effective January 1 of the following year for all eligible dependents.

Making Changes During It's Your Choice Open Enrollment

If you decide to change to a different plan, you are encouraged to make changes online using the myETF Benefits website, or you may submit a paper application using the following instructions:
Active employees** may download a paper application (ET-2301) or receive paper applications from your benefits/payroll/personnel office to complete and return to that office. Applications received after the deadline will not be accepted.

Note: If you plan to stay with your current plan for next year and you are not changing your coverage, you do not need to take any action.

Your changes will not be stored unless you click on the Submit button. You will need to log back in and make the changes again. To view what you submitted, click the myRequests button on the bottom of the myInfo page.

It’s Your Choice coverage changes are effective January 1 of the following year.

You may submit or make changes anytime during the It’s Your Choice open enrollment period, either online using the myETF Benefits website or by filling out a paper application. After that time, you may rescind, that is, withdraw your application (and keep your current coverage) by following these instructions before December 31:

  • Active employees should inform their benefits/payroll/personnel office in writing; or
  • insured retirees and continuants should notify ETF in writing.

Other rules apply when canceling coverage. For more information, see the Cancellation or Termination of Coverage section.

During the annual open enrollment period, you can add or drop coverage for yourself and/or your adult dependent children or do a spouse to spouse transfer of your health insurance coverage.

Changes in Employment Status
Employees

Layoff/Leave of Absence
Continuation of Coverage: Coverage may be continued for up to three years while you remain in employee status but receive no salary (limited to layoff or approved leave of absence). Arrangements for premium payment must be made with your personnel or payroll office prior to the time the layoff/leave of absence begins. A leave of absence is not considered ended until you have terminated employment or have resumed employment for at least 50% of what is considered your normal work time for that employer for 30 consecutive calendar days. If coverage is not continued during layoff/leave of absence, there are no continuation rights if employment terminates.

Reinstatement of Coverage: If your health coverage lapses during your leave or layoff due to non-payment of premiums, you must submit a new application either electronically or via paper within 30 days of returning to payroll to reinstate prospectively the lapsed coverage. Coverage will be effective the first of the month after the application is received by your payroll office. If an It's Your Choice open enrollment period has occurred while you were on leave, you will be offered an enrollment opportunity upon your return. (See Question: Are there other enrollment opportunities available to me after my initial one expires?)

Lapsed coverage can also be reinstated for an employee who has been on a leave of absence, who is entitled to and applies for an immediate annuity. Coverage shall be effective the first day of the calendar month that occurs on or after the date the annuity application is approved by ETF, provided an application for health insurance has been received by that date either electronically or via paper.

If you occupy a seasonal or teaching position and do not receive pay between the end of one term of service and the beginning of another, your coverage may continue if you authorize a payroll deduction before your earnings are interrupted or make other provisions to pay premiums in advance.

Termination of Employment
Coverage will end on the last day for which premiums are paid. (See Continuation of Health Coverage)

Appealing a Discharge
Coverage may be continued if you have been terminated from employment and are appealing discharge. The first premium payment and the appeal must both be filed within 30 days of discharge. Premium payments must be made through your employer and be received at least 30 days prior to the end of the period for which premiums were previously paid. You must pay the gross amount of premium due until the appeal is resolved. If the appeal is resolved in your favor, the amount normally considered the employer contribution will be refunded to you.

Retirement
If your employer offers post-retirement health insurance payments and you are an employee who deferred coverage, you may enroll for coverage in the IYC Access Health Plan immediately prior to retirement in order to use post-retirement employer premium contribution.

If you are covered when you retire, the health benefit plan will automatically continue if your retirement annuity from the Wisconsin Retirement System begins within 30 days after employment ends. If you are eligible for Medicare, effective dates must be provided before coverage continues. (Those eligible for Medicare and enrolled in the IYC Access Health Plan or SMP will be switched to IYC Medicare Plus.) You must fill out the employer verification form and return it with your retirement application.

Note: If you are eligible for Medicare, you must be enrolled in the hospital (Part A), medical (Part B) and prescription drug (Part D) portions of Medicare at the time of your retirement.

Medicare Part D
While The Centers for Medicare and Medicaid Services (CMS) considers Part D voluntary, Medicare enrolled retirees will be automatically enrolled in the Navitus MedicareRx (PDP) plan, which is underwritten by Dean Health Insurance Inc., a federally-qualified Medicare-contracting prescription drug plan. This is Medicare Part D coverage through an Employer Group Waiver Plan (EGWP) administered by Navitus" Health Solutions, the Wisconsin Public Employers Group Health Insurance Program's pharmacy benefit manager. This replaces the commercial creditable coverage provided by Navitus prior to the retiree being enrolled in Medicare. Supplemental wrap coverage is also included to ensure your prescription drugs are covered when you reach the Medicare Part D coverage gap, commonly referred to as the "donut hole." Please see the Medicare Information section in this Frequently Asked Questions for additional information. Also see the Navitus plan and Navitus MedicareRx description pages in the health plan descriptions section.

If you do not enroll for all available portions of Medicare (A, B and D) upon retirement, you may be liable for the portion of your claims that Medicare would have paid on the date Medicare coverage would have become effective. (See the Medicare Information provided later in this section.)

Premium rates for retired employees are the same as for the active employees (except that your premium will decrease when you or a dependent becomes covered by Medicare). The employer may, at its option, pay all or a portion of the premium. If any portion of the premium is employer paid, you must remit your portion of the premium directly to the former employer. If/when your employer does not pay any portion of the premium, the premium will be deducted from your monthly annuity. If the annuity is not sufficient to allow a premium deduction, you will be billed directly.

Re-Employed Annuitants

If you return to work for a non-WRS participating employer after retirement, your WRS annuity and health benefits will not be affected.

If you return to work for a WRS-participating employer, you may be eligible to once again become an active WRS employee. If you make this election and become an active WRS employee, your annuity will be suspended and you will no longer be eligible for health insurance as a retiree/annuitant. You will be eligible for health insurance as an active WRS employee through your WRS-participating employer if the employer is participating in an ETF health plan. Check with your employer to make sure you have other health insurance coverage available before you elect WRS participation.

You may also waive or terminate enrollment under Medicare until the first Medicare enrollment period after active WRS employment ceases. Your premium rates, while covered through active employment, will be the active employee contribution rates for your plan, not the Medicare rates.

When you subsequently terminate employment and resume your annuity, your eligibility for Wisconsin Public Employers Group Health Insurance Program coverage is once again dependent on you meeting the requirements for newly retired employees (that is, you must be insured under the Wisconsin Public Employers Group Health Insurance Program, and you must apply for an immediate annuity from the WRS).

Dependent Information

Individual coverage covers only you. Family coverage covers those described below. All eligible, listed dependents are covered under a family contract. A subscriber cannot choose to exclude any other eligible dependent from family coverage except as described in the question: When does health coverage terminate for my dependents?

Dependent Eligibility
  • Your spouse.
  • Your children who include:
    1. Your natural children.
    2. Stepchildren.
    3. Adopted children and pre-adoption placements. Coverage will be effective on the date that a court makes a final order granting adoption by the subscriber or on the date the child is placed in the custody of the subscriber, whichever occurs first. These dates are defined by Wis. Stat. § 632.896. If the adoption of a child is not finalized, the insurer may terminate coverage of the child when the adoptive placement ends.
    4. Legal wards that become your permanent ward before age 19. Coverage will be effective on the date that a court awards permanent guardianship to you (the subscriber or your spouse).

    Note: Dependents and subscribers may only be covered once under both the State of Wisconsin Group Health Insurance Program and the Wisconsin Public Employers Group Insurance Program. In the event it is determined that a dependent is covered by two separate subscribers, the subscribers will be notified and will have 30 days to determine which subscriber will remove coverage of the dependent and submit an application to remove the dependent. If the dependent(s) is to be newly covered by a subscriber that has individual coverage, the contract may be converted to a family contract. The effective date will be the first of the month following receipt of the application. The health plan(s) will be notified.

    Children may be covered until the end of the month in which they turn age 26. His/her spouse and dependents are not eligible. Upon losing eligibility, they may be eligible for COBRA continuation. (See Question:Who is eligible for continuation?) Coverage may continue beyond turning age 26 when children:

    1. Have a disability of long standing duration, are unmarried, dependent on you or the other parent for at least 50% of support and maintenance and are incapable of self-support; or
    2. Are full-time students and were called to federal active duty when they were under age 27 and while they were attending, on a full-time basis, an institution of higher education. Note: The adult child must apply to an institution of higher education as a full-time student within 12 months from the date the adult child fulfilled his or her active duty obligation.

  • Your grandchildren born to your insured dependent children may be covered until the end of the month in which your insured dependent (your grandchild's parent) turns age 18. Your child's eligibility as a dependent is unaffected by the birth of the grandchild.

Your employer may determine whether married employees may each elect individual or family coverage or if they are eligible only for family coverage through one of the spouses.

Note: If you are a retiree and cancel your health insurance coverage, you will not be able to re-enroll in this program.

  • If your spouse is an eligible state employee or retiree, you may each elect individual coverage with your current plan(s) if you have no other eligible dependents; or one of you may select family coverage that will cover all of your eligible dependents.
    • Note: Dependents and subscribers may only be covered once under both the State Group Health Insurance Program and the Wisconsin Public Employers Group Insurance Program. In the event it is determined that a dependent is covered by two separate subscribers, the subscribers will be notified and will have 30 days to determine which subscriber will remove coverage of the dependent and submit an application to remove the dependent. If the dependent(s) is to be newly covered by a subscriber that has single coverage, the contract may be converted to a family contract. The effective date will be the first of the month following receipt of the application. The health plan(s) will be notified.
  • If both spouses are each enrolled for individual coverage and premiums are being deducted on a pre-tax basis, family coverage may only be elected effective at the beginning of the calendar year or when the employees have gained a dependent that necessitates family coverage.
  • If premiums for family coverage are being deducted on a pre-tax basis, coverage may only be changed to individual coverage effective at the beginning of the calendar year or when the last dependent becomes ineligible for coverage, or becomes eligible for and enrolled in other group coverage.
  • If premiums are being deducted on a post-tax basis, one of the individual contracts may be changed to a family plan at anytime without restriction and the other individual contract will be canceled (see "Note" above). Family coverage will be effective on the beginning of the month following receipt of an electronic or paper application, or a later date specified on the application.
  • If premiums are being deducted post-tax, one family policy can be split into two individual plans with the same carrier effective on the beginning of the month following receipt of an electronic or paper application, or a later date specified on the application from both spouses.

    (See Question: How do I pay my portion of the premium?)

Some things to note:

  1. If you and your spouse each have individual coverage, no dependents are covered and if he or she should die, that individual's sick leave credits are not available for your use. Under a state of Wisconsin family plan, sick leave credits are preserved for the surviving dependents regardless of who should die first. If your employer offers post-retirement benefits, discuss the program's options with your payroll/benefits/personnel office.
  2. If you or your spouse have family coverage and want to change the named subscriber for the family coverage to the other spouse and the coverage is being deducted on a pre-tax basis, coverage may only be changed to the other spouse:
    • effective at the beginning of the calendar year;
    • when the subscriber carrying the coverage terminates employment or goes on an unpaid leave of absence;or
    • the premium contribution increases because of reduced work hours.
  3. For subscribers whose premiums are being deducted on a post-tax basis, coverage can be changed at anytime.

    Coverage will be effective on the beginning of the month following receipt of an electronic or paper application, or a later date specified on the application. (Note: WPE retirees who terminate their coverage may not re-enroll).

  4. If at the time of marriage, the employees and/or annuitants each have family coverage or one has family coverage and the other has individual coverage, coverage must be changed to one of the options listed above within 30 days of marriage to be effective as of the date of marriage (unless you both work for the same WPE that allows double coverage). Failure to comply with this requirement may result in denial of claims for eligible dependents. Note: Change from individual to family coverage due to marriage is effective the date of marriage if an electronic or paper application is received by your employer (or for retirees/continuants by ETF) within 30 days of the marriage.

If your unmarried child has a physical or mental disability that is expected to be of long-continued or indefinite duration and is incapable of self-support, he or she may be eligible to be covered under your health insurance through our program.

You must work with your health plan to determine if your child meets the disabled dependent eligibility criteria. If disabled dependent status is approved by the health plan, you will be contacted annually to verify the adult dependent's continued eligibility.

If your child loses eligibility for coverage due to age or loss of student status, but you are now indicating that the child meets the disabled dependent definition, eligibility as a disabled dependent must be established before coverage can be continued. If you are providing at least 50% support, you must file an electronic or paper application with your employer to initiate the disability review process by the health plan. Your dependent will be offered COBRA continuation*.

If your disabled dependent child, who has been covered due to disability, is determined by the health plan to no longer meet their disability criteria, the health plan will notify you in writing of their decision. They will inform you of the effective date of cancellation, usually the first of the month following notification, and your dependent will be offered COBRA continuation*. If you would like to appeal the plan's decision, you must first complete the plan's grievance procedure. If the plan continues to deny disabled dependent status for your child, you may appeal the plan's grievance decision to ETF by filing an ETF Insurance Complaint (ET-2405) form. Note: If you are changing health plans, see also the Changing Health Plans section.

* Electing COBRA continuation coverage should be considered while his or her eligibility is being verified. If it is determined that the individual is not eligible as a disabled dependent, there will not be another opportunity to elect COBRA. If it is later determined that the child was eligible for coverage as a disabled dependent, coverage will be retroactive to the date they were last covered, and premiums paid for COBRA continuation coverage will be refunded.

Even though custody of your children may have been transferred to the other parent, you may still insure the children if the other dependency requirements are met.

Note: Dependents may only be covered once under both the State of Wisconsin Group Health Insurance Program and the Wisconsin Public Employers Group Insurance Program. In the event it is determined that a dependent is covered by two separate subscribers, the subscribers will be notified and will have 30 days to determine which subscriber will remove coverage of the dependent and submit an application to remove the dependent. The effective date will be the first of the month following receipt of the application. The health plan(s) will be notified.

Coverage for dependent children who are not physically or mentally disabled terminates on the earliest of the following dates:

  • The date eligibility for coverage ends for the subscriber.
  • The end of the month in which:
    1. The child turns age 26.
    2. Coverage for the grandchild ends when your child (parent of grandchild) ceases to be an eligible dependent or becomes age 18, whichever occurs first. The grandchild is then eligible for continuation coverage.
    3. Coverage for a spouse and stepchildren under your health plan terminates when there is an entry of judgment of divorce.
    4. The child was covered per Wis. Stat. § 632.885 (2) (b) and ceases to be a full-time student.
    5. The child becomes insured as an employee of a state agency, or an employer who participates in the State of Wisconsin Group Health Insurance Program.
    6. You terminate coverage for your adult dependent within 30 days of their eligibility for and enrollment in another group health insurance program. Termination will be effective the first of the month following receipt of an electronic or paper application. You may also terminate coverage for your adult dependent during the annual It's Your Choice enrollment period to be effective January 1 of the following year.
    7. Note: If it is determined that a dependent is covered by two separate subscribers, the subscribers will be notified and will have 30 days to determine which subscriber will remove coverage of the dependent and submit an application to remove the dependent. The effective date will be the first of the month following receipt of the application. The health plan(s) will be notified.

See Continuation of Health Coverage for information on continuing coverage after eligibility terminates.

Family Status Changes

You need to file an electronic or paper application as notification for the following changes to your benefits/payroll/personnel office within 30 days of the change. Retirees and continuants will need to contact ETF. Additional information may be required. Failure to report changes on time may result in loss of benefits or delay payment of claims.

  • Change of name, address, telephone number and Social Security number, etc.
  • Obtaining or losing other health insurance coverage, including any part of Medicare
  • Addition of a dependent (within 60 days of birth, adoption or date legal guardianship is granted)
  • Loss of dependent's eligibility, including Medicare eligibility
  • Marriage
  • Divorce
  • Death (Contact ETF if dependent is your named survivor.)
  • Eligibility/enrollment for Medicare

You have the responsibility to inform your employer (ETF for retirees and continuants) of any dependents losing eligibility for coverage under the Wisconsin Public Employers Group Health Insurance Program. Under federal law, if notification is not made within 60 days of the later of (1) the event that caused the loss of coverage, or (2) the end of the period of coverage, the right to continuation coverage is lost. A voluntary change in coverage from a family plan to a single plan does not create a continuation opportunity.

If your last dependent is losing eligibility, you must file an application to change to individual coverage.

There are other limited opportunities for coverage to be changed from individual to family coverage without restrictions as described below:

If an electronic or paper application is received by your benefits/payroll/personnel office for active employees (or ETF for retirees/continuants) within 30 days of the following events, coverage becomes effective on the date of the following event:

  • Marriage.
  • You or any of your eligible dependents involuntarily lose eligibility for other medical coverage or lose the employer contribution for the other coverage.
  • An unmarried parent whose only eligible child becomes disabled and thus is again an eligible dependent. Coverage will be effective the date eligibility was regained.

If an application is received by your benefits/payroll/personnel office for active employees or ETF for retirees/continuants, within 60 days of the following events, coverage becomes effective on the date of the following event:

  • Birth or adoption of a child or placement for adoption (timely application prevents claim payment delays).
  • Legal guardianship is granted.
  • A single father declaring paternity. Children born outside of marriage become dependents of the father on the date of the court order declaring paternity, on the date the acknowledgement of paternity is filed with the Department of Health Services (or equivalent if the birth was outside of the state of Wisconsin) or on the date of birth with a birth certificate listing the father's name. The effective date of coverage will be the birth date, if a statement of paternity is filed within 60 days of the birth. If filed more than 60 days after the birth, coverage will be effective on the first of the month following receipt of application.

If an application is received by your benefits/payroll/personnel office for active employees or ETF for annuitants/continuants, upon order of a federal court under a National Medical Support Notice, coverage will be effective on either:

  • The first of the month following receipt of application by the employer; or
  • The date specified on the Medical Support Notice.

Note: This can occur when a parent has been ordered to insure one or more children who are not currently covered.

Marriage
You can change from individual to family coverage to include your spouse (and stepchildren if applicable) without restriction, provided your electronic or paper application is received within 30 days after your marriage, with family coverage being effective on the date of your marriage.

If you were enrolled in family coverage before your marriage, you need to complete an electronic or paper application as soon as possible to report your change in marital status, add your new spouse (and stepchildren) to the coverage, and if applicable, change your name. In most cases, coverage for the newly added dependent(s) will be effective as of the date of marriage. (See the Life Change Event Guide and Question: What if my spouse and I work for the same employer?)

Note: You may also change health plans when adding a dependent due to marriage. The subscriber will need to file an application within 30 days of the marriage with coverage effective with the new plan on the first day of the month on or following receipt of the application.

Birth/Adoption/Legal Guardianship/Dependent Becoming Eligible
If you already have family coverage, you need to submit a timely electronic or paper application to add the new dependent. Coverage is effective from the date of birth, adoption, when legal guardianship is granted, or when a dependent becomes eligible and otherwise satisfies the dependency requirements. Be prepared to submit documentation of guardianship, paternity or other information as requested by your employer.

If you have individual coverage, you can change to family coverage with your current health plan by submitting an application within 30 days of the date a dependent becomes eligible or within 60 days of birth, adoption or the date legal guardianship is granted.

Note: You may also change health plans if you, the subscriber, file an application within 30 days of a birth or adoption with coverage effective on the first day of the month on or following receipt of the application.

Single Mother or Father Establishing Paternity
A subscriber may cover his or her dependent child, effective with the child's birth or adoption, by submitting a timely electronic or paper application, changing from individual to family coverage.

Children born outside of marriage become dependents of the father on the date of the court order declaring paternity or on the date the "Voluntary Paternity Acknowledgment" (form DPH 5024) is filed with the Department of Health Services (or equivalent if the birth was outside the state of Wisconsin), or the date of birth with a birth certificate listing the father's name. The effective date of coverage will be the date of birth if a statement of paternity is filed within 60 days of the birth. If more than 60 days after the birth, coverage is effective on the first of the month following receipt of the electronic or paper application.

A single mother may cover the child under her health plan effective with the birth by submitting an application changing from single to family coverage.

Upon Order of a Federal Court Under a National Medical Support Notice
This can occur when a parent has been ordered to insure his/her eligible child(ren) who are not currently covered. You will need to submit an electronic or paper application to your benefits/payroll/personnel office (retirees and continuants will notify ETF) with coverage becoming effective on either:

  • The first of the month following receipt of application by the employer; or
  • The date specified on the National Medical Support Notice.

Divorce
Your ex-spouse (and stepchildren) can remain covered under your family plan only until the end of the month in which the marriage is terminated by divorce or annulment, or to the end of the month in which the Continuation-Conversion Notice (ET-2311) is provided to the divorced spouse, if family premium continued to be paid, whichever is later. (In Wisconsin, a legal separation is unlike divorce in that it does not affect coverage under the Wisconsin Public Employers Group Health Insurance Program.) Divorce is effective on the date of entry of judgement of divorce. This date is usually when the judge signs the divorce papers and the clerk of courts date stamps them. You should notify your payroll office prior to the divorce hearing date and once the entry of judgment of divorce has occurred. You will need to contact the clerk of courts to learn the date of entry of judgment of divorce. If you fail to provide timely notice of divorce, you may be responsible for premiums paid in error which covered your ineligible ex-spouse and stepchildren. Following divorce, your ex-spouse and stepchildren are eligible to continue coverage under a separate contract with the group plan for up to 36 additional months. Conversion coverage would then be available. You can keep your dependent children and adopted stepchildren on your family plan for as long as they are eligible (age, student status, etc.). (See Continuation of Health Coverage section for further information.)

You must file an electronic or paper health application with your employer to change from family to individual coverage or to remove ineligible dependents from a family contract.

When both parties in the divorce are employees or retirees, and each party is eligible for this health insurance in his or her own right and is insured under this program at the time of the divorce, each retains the right to continue this health insurance coverage, regardless of the divorce (unless the employer withdraws from this program).

  • The participant who is the subscriber of the insurance coverage at the time of the divorce must submit an electronic or paper health application to remove the ex-spouse from his or her coverage and may also elect to change to individual coverage.
  • The participant insured as a dependent under his or her ex-spouse's insurance must submit a health application to establish coverage in his or her own name. The ex-spouse must continue coverage with the same plan unless he or she moves out of the service area (e.g., county). The electronic or paper application must be received by the employee's benefits/payroll/personnel office (or ETF, for retirees) within 30 days of the date of the divorce.
  • Only one participant may cover any eligible dependent children (not former stepchildren) under a family contract. Coverage of the same dependents by both parents is not permitted.

Note for active employees: Failure to apply in a timely manner will limit enrollment to the annual It's Your Choice open enrollment period for coverage effective January 1.

Note for retirees: If you fail to enroll within 30 days of the date of divorce, you have no enrollment or continuation rights. You will not be able to re-enroll in this program.

Medicare Eligibility
Please refer to the Medicare information in this FAQ for details regarding Medicare eligibility and enrollment requirements.

Death
Surviving Dependents.
If an active or retired employee with family coverage dies, the surviving insured dependents shall have the right to continue coverage for life under the Wisconsin Public Employers Group Health Insurance Program at group rates as long as the former employer continues to participate in the program. The dependent children may continue coverage until eligibility ceases if they:

  • Were enrolled at the time of death; or
  • Were previously insured and regain eligibility; or
  • Are a child of the employee and born after the death of the employee.

Health insurance coverage will automatically continue for your covered surviving dependents. Continued coverage will be effective on the first of the month after your date of death. Surviving dependents may voluntarily terminate coverage by providing written notification to ETF and coverage will terminate on the last day of the month in which their written request is received by ETF.

If the surviving dependent(s) terminates coverage for any reason he or she may not re-enroll later.

Note: The survivors may not add persons to the policy who were not insured at the time of death.

If individual coverage was in force at the time of death, the monthly premiums collected for coverage months following the date of death will be refunded. No partial month's premium is refunded for the month of coverage in which the death occurred. Surviving dependents are not eligible for coverage.

If your employee premiums are deducted on a pre-tax basis under Internal Revenue Code Section 125, switching from family to individual coverage is not allowable unless there is an IRS qualified family status change such as divorce, marriage, birth or adoption. For example, all covered family members lose eligibility for health coverage or become eligible for and enroll in another group plan. (Group plans do not include Medicare or individual Medicare supplement policies.) However, you must check this with your employer or your Section 125 plan administrator. If any covered dependents remain eligible for coverage, a change from family to individual coverage is allowed only during the It's Your Choice open enrollment period.

If your premiums are deducted on a post-tax basis, you may change from family to individual coverage at anytime. The change will be effective on the first day of the month on or following receipt of your electronic or paper application by your benefits/payroll/personnel office (ETF for retirees and continuants). Switching from family to individual coverage when you still have eligible dependents is deemed a voluntary cancellation of coverage for all covered dependents and is not considered a "qualifying event" for continuation coverage.

Changing from individual to family coverage, regardless of whether your premiums are deducted on a pre- or post-tax basis, is only allowed during the It's Your Choice open enrollment period, or when you or an eligible dependent has a qualifying event that allows for family coverage. See the Question: "If I do not change from individual to family coverage during the It's Your Choice open enrollment period, will I have other opportunities to do so?".

Benefits and Services
Health Plan Information

All changes in coverage are accomplished by completing an approved electronic or paper application within 30 days after the change occurs. Employees should file an application through your benefits/payroll/personnel office to notify your plan of changes. Retirees and continuants should file with ETF. Failure to report changes on time may result in loss of benefits or delay payment of claims. (See Question: Which family changes need to be reported?):

  • Change in plan (for example, from IYC Local Plan to IYC Access Health Plan)
  • Change in plan coverage (for example, from individual to family)
  • Name change
  • Change of address or telephone number
  • Addition/deletion of a dependent to an existing family plan

Exception: If you change your primary care physician (PCP), you may contact your health plan for details.

You will receive identification cards from the health plan you select. If you lose these cards or need additional cards for other family members, you may request them directly from the health plan. Health plans are not required to provide you with a certificate describing your benefits. The It's Your Choice Uniform Benefits, IYC Access Plan or Medicare Plus Certificate of Coverage online provides this information.

Present your identification card to the hospital or physician who is providing the service. Identification numbers are necessary for any claim to be processed or service provided.

Most of the health plans require that non-emergency hospitalizations be prior authorized and contact be made if there is an emergency admission. Prior authorizations are required for high-tech radiology (for example, MRI, PET, CT scans) and for low back surgeries. Check with your plan, and make sure you understand any requirements.

For the IYC Access Health Plan and SMP, it is recommended or required that you or your physician contact the health plan before you are admitted to a hospital unless it is an emergency. In an emergency, it is in your best interest to notify the plan as soon as reasonably possible.

Only if the IYC Health Plan HMO has providers in the community in which the child resides. Emergency or urgent care services are covered wherever they occur. However, non-emergency treatment must be received at a facility approved by the health plan. Outpatient mental health services and treatment of alcohol or drug abuse may be covered. Refer to the It's Your Choice Uniform Benefits. Contact your health plan for more information.

Most of the services provided by health plans do not require filing of claim forms. However, you may be required to file claims for some items or services. All health plans require claims be filed within 12 months of the date of service or, if later, as soon as reasonably possible.

When you are covered under two or more group health insurance policies at the same time and both contain coordination of benefit provisions, insurance regulations require the primary carrier be determined by an established sequence. This means that the primary carrier will pay its full benefits first; then the secondary carrier would consider the remaining expenses. (See the Coordination of Benefits Provision found in the It's Your Choice Uniform Benefits, IYC Access Plan or Medicare Plus Certificate of Coverage online.) Note that with coordination of benefits, the secondary carrier may not always cover all of your expenses that were not covered by the primary carrier.

Once you reach your OOPL, you no longer have to pay most copayments. You will continue to pay copayments for certain level 3 and level 4 prescription drugs, and any other essential health benefit services that do not accumulate to the OOPL. If you are enrolled in the high deductible health plan (HDHP), you do not have to pay for any copayments once you reach your OOPL.

There is a federal maximum out-of-pocket (MOOP) of $6,850/$13,700 for 2016 through 2018 which is the maximum you will pay for essential health benefits, including services that do not apply to the OOPL.

Provider Information

Most IYC Local Health plans will pay nothing when non-emergency treatment is provided by physicians outside of the plan unless there is an authorized referral. Contact the health plans directly regarding their policies on referrals.

For emergency or urgent care, plans are required to pay for care received outside of the network, but it may be subject to usual and customary charges. This means the plan may not pay the entire bill and try to negotiate lower fees. However, ultimately the plan must hold you harmless from collection efforts by the provider. (See the Uniform Benefits definition of Emergency Care in the Certificate of Coverage online.)

Check your health plan's or Navitus's website for helpful information on selecting a provider. You can also call and inquire. If you do not select a medical PCP, the health plan will select one for you and notify you.

If you're not sure a provider holds the same beliefs as you do, call the clinic or pharmacy and ask about your concerns. For example, you may want to ask about the provider's opinion about dispensing a prescription for oral contraceptives.

See the Interactive Map online for more information on how to access or receive a provider directory. You may also contact the health plan to receive a printed copy of the provider directory. Neither ETF nor your employer maintain a current list of this information.

Contact your health plan to find out their requirements to make this change and when your change will become effective.

If you want to continue seeing a particular physician (or psychologist, dentist, optometrist, etc.), contact that physician to see if he or she will be available to you under your IYC Local Plan. Confirm this with the IYC Local Plan's provider directory. Even though your current physician may join an IYC Local Plan, he or she may not be available as your primary care physicians (PCP) just because you join that IYC Local Plan.

If you are enrolled in an IYC Local Plan HMO, you will need to find an in-network provider for your care unless you are a participant who is in her second or third trimester of pregnancy. Then you may continue to have access to her provider until the completion of postpartum care for yourself and the infant. If you are enrolled in a Preferred Provider Organization (PPO) such as WEA Trust or the IYC Access Plan and you continue to see this provider, your claims will be paid at the out-of-network benefit level.

If a provider contract terminates during the year (excluding normal attrition or formal disciplinary action), and you are a participant in your second or third trimester of pregnancy, the plan is required to pay charges for covered services from these providers on a fee-for-service basis. Fee-for-service means the usual and customary charges the plan is able to negotiate with the provider while the member is held harmless.

Health plans will individually notify members of terminating providers (prior to the It's Your Choice open enrollment period) and will allow them an opportunity to select another provider within the plan's network.

Your provider leaving the plan does not give you an opportunity to change plans midyear.

Beginning in 2018, all participants must designate a primary care physician (PCP). Your primary PCP is responsible for managing your health care. Under most circumstances, he or she may refer you to other medical specialists within the health plan's provider network as he or she feels is appropriate. However, referrals outside of the network are strictly regulated for most health plans. Check with your health plan for their referral requirements and procedures.

In case of an injury that may fall under workers' compensation, you should utilize only providers in your health plan, in case workers' compensation denies your claim.

Premium Contribution Tiering

Employers determine the amount they will contribute toward the premium under one of the two methods described here.

  1. Your employer pays between 50% and 88% of the premium rate of the average cost qualified plan in the employer's service area for either individual or family coverage for employees who are participants under the Wisconsin Retirement System.

    Your employer may pay as little as 25% of the premium for either individual or family coverage for an employee appointed to a position working less than 1,040 hours per year and who is a participating employee under the WRS.

  2. A three-tier health insurance premium option is available. Each health plan is assigned to one of three tiers based on the quality of care and relative efficiency with which it provides benefits. Health plans providing the most cost-effective, quality care (as determined by ETF) are assigned to Tier 1, moderately cost-effective plans to Tier 2 and the least cost-effective plans to Tier 3. Health plans in the same tier have been determined to be within certain thresholds in their level of providing cost-effective, quality care.

    The employee's required contribution to the health insurance premium for coverage is the same dollar amount for all health plans in the same tier, regardless of the total premium.

Note: Your employer may contribute any amount toward the premium for retired employees who continue group coverage.

No; all IYC Local Plans are required to offer the Uniform Medical Benefits (this excludes Medicare Plus). Premium rates and tier placement may vary because of many factors:

  • how efficiently the health plan is able to provide services and process benefit payments;
  • the fees charged in the area in which service is being rendered;
  • the manner in which the health care providers deliver care and are compensated within the service area;
  • and how frequently individuals covered by the health plan use the health plan.

All group premium rates change at the same time: January 1 of each year. The monthly cost of all health plans will be announced during the annual It's Your Choice open enrollment period.

Active Employees: Premiums may be paid in advance. Therefore, initial deductions from your salary probably will occur about one month or more before coverage begins. If the initial deduction cannot occur that far in advance, then double deductions may be required initially so as to make premium payments current.

Retired Employees: Premium rates for retired employees are the same as for active employees (except that your premium will decrease when you or a dependent becomes covered by Medicare). The employer may, at its option, pay a portion or all of the premium. If you are paying your entire premium, it will be deducted from your monthly annuity. If the annuity is not sufficient to allow a premium deduction, you will be billed directly from your health plan. Warning: Your coverage will be canceled if you fail to pay your premium in a timely manner. You will not be able to re-enroll later.

If you are retired and have life insurance coverage through the Wisconsin Public Employers Group Life Insurance Program, you may be eligible to convert the present value of your life insurance to pay health insurance premiums. You must be at least age 67, or age 66 if your employer provides post-retirement life insurance coverage at the 50% level. If you make this election, your life insurance coverage will cease and you will receive credits in a conversion account equal to the present value of your life insurance. The present value ranges from about 44% to 80% of the amount, depending on your age. The life insurance company, Securian Financial Group, will pay health insurance premiums on your behalf from your conversion account until the account is exhausted. You will not receive any direct cash payment. You may file the election at anytime, and it will be effective no earlier than 61 days after ETF receives it. For more information and an election form, contact ETF.

Deductible/Copayment/Coinsurance/Out-of-Pocket Limit

No, but your employer may offer a similar program.

Each local government employer must choose whether to offer the Uniform Dental Benefit to employees. The benefits are the same for state and local employees who participate in the Uniform Dental Benefit plan. Please check with your employer to determine whether the Uniform Dental Benefit is available to you.

Preventive services are routine health care that includes check-ups, patient counseling and screenings to prevent illness, disease and other health-related problems. Federal law requires that specific preventive services performed by in-network providers be offered at no cost to you. You can find a list of these preventive services here.

A copayment is a fixed amount you pay for certain covered health care services or prescription drugs, usually due at the time you receive the service.

Coinsurance is your share of the costs of certain covered health care services or prescription drugs, calculated as a percent of the amount for the service or cost of the drug.

Example: If a diagnostic test costs $100 and you have met your deductible, your coinsurance payment of 10% would be $10 (10% of $100). The health plan pays the rest of the cost ($90).

An out-of-pocket limit (OOPL) is a plan provision that limits a member’s cost sharing. The OOPL is the maximum amount that a member will pay for in-network, covered services during a plan year (same as calendar year).

The WPE (local government) program has OOPLs in place that apply to certain medical and prescription drug out-of-pocket costs. The federal government also enforces Maximum Out-of-Pocket (MOOP) limits that are much higher than the OOPLs of the State and WPE (local government) group health insurance programs. For any essential health benefit costs that do not stop at the program OOPL, the federal MOOP limits provide a safety net that does not allow you to incur any out-of-pocket expenses more than $6,850 individual or $13,700 family.

Note: For the group health insurance program, this only applies to Level 3 and Level 4 non-preferred prescription drugs.

Pharmacy Benefit Manager (PBM)

A PBM is a third-party administrator of a prescription drug program that is primarily responsible for processing and paying prescription drug claims. In addition, it typically negotiates discounts and rebates with drug manufacturers, contracts with pharmacies and develops and maintains the drug formulary. Navitus Health Solutions is the PBM for the Wisconsin Public Employers Group health Insurance Program.

A formulary is a list of prescription drugs that are determined to be both medically effective and cost-effective by a committee of physicians and pharmacists.

Drugs are evaluated by the committee based on their effectiveness, side-effects, drug interactions and then cost. Drugs are reviewed on a continuous basis to make sure the formulary is kept up-to-date and that patient needs are being met.

You can find the complete formulary on Navitus' member portal.

You may also call Navitus Customer Care toll free at 1-866-333-2757 with questions about the formulary. If you are enrolled in the Navitus MedicareRx plan (Medicare Part D) you can access the formulary through the "Members" section on the Navitus MedicareRx web site, medicarerx.navitus.com. See more on using Navi-Gate.

Your drug benefit has four different tiers, Levels 1 through 4. Drugs are divided between those tiers and you will pay different amounts for a drug based on its tier. The lower the tier, the less you pay.

Your plan encourages you to use preferred formulary drugs by having a lower copayment or coinsurance for Level 1 and Level 2 drugs. Drugs listed at Level 3 have a coinsurance and are considered non-preferred drugs. These drugs are still covered, but will cost you more money if you decide to use them. Level 4 drugs are Specialty drugs, and have the largest amount of cost-sharing.

For non-Medicare members, Level 4 drugs must be filled through either Lumicera or UW Health specialty pharmacies. With the exception of certain limited distribution drugs, specialty drugs will not be covered at other pharmacies.

For Medicare members, you may use Lumicera or UW Health, or you may use a different specialty pharmacy. If you use Lumicera or UW Health, your costs will be lower, and will apply to your annual out-of-pocket limit (OOPL) for specialty drugs.

Copayments and Coinsurance for Level1 and Level 2 drugs count toward your annual Level 1/Level 2 OOPL. The copayments for preferred Specialty drugs are applied to your Level 4 OOPL, which is separate from the Level 1/Level 2 OOPL. Coinsurance for Level 3 drugs and non-preferred Level 4 drugs (Medicare only) do not count toward the OOPL; they only count toward the federal maximum out of pocket limit.

You may need prior authorization before some drugs are covered. Check with your provider or Navitus to learn more.

For non-Medicare members, preferred specialty prescription drugs are classified as Level 4 drugs when they are filled through Lumicera or UW Health. These drugs have a $50 copayment each time you fill the drug, and that copayment counts toward your Level 4 out-of-pocket limit (OOPL). Getting your drugs through Lumicera or UW Health will also give you access to programs that can help you manage your medications. Call the phone number on your Navitus Member ID card for more details.

Specialty drugs that are non-preferred, or specialty drugs filled outside of Lumicera or UW Health, will not be covered.

For Medicare members, specialty drugs are classified as Level 4 drugs. If you fill your prescriptions for preferred specialty drugs at Lumicera or UW Health, you will have a $50 copayment each time you fill the drug, and that copayment counts toward your Level 4 out-of-pocket limit (OOPL).

If you receive a non-preferred drug, or fill your prescription at a network pharmacy other than Lumicera or UW Health, you will have a non-preferred coinsurance of 40% (up to a maximum of $200), and that coinsurance will not count towards the Level 4 OOPL, only the federal maximum out of pocket limit.


Yes. You will have two identification cards: one from your health plan and one from either (a) Navitus Health Solutions or (b) the Navitus MedicareRx (PDP) plan (for eligible retirees enrolled in Medicare) for pharmacy benefits. Your member identification number will be different on each card, so it is important that you show the correct card when getting services. When filling prescriptions, you must present your pharmacy benefits ID card to the pharmacist.

The cost of prescription drugs can change frequently, sometimes even month-to-month. Navitus has a new tool on their website that will tell you how much your drugs will cost at the specific pharmacy you go to.

Log on at https://members.navitus.com to set up an account for the Navitus Portal, then click on Cost Compare to check the price of your drugs. For more detailed instructions, please see the NaviGate for Members page.

You can view the formulary on the Navitus website. You must log in to the Navi-gate for Members section and then select “Formulary” from the options available.

Medicare Information

If you are eligible for Medicare, you must be enrolled in the hospital (Part A) and medical (Part B) portions of Medicare at the time of your retirement. If you are an active employee, these requirements to enroll for Medicare coverage are deferred for you and your dependents until the termination of your employment. Because all health plans that participate in the Wisconsin Public Employers Group Health Insurance Program have coverage options that are coordinated with Medicare, you will remain covered by the health plan you have selected even after you enroll in Medicare. Premium rates will decrease if Medicare covers you or a dependent, and you are retired. Medical and prescription drug coverage under the IYC Local Plans (health plans that offer Uniform Benefits for medical coverage) does not change. The health plan will simply not duplicate benefits paid by Medicare. However, if enrolled in the IYC Access Plan or SMP, your coverage will change to IYC Medicare Plus when you enroll in Medicare Parts A and B.

If you are not enrolled for all available portions of Medicare (A, B and D) upon retirement, you will be liable for the portion of your claims that Medicare would have paid beginning on the date Medicare coverage would have become effective.

For information about Medicare benefits, eligibility and how to enroll, contact your local Social Security Administration office or call 1-800-772-1213. In addition, the State Health Insurance Assistance Program (SHIP) has counselors in every state and several territories who are available to provide free one-on-one help with your Medicare questions or problems. The Wisconsin SHIP can be reached at 1-800-242-1060. Additional information and assistance can be found at www.dhs.wisconsin.gov/benefit-specialists/ship.htm. A list of SHIP programs outside of Wisconsin can be found at www.medicare.gov/contacts/staticpages/ships.aspx.

 

Important: When you receive your Medicare card, please send a photocopy to ETF immediately or your Medicare coordinated coverage may be delayed. If you become eligible for Medicare, your eligibility for COBRA coverage ends. Contact ETF for more information.

ETF does not require you and your dependents to enroll in Medicare until you, as the subscriber, terminate employment or health insurance coverage as an active employee ceases. (If you or your insured spouse is insured as an active employee under a non-state group plan, enrollment in Medicare may be deferred until retirement from that job.) At the time of your retirement, you and your dependents who are eligible for Medicare must enroll for the Part A (hospital) portion and Part B (medical) portion of Medicare. When you and/or your dependents enroll in Medicare Parts A and B, your group health insurance coverage will be integrated with Medicare and the monthly premium will be reduced.

In general, enrollment in Medicare Part D (prescription drug coverage) is voluntary; however, you may pay a penalty if you do not enroll when you are first eligible or are not covered by what Medicare considers creditable coverage. Regardless, Medicare Part D coverage is provided by the Wisconsin Public Employers (WPE) Group Health Insurance Program. Additional information about all parts of Medicare can be found in the following questions and answers.

If you become eligible for Medicare, your eligibility for COBRA coverage ends. Contact ETF for more information.

Medicare Part A
Most people become eligible for Medicare upon reaching age 65. Individuals who have been determined to be disabled by the Social Security Administration (SSA), become eligible after a 24-month waiting period.

  • If you or your spouse are actively working when you become eligible, you may want to consider enrolling in Medicare Part A, as it may cover hospital services if your health plan denies them. There is no premium for Medicare Part A.

Medicare Part B
The requirement to enroll in Medicare Part B coverage is deferred for active employees and their dependents until the subscriber's termination of their WRS-covered employment, through which active employee health insurance coverage is provided.

If you have terminated employment, or are a surviving dependent, or a continuant and are eligible for coverage under the federal Medicare program, you must immediately enroll in both Part A and Part B of Medicare unless you are otherwise employed and have health insurance coverage through that employment. If you do not enroll for all available portions of Medicare upon retirement, you will be liable for the portions of your claims that Medicare would have paid beginning on the date Medicare coverage would have become effective.

If you or your insured spouse is employed by an employer that does not participate in the WPE group health insurance program, and has coverage as an active employee under that employer's group plan, enrollment in Medicare may be deferred until retirement from that job. Health insurance premiums will not be reduced until the employee retires and Medicare pays as primary.

For subscribers and their dependents with End Stage Renal Disease (ESRD): You will want to contact your local Social Security office, health plan, provider and Medicare to make sure you enroll in Medicare Part A and Part B at the appropriate time. The Wisconsin Public Employers Group Health Insurance Program will provide primary coverage during the 30-month coordination period for members with ESRD. You will want to decide if it would be beneficial to enroll in Part B during your initial or general enrollment opportunities to avoid later delayed Medicare enrollment and potential premium penalties after your 30-month coordination period ends.

Medicare Part D
U.S. resident retired members and their spouses and/or dependents who are Medicare enrolled and who participate in the Wisconsin Public Employers Group Health Insurance Program will automatically be enrolled in the Navitus MedicareRx (PDP) plan, which is underwritten by Dean Health Insurance Inc., a federally-qualified medicare contracting prescription drug plan. The prescription drug coverage under this program is Medicare Part D coverage. Your monthly health insurance premium includes a portion that applies to this program's coverage.

Before Navitus can report your enrollment in Medicare Part D to Medicare, they need to have your Medicare Health Insurance Claim (HIC) number and Parts A and B effective dates. In most cases, ETF will request this information from you two to three months in advance of your 65th birthday by sending you a Medicare Eligibility Statement (ET-4307). ETF will then provide the information to Navitus. Please complete and return this form as soon as possible to ensure you receive the benefits you are eligible for and your claims are paid properly.

If you do not receive the Medicare Eligibility Statement (ET-4307) at least one month before your 65th birthday please contact ETF. The form is also available.

If you are retired and cover a Medicare-eligible spouse or disabled dependent on your health plan, please notify ETF and provide your dependent's Medicare information.

Individuals may choose to enroll in another Medicare Part D prescription drug plan; however, it is not recommended or required for your continued coverage under the Wisconsin Public Employers (WPE) group health insurance program.

If you choose to enroll in a different Medicare Part D plan, your health insurance premium for the WPE plan does not change, but your supplemental, wrap-around pharmacy coverage will be secondary to the other Medicare Part D plan. For more information, see Question: Does Medicare Part D affect my prescription drug coverage? Should I enroll? and Question: Will my health insurance premium go down if I enroll in a Medicare Part D prescription drug plan?

If Medicare is the primary insurance, your provider must submit claims to Medicare first. Once Medicare processes the claim(s), Medicare will send you a quarterly Medicare Summary Notice (MSN).

IYC Health Plan Medicare (health plans that offer Uniform Benefits for medical coverage):
Many of the health plans have an automated procedure after Medicare processes the claim, where the provider then submits it to the health plan for processing. However, some health plans require members to submit a copy of the MSN and, in certain circumstances, a copy of the provider's bill. You should discuss with your provider if they will bill Medicare and your health plan on your behalf. Contact your health plan for additional information.

IYC Medicare Plus:
Your responsibilities in the claims process will depend on the policies and practices of the medical facility from which you receive care. You may be required to submit the claims to Medicare and then submit the proper forms to WEA Trust for supplemental payments. Refer to the IYC Medicare Plus certificate of coverage available online (also available on paper from ETF) for more information, and contact your health care provider or facility regarding their particular Medicare claims procedures.

Pharmacy Benefit Manager:
As long as you maintain the Navitus MedicareRx (PDP) plan as your Medicare Part D PDP, Navitus will process your claims for both Part D and the supplemental wrap coverage that is included.

However, if you choose to enroll in a Medicare Part D plan other than the Navitus MedicareRx (PDP) plan, your supplemental wrap coverage, which is part of the WPE group health insurance program pharmacy benefits, will be considered secondary. You should be prepared to file the secondary claims manually through Navitus. Contact Navitus for more information on filing manual claims. Refer to the Medicare Part D Information section of the FAQs for more details.

Medicare Part B pharmacy claims are covered under the supplemental wrap benefit. For specific information on Medicare Part B pharmacy coverage and Part B claims processing, see the plan description page for Navitus™ Health Solutions.

Since all health plans have coverage options that are coordinated with Medicare, you will remain covered by the health plan you selected after you are enrolled in Medicare, even though Medicare is the primary payor of your claims.

Exception: If you are enrolled in the IYC Access Plan or SMP, your coverage will be changed to IYC Medicare Plus. There are some differences in benefits between these health plans. IYC Medicare Plus is designed to supplement the benefits you receive under Medicare. For purposes of paying benefits, Medicare is the primary plan and IYC Medicare Plus is the secondary plan. This means Medicare reviews claims first and determines what, if anything, should be paid and then the IYC Medicare Plus plan reviews the claims to determine if there is anything else that is payable.

If you are enrolled in one of the IYC Health Plans, Medicare, your health coverage will remain substantially the same as before Medicare coverage became effective. For purposes of paying benefits, Medicare is the primary plan and the state health plans are the secondary plan. This means Medicare reviews claims first and determines what, if anything, should be paid and then the state health plans review the claims to determine if there is anything else that is payable. Because of this coordination with Medicare, your monthly premiums for your Wisconsin Public Employers Group Health Insurance Program will be less.

Note: For some benefits under Uniform Benefits, such as durable medical equipment, Medicare Part B and the health plan both have a 20% coinsurance that you are responsible to pay.

If you are enrolled in Medicare and your modified adjusted gross income exceeds certain limits established by federal law, you may be required to pay an adjustment to your monthly Medicare Part B (medical) and Medicare Part D (prescription drug, i.e. Navitus MedicareRx (PDP) plan) coverage premiums. The additional premium amount you will pay for Medicare Part B and Medicare prescription drug coverage is called the income-related monthly adjustment amount or IRMAA. Since Medicare beneficiaries enrolled in the Wisconsin Public Employers Group Health Insurance Program are required to have Medicare Parts A, B and D, the IRMAA may impact you if you have higher income.

To determine if you will pay the additional premiums, Social Security uses the most recent federal tax return that the IRS provides and reviews your modified adjusted gross income. Your modified adjusted gross income is the total of your adjusted gross income and tax-exempt interest income.

Social Security notifies you in November about any additional premium amounts that will be due for coverage in the next year because of the IRMAA. You must pay the additional premium amount, which will be deducted from your Social Security check if it's large enough. Failure to pay may result in Medicare terminating your coverage. The IRMAA is paid to Social Security, not the Wisconsin Public Employers Group Health Insurance Program. It is not included in your Wisconsin Public Employers Group Health Insurance Program premium.

Additional information can be found in SSA Publication No. 05-10536 or by calling the Social Security Administration toll-free at 1-800-772-1213.

Medicare Part D Information

Medicare related prescription drug coverage will be provided by Navitus Health Solutions (Navitus) through a self-funded, Medicare Part D Employer Group Waiver Plan (EGWP) called the Navitus MedicareRx (PDP) plan. This plan is underwritten by Dean Health Insurance Inc. a federally-qualified Medicare contracting prescription drug plan. This affects Medicare-eligible participants covered under an annuitant contract enrolled in the WPE group health insurance program. As required by Uniform Benefits and IYC Medicare Plus, a supplemental wrap benefit is also included to mainly provide full coverage to WPE members when they reach the Medicare coverage gap, also known as the "donut hole." But the supplemental wrap benefit will also provide coverage at other times when the EGWP does not, such as during the Medicare Part D deductible and the initial coverage phases. Dean has been contracted with the Centers for Medicare and Medicaid Services since 2006, when Medicare Part D was first implemented to offer Medicare Part D prescription drug plans to employer groups.

Your group health insurance premium already includes the cost of this benefit. There is no separate premium that needs to be paid for this Medicare Part D coverage. It is important that you read and understand the information presented on the Navitus MedicareRx plan description page.

A Medicare Part D prescription drug plan (PDP) provides primary coverage of prescription benefits through Medicare. While enrollment in a PDP is voluntary, if you do not enroll when you are first eligible and do not have what Medicare considers creditable coverage, you may have to pay a penalty in the form of a higher PDP premium once you do enroll.

Under the Wisconsin Public Employers Group Health Insurance Program, after you become eligible for Medicare Part D, the following will happen:

  • You will be automatically enrolled in the Navitus MedicareRx (PDP) plan. Medicare eligible spouses and/or dependents will also be enrolled. This is Medicare Part D coverage. Your group health insurance premium already includes the costs of this Medicare Part D coverage.
  • You will also be automatically enrolled for supplemental wrap coverage to ensure your prescription drugs are covered when you reach the Medicare Part D coverage gap, commonly referred to as the "donut hole." This provides you with additional benefits that "wrap around" the benefits available from your Medicare Part D coverage. Your health insurance premium already includes the cost of this supplemental wrap coverage.

When you are enrolled in the Navitus MedicareRx (PDP) plan you will be issued a new ID card that you will be required to use.

If you would like to maintain your current level of prescription drug benefits under our program, it is not necessary to enroll in another Medicare Part D plan. Nevertheless, participation in a Medicare Part D prescription drug plan is voluntary and you should carefully consider all options before making any kind of decision to enroll in a different Medicare Part D plan.

Also, if you are enrolled in Medicare and your modified adjusted gross income exceeds certain limits established by federal law, you may be required to pay an additional amount for your Medicare Part D coverage under the Navitus MedicareRx (PDP) plan. Please refer to the Question: What is the Social Security income-related monthly adjusted amount (IRMAA) and does it affect me? Please note that IRMAA is not unique to the Navitus medicareRx (PDP) plan. If you are required to pay the IRMAA, you would have to do so under any Medicare Part D plan.

No. Your health insurance premium includes both medical and prescription drug coverage. If you choose to enroll in a different Medicare Part D plan, you will be dropped from the Navitus MedicareRx (PDP) plan and you will have to pay an additional premium to the other plan you enroll in. However, you will still have secondary coverage with the supplemental wrap benefits under the WPE group health insurance program. There is no partial refund of the WPE group health insurance premium if you choose to enroll in a different PDP. Navitus will coordinate coverage with Medicare and pay secondary claims after Medicare processes your prescription claims from the other Medicare Part D plan, minus the applicable copayments and coinsurance that are your responsibility. If you enroll in another Medicare Part D plan and you intend to stay in that program, notify ETF immediately. If ETF enrolls you in Navitus MedicareRx, you will be automatically disenrolled from your other plan by CMS.

Dental

Each employer has the option to offer the Uniform Dental Benefit to employees and retirees. Please contact your employer to see if you have the Uniform Dental Benefit available to you.

If you are currently enrolled in Uniform Dental Benefits, and you do not waive these benefits during It's Your Choice open enrollment, you will automatically continue to be enrolled for the next year.

Cick on the enrollment tab above. You can also submit a paper application which you can download online, or request one from your payroll or benefits office.

For specific benefit details, view the Uniform Dental Benefit Certificate of Coverage. You may visit Delta Dental's website at www.deltadentalwi.com/state-of-wi or call Delta Dental directly at 1-844-337-8383.

Contact Delta Dental directly at 844-337-8383 or visit their website at deltadentalwi.com/state-of-wi to view the provider directories. You may use a provider in either the "Delta PPO" or the "Delta Premier" network, which are both considered in-network for this plan.

Wellness

The Well Wisconsin Program is available to eligilble employees, retirees and their spouses enrolled in the group health insurance program. It provides services and resources through StayWell and rewards participants with a $150 cash incentive after completion of the StayWell health assessment, health screening and a health engagement activity.

Effective January 1, 2017, StayWell manages all aspects of the Well Wisconsin Program. You will complete the Well Wisconsin Program requirements using the secure StayWell wellness portal. StayWell will issue the $150 incentive if you complete the requirements by wellness program year deadline. Visit wellwisconsin.staywell.com to learn more.

Yes. All of the information you provide to StayWell will be kept strictly confidential as required by federal law. Only aggregate de-identified information will be shared with the group health insurance program or large employer groups. See the Equal Employment Opportunity Commission (EEOC) Notice Regarding Wellness Program and the StayWell privacy statement for more information.

Additional wellness incentives vary by health plan. Check with your health plan to learn more about additional incentives that may be available to you.

Yes, the Internal Revenue Service considers all incentives issued to you or your enrolled family members to be a fringe benefit of employment. Incentive payment information from StayWell and your health plan will be provided to your employer to be reported as taxable income and applicable deductions will be applied. No personal health information is shared with your employer, only the incentive payment amount. Retirees will receive a W-2 from ETF for incentive payments.

Visit wellwisconsin.staywell.com for additional FAQs about the Well Wisconsin Program and StayWell resources.

Changing Health Plans

Yes, but only if you, the subscriber, file an electronic or paper application within 30 days for the following events with coverage effective on the first day of the month on or following receipt of the application:

  • Move from your plan's service area (for example, out of the county) for a period of at least 3 months. Your new coverage will be effective subsequent to your move. You may again change plans when you return for 3 months by submitting another application within 30 days after your return. (See Question: What if I have a temporary or permanent move from the service area?)
  • You involuntarily lose eligibility for other coverage or lose the employer contribution for it.
  • You add one or more dependents due to marriage, birth, adoption or placement for adoption.

See the Life Change Event Guide for more information.

Note: If your premiums are being deducted post-tax, you may cancel coverage at anytime. If your premiums are being deducted on a pre-tax basis, you may cancel coverage midyear only if you become eligible for and enroll in other group coverage or terminate employment.

Otherwise, you can only change health plans without restriction during each It's Your Choice open enrollment period and coverage will be effective the following January 1.

When you change plans for any reason (for example, during an It's Your Choice open enrollment period or for a move from a health plan's service area), any annual health insurance benefit maximums under Uniform Benefits (such as durable medical equipment) will start over at $0 with your new plan, even if you change plans mid-year, with the exception of the prescription annual out-of-pocket maximum. If you are enrolled in the Uniform Dental Benefit, you will continue accumulating to the same benefit maximums as well.

A subscriber who moves out of a service area (for example, out of the county), either permanently or temporarily for 3 months or more, will be permitted to enroll in the IYC Access Health Plan or an available IYC Local Plan that offers in-network providers near you, provided an electronic or paper application for such plan is submitted within 30 days after relocation. You will be required to document the fact that your application is being submitted due to a change of residence out of a service area.

If your relocation is temporary, you may again change plans by submitting an application within 30 days after your return. The change will be effective on the first of the month on or after your application is received by your employer or by ETF, but not prior to your return.

It is important that you submit your application to change coverage as soon as possible and no later than 30 days after the change of residence to maintain coverage for non-emergency services. The change in plans will be effective on the first day of the month on or after your application is received by your employer but not prior to the date of your move. If your application is received after the 30-day deadline, you will not be allowed to change plans until the following It's Your Choice open enrollment period or in certain situations. See Question: Are there other enrollment opportunities available to me after my initial one expires?

If your relocation is temporary, you may again change plans by submitting an application within 30 days after your return. The change will be effective on the first of the month on or after your application is received by your employer or by ETF, but not prior to your return.

If you are confined as an inpatient (in a hospital, a skilled nursing facility or, in some cases, an Alcohol and Other Drug Abuse (AODA) residential center) or require 24-hour home care on the effective date of coverage with the new plan, you will begin to receive benefits from your new plan unless the facility you are confined in is not in your new plan's network. If you are confined in such a facility, your claims will continue to be processed by your prior plan as provided by contract until that confinement ends and you are discharged from the non-network hospital or other facility, 12 months have passed or the contract maximum is reached. If you are transferred or discharged to another facility for continued treatment of the same or related condition, it is considered one confinement.

In all other instances, the new plan assumes liability immediately on the effective date of your coverage, such as January 1.

Each health plan has the responsibility to determine whether or not a newly enrolled disabled dependent continues to meet the contractual definition of disabled dependent.
(See the Dependent Information section of this FAQ.)

COBRA/Cancellation or Termination of Health Coverage

If you are a retiree, you may cancel at anytime, however, once your coverage is canceled, neither you nor your surviving dependents may re-enroll in this program. Another insurance opportunity may exist under the Local Annuitant Health Program (LAHP). Contact ETF for more information. You must provide written, signed notification of cancellation to ETF.

An employee’s voluntary cancellation (or switching from family to individual coverage which is deemed voluntary cancellation for all insured dependents) requires written, signed notification to the employer denoting a cancellation of coverage. If your premiums are being deducted on a pre-tax basis under Internal Revenue Code Section 125, you may cancel coverage only if:

  • you experience a qualifying change or life event and submit an application to cancel coverage within 30 days of the event;
  • you terminate employment;
  • you become eligible for and enroll in another group health insurance plan; or
  • you cancel your coverage during the annual It's Your Choice open enrollment period.

If your adult dependent child becomes eligible for and enrolled in other group health insurance coverage, and you want to drop coverage for him/her, you must submit an application electronically or via paper to your employer (to ETF for annuitants) within 30 days of the effective date of other coverage. In addition, you must submit proof of enrollment such as an ID card from that coverage. If this is your last dependent and you want to change to single coverage, you must note that on your application.

If your spouse becomes eligible for and enrolled in other group health insurance coverage and you want to change to individual coverage or cancel your family coverage, you must submit an application electronically or via paper to your employer (to ETF for retirees) within 30 days of the effective date of other coverage. In addition, you must submit proof of enrollment such as an ID card that lists all individuals covered under that plan. (Retirees, please see the first paragraph in this Frequently Asked Question for important information.)

If your premiums are being deducted post-tax, you may cancel at anytime.

Be aware that voluntary cancellation of coverage does not provide an opportunity to continue coverage for previously covered dependents as described in the Continuation of Health Coverage section. Cancellation affects both medical and prescription drug coverage.

No refunds are made for premiums paid in advance unless your employer (or ETF if you are no longer an employee of a participating local employer) receives your written, signed request on or before the last day of the month preceding the month for which you request the refund. Under no circumstances are partial month's premiums refunded. Once coverage terminates, you will be responsible for any claims inadvertently paid beyond your coverage effective dates.

Your coverage can only be terminated because:

  • Premiums are not paid by the due date. Coverage is also waived (known as "constructive waiver") when the employee portion of the premium is not deducted for 12 consecutive months.
  • Coverage is voluntarily cancelled.
  • Eligibility for coverage ceases (for example, termination of employment).
  • Death of the subscriber.
  • Fraud is committed in obtaining benefits or there is an inability to establish a physician/patient relationship. Termination of coverage for this reason requires Group Insurance Board approval.
  • Employer withdraws from the Wisconsin Public Employers Group Health Insurance Program.

Retirees only: Your coverage can be terminated because you:

  • Failed to apply for both Medicare Part A and B when first eligible. The Medicare enrollment requirement is deferred while you or your spouse are employed and covered under a group health insurance plan from that employment. (See Question: When must I apply for Medicare?)
  • Became ineligible for coverage as a retiree because of becoming an active Wisconsin Retirement System employee. (See Question: How are my health benefits affected by my return to work for an employer who is under the WRS?)

Contact your benefits/payroll/personnel office or ETF for the date coverage will end.

When your employer's participation ends in this program, coverage will cease for all participants. This includes retirees, survivors and those who have continuation coverage. If the employer obtains group health insurance from another carrier, ask the employer if the new carrier will provide coverage for retirees, survivors and continuants.

When the employer terminates participation, you will not be eligible for continuation of health coverage.

Continuation of Health Coverage

Your COBRA continuation rights are described in the Federal/State Notifications section, under Helpful Info. Both you and your dependents should take the time to read that section carefully. This section provides additional information about continuation coverage.

You do not have to provide evidence of insurability to enroll in continuation coverage. However, coverage is limited to the plan you had as an active employee or covered dependent. (For example, if you change plans January 1 and your dependent loses eligibility December 31, that dependent would be eligible for COBRA from the plan you were enrolled in on December 31. An exception is made when the participant resides in a county that does not include a primary care physician for the subscriber's plan at the time continuation is elected. In that case, the participant may elect a different plan that is offered in the county where the participant resides.) You may select another plan during the It's Your Choice open enrollment period or if you move from the service area. If family coverage is in effect when continuation is first offered, each dependent may independently elect individual continuation coverage. A family of two may select two individual contracts at a lower cost than the premium for a family contract. The health plan will bill you directly.

There can be no lapse in coverage, so multiple premiums may be required.

A second qualifying event while on continuation will not serve to extend your period of continuation. Coverage will be limited to the original time period. At the end of the continuation period you will be allowed to enroll in a Marketplace or an individual conversion plan through the health plan.

Employees need to report this change to the benefits/payroll/personnel office within 60 days of the dependent losing his/her eligibility to ensure COBRA coverage is offered. Retirees and continuants must contact ETF. Your dependent will be entitled to 36 months of continuation coverage.

No, continuation coverage is identical to the active employee coverage. In most cases, you are eligible to maintain continuation coverage for 18 months from the month of the qualifying event. These events are termination of employment or reduction in work hours. Events such as death of employee, divorce or the loss of eligibility for a dependent child entitles the dependent to 36 months of coverage. You are allowed to change plans during the annual It's Your Choice open enrollment period or if the subscriber moves from the service area. However, your continuation coverage may be cut short for any of the following reasons:

  • The premium for your continuation coverage is not paid when due.
  • You or a covered family member become covered under another group health plan that does not have a preexisting conditions clause that applies to you or your covered family member.
  • You were divorced from an insured employee, and you subsequently remarry and are insured through your new spouse's group health plan.
  • You or a covered family member become entitled to Medicare benefits.

If you or your covered dependent becomes eligible for Medicare, you may need to enroll in Medicare as soon as you are eligible. (See Question: When Must I Apply for Medicare?)

It may change, as you will pay the total premium amount, which includes both the employee and employer share. Contact your benefits/payroll/personnel office to obtain the total amount.

To cancel continuation coverage, send a signed, written notice to ETF. Include your name, Social Security number, birth date and address. ETF will forward your request to the health plan. Your coverage will be canceled at the end of the month in which ETF receives the request to cancel coverage.

If you move out of the service area (either permanently or temporarily for three months or more), you are eligible to change plans. (See Question: What if I have a temporary or permanent move from the service area?)

Your electronic or paper application to change plans must be postmarked within 30 days after your move. Because you are on continuation coverage, call the ETF Employer Communication Center at 608-266-5020 or go online to obtain a Health Insurance Application/Change (ET-2301) form. Complete and submit the application to: Department of Employee Trust Funds, P. O. Box 7931, Madison, WI 53707-7931.

As required by law, you are eligible to apply for Marketplace or conversion coverage when group continuation coverage terminates. Contact the plan directly to make application for coverage. Marketplace or conversion coverage is available without a waiting period for preexisting conditions. The coverage and premium amount may vary greatly from plan to plan.

If the health plan automatically bills you for coverage that you do not want, simply do not pay the premium for the coverage.

If you reside outside of the IYC Local Plan service area at the time you apply for Marketplace or conversion coverage, you may only be eligible for an out-of-area policy through another insurance carrier. The benefits and rates of the plan are subject to the regulations in effect in the state in which you reside.

The Marketplace or conversion privilege is also available to dependents when they cease to be eligible under the subscriber's family contract. The request for Marketplace or conversion coverage must be received by the plan within 30 days after termination of group coverage. If you have questions, write or call the plan in which you are enrolled.

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: 11/1/2017 2:06:55 PM
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