It's Your Choice 2019
State of Wisconsin
Group Health Insurance Program
(State Employees, Retirees, Continuants and Graduate Assistants)
Frequently Asked Questions
Below is detailed information regarding enrollment and plan change opportunities during and beyond the annual It’s Your Choice 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 Plan Certificate of Coverage and the information contained in the Frequently Asked Questions section, the terms of the Certificate of Coverage shall control.
Each year ETF and the Group Insurance Board (GIB) conduct 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?
Previous changes, which were effective in 2016, aimed to achieve cost savings required by the Governor's 2015-2017 Biennial Budget. In order to meet this savings, the GIB approved changes to health plan deductibles, copayments and prescription drug coverage.
Some changes are long-term savings solutions. Federal provisions are expected to impose an additional tax on health plans with benefits over a certain value beginning in 2020; this additional tax would affect the amount you pay for health insurance. Some changes (i.e. separating the Uniform Dental Benefit from the health plans) were necessary to minimize the effect of this tax.
Information about the State of Wisconsin Group Health Insurance Program in the Frequently Asked Questions applies to the following individuals:
The Following Will Be Considered Active Employees:
Eligible Graduate Assistants (Hereafter called "Grad" in this guide section.)
The Following Will Be Considered Former Employees:
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
gold and 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 State of Wisconsin Group Health Insurance Program is required to have a complaint and grievance resolution procedure in place to help resolve participants' problems. Contact your plan or the PBM to get information on how to initiate this process. You must exhaust all of your appeal rights through the plan or the 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. 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 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 State of Wisconsin 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 for reasons 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 Form (ET-2405). Complete this 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.
The health insurance premiums for employees are automatically deducted from your paycheck on a pre-tax basis. This is often referred to as Automatic Premium Conversion. This means that you save on federal and state income tax, and FICA taxes (Social Security and Medicare taxes). This is a permanent tax exclusion, no taxes will be owed at a later date.
Important Note: When premiums are deducted on a pre-tax basis, Internal Revenue Code regulations governing premium conversion restrict changes that can be made to your health insurance benefits during the plan year. You may not make changes or cancel your participation in the health plan during the plan year unless your decision to do so is a result of a qualifying change in status event and is allowed by the health plan rules. For more information, see the Life Change Event Guide and What are my coverage options if my spouse is also a state of Wisconsin or participating Wisconsin Public Employer (WPE) employee or state retiree?
If you wish to pay your premiums on a post-tax basis, you may fill out an Automatic Premium Conversion Waiver/Revocation of Waiver (ET-2340) form and return it to your payroll/benefits office before the end of the year. Post-tax premium deductions will begin with the January deduction. Once you have filed a waiver, it will remain in effect for future plan years unless you file another Automatic Premium Conversion Waiver/Revocation of Waiver (ET-2340) form to revoke the waiver.
Retirees: Since your premiums are not taken from a paycheck, they are considered post-tax.
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.
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 for dental or choose to decline the Uniform Dental Benefit.
Similarly, if you elect individual coverage for medical, you may only choose individual coverage for dental 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 Health Plan HMO, you are required to obtain allowable care only from providers in the IYC Health Plan HMO's network. IYC Health 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 Health Plan HMO's network. Do not expect to join an IYC Health Plan HMO and get a referral to a non-HMO physician. An IYC Health 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 Health 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 Medicare Advantage or Medicare Plus, you have the freedom of choice to see any provider who accepts Medicare. Medicare Advantage offers coverage for participants with Medicare Parts A and B, with both in- and out-of-network benefits. 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 Health Plans page by clicking on the health plan name. ETF and your benefits/payroll/personnel office do not have this information.
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
(State and Grad) If eligible, you may enroll for individual or family coverage in any of the available health plans, provided you file an electronic or paper health application with your benefits/payroll/personnel office within the required enrollment period stated below:
There are no interim effective dates except as required by law. If you do not submit a completed application within 30 days of your date of hire, your coverage cannot be effective before the month you become eligible for the employer contribution toward health insurance premiums. 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 state contribution starts, you may re-enroll in health insurance with the new coverage becoming effective on the first day of the month state 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 and coverage effective dates, contact your benefits/payroll/personnel office.
(State only) Important information for limited-term employees (LTE) and employees not eligible for full-time contributions:
If you apply for coverage within 30 days after one of these events, coverage will be effective on the first of the month following your new hire date, or the date you are eligible for the increase in employer contribution. Retroactive effective dates are not allowed. This does not provide an opportunity to change from individual to family coverage.
Other Enrollment Opportunities
You may be able to get health insurance coverage if you are otherwise eligible under specific circumstances as described below:
The It's Your Choice open enrollment period is the annual opportunity for eligible employees, currently insured retirees and currently insured continuants and retirees to select one of the many health plans offered by the State of Wisconsin 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. Additional medical definitions are found in the online Certificates of Coverage.
The It's Your Choice open enrollment period is an opportunity to change health 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, retirees, continuants and surviving spouses and dependents who are eligible under the State of Wisconsin Group Health Insurance Program. Changes made become effective January first 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 health plan, you are encouraged to make changes online using your employer's electronic enrollment system or the myETF Benefits website, or you may submit a paper application using the following instructions:
Active employees** may get an application online or receive paper applications from your benefits/payroll/personnel office to complete and return to that office.
Retirees and continuants may get an application online, or contact ETF for a copy and submit it to ETF.
Applications received after the deadline will not be accepted.
Note: If you plan to stay with your current health plan for next year and you are not changing your coverage, you do not need to take any action. However, members in the IYC HDHP must re-enroll in their HSA annually.
** UW Hospital and Clinics employees should enroll using the paper application and may not use myETF Benefits to enroll or make changes.
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 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:
Other rules apply when cancelling coverage. For more information, see the Cancellation/Termination of Coverage section.
During the annual 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.
Important Note: If you are eligible or will become eligible for Medicare, you will also want to refer to the Medicare Information in the Benefits and Services section.
When you retire, your health insurance plan will automatically continue if your retirement annuity from the Wisconsin Retirement System begins within 30 days after your employment termination date. If you terminate employment after 20 years of creditable service but are not eligible for an immediate annuity, your completed Group Health Insurance Application/Change (ET-2301) form with a Continuation-Conversion Notice (ET-2311) form must be received by ETF within 90 days of your termination of employment to continue coverage. You may switch coverage to any other available health plan during the It's Your Choice open enrollment period.
For Wisconsin Retirement System (WRS) retirees only (Note: a 40.65 disability benefit is not considered a WRS disability annuity under the law):
An enrollment opportunity is available to former state employees receiving a WRS retirement annuity or those who received a lump sum WRS retirement benefit.
This option is not available to survivors or dependents.
To enroll or re-enroll:
Yes. For Wisconsin Retirement System retirees, 40.65 disability or Long Term Disability Insurance recipients, or their surviving insured dependents, if you are eligible to use your sick leave credits, you may elect to delay use (escrow) or initiate use (unescrow) of sick leave credits annually. In order to escrow, you must certify that you have health coverage comparable to the State of Wisconsin's IYC Access Health Plan. You may escrow only once during a calendar year, and your credits will be in escrow the first of the month following receipt of the Sick Leave Escrow Application (ET-4305). You may unescrow during It's Your Choice open enrollment period for coverage effective January 1 of the following year or the first of the month in the following year that you select. In addition, if you lose eligibility for your comparable coverage (not voluntary cancellation) or the contribution for it (if it is an employer sponsored health plan), you may unescrow (re-enroll) by filing an application within 30 days of the loss. (See the Sick Leave Conversion Credit Program (ET-4132) brochure for more information or contact ETF.)
(State only) If you are an employee who deferred coverage and who wants to preserve your sick leave credits for later use, you may enroll for coverage in the IYC Access Health Plan 30 days prior to retirement.
If you occupy a seasonal 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. Accumulated sick leave credits may be used to pay premium for up to five years. A written request to use sick leave credit must be submitted to your benefits/payroll/personnel office before the date of layoff.
Accumulated sick leave credits may be used to pay premium for up to five years. A written request to use sick leave credit must be submitted to your benefits/payroll/personnel office before the date of layoff.
Accumulated sick leave credits may be used to pay premium for up to five years. A written request to use sick leave credit must be submitted to your benefits/payroll/personnel office before the date of layoff.
After sick leave credits are exhausted, or if you have no sick leave credits and state share of premium is no longer available, COBRA continuation will be offered, which will allow you to purchase, at your own expense, an additional 36 months of coverage.
If you have 20 years of Wisconsin Retirement System (WRS) service at the time of the layoff but were not eligible for an immediate annuity at the time of layoff, any sick leave remaining after paying premium during layoff is available upon retirement. You cannot use your sick leave after five years from the layoff date until you retire. If you had 20 years of WRS service and were eligible for an immediate annuity at the time of layoff, you may continue to use it after five years or begin using the sick leave at anytime.
Unpaid Leave of Absence
Note: If your health coverage lapses in whole or only for your dependents during your leave due to nonpayment of premiums, you must submit a new application either electronically or via paper within 30 days of returning to work to reinstate prospectively the coverage that lapsed. 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 It's Your Choice enrollment opportunity upon your return.
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.
(State only) Lapsed coverage can also be reinstated for an employee who has been on a leave of absence and who is entitled to, and applies for, an immediate annuity. Coverage shall be effective the first day of the calendar month which 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.
Military Leave of Absence
You may not select a new health plan when you submit your insurance application due to a transfer, unless it coincides with one of the other designated enrollment opportunities.
(Grad only) If you transfer from one employing state department to another, contact your benefits/payroll/personnel office for information on how to maintain continuous coverage.
Termination of Employment
Appealing a Discharge
You may be eligible for supplemental sick leave credits if you have at least 15 full years of adjusted continuous service with the state of Wisconsin at the time of retirement. (Continuous service means the number of full years the employee has worked for the state without a break in service. Local service does not apply.) Your employer will determine whether you are eligible for supplemental sick leave credits and submit the certification to ETF. If you have questions regarding your eligibility for supplemental sick leave credits, contact your payroll office.
If you are an employee who deferred coverage and who wants to preserve your sick leave credits for later use, you may enroll for coverage in the IYC Access Plan 30 days prior to retirement.
IYC High Deductible Health Plans and Retirement
If you are retired and Medicare eligible (either 65 or older or disabled), you must enroll in Medicare and move to the non-HDHP plan. You should contact ETF to arrange this change before your Medicare enrollment becomes active.
Medicare Part D
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.
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 canceled 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 the ETF health insurance program. If you work for a state employer, the state (non-Graduate Assistant) premium rates will apply. Check with your employer to make sure you have other health insurance coverage available before you elect WRS participation.
As a state retiree, if you were paying for your health insurance from your converted sick leave credit account, your account will be inactivated if you return to work for a state government employer. Your sick leave credit account will be activated when you retire again. Any sick leave credit you accumulate during re-employment with a state government employer will be added to the balance in your account when you re-retire. If your re-employment is with a local government employer, and you have comparable health insurance coverage, you may escrow your sick leave account balance. Contact ETF or visit the ETF website for a Sick Leave Credit Escrow Application (ET-4305). Your sick leave credit account balance will be available to you when you re-retire.
You may also waive or terminate enrollment under Medicare until the first Medicare enrollment period after active WRS employment ceases. While covered through active employment, your premium rates will be the active employee rates, not the Medicare rates.
When you subsequently terminate employment, eligibility for state group health coverage is once again dependent on your meeting the requirements for newly retired employees (that is, you must be insured, and you must apply for an immediate annuity from the WRS).
If you are a disability annuitant under § 40.63(1) who is under normal retirement age and return to any employment, you are subject to a flat rate earnings limit. If you exceed your earnings limit, your disability annuity is suspended, but you will remain eligible for health insurance as an annuitant.
If you are receiving a disability annuity, you may not actively participate in the Wisconsin Retirement System (WRS) until it is determined that you are no longer eligible for a disability annuity because of medical certification. If your disability annuity is terminated, and you are employed by a employer participating in the WRS, you will become eligible for the health insurance offered by your employer.
Important Caution: Continuation coverage will end after a maximum of 36 months. It does not make you eligible to re-enroll in the state health plan when you terminate. You will only be eligible for the health insurance your employer offers its retirees, subject to its rules and requirements.
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?
You have the following options:
(See Question: How do I pay my portion of the premium?)
Some things to note:
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 the state 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 health plan's decision, you must first complete the health plan's grievance procedure. If the health plan continues to deny disabled dependent status for your child, you may appeal the health plan's grievance decision to ETF by filing an ETF Insurance Complaint Form (ET-2405). 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:
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.
You have the responsibility to inform your employer (ETF, for retirees and continuants) of any dependents losing eligibility for coverage under the State of Wisconsin 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 individual plan does not create a continuation opportunity.
If your last dependent is losing eligibility, you must file an application to change to single 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:
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:
If an application is received by your benefits/payroll/personnel office for active employees or ETF for retirees/continuants, upon order of a federal court under a National Medical Support Notice, coverage will be effective on either:
Note: This can occur when a parent has been ordered to insure one or more children who are not currently covered.
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 Chart and Question: What are my coverage options if my spouse is also a state of Wisconsin or participating Wisconsin Public Employer (WPE) employee or state retiree?)
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 with the new health plan effective on the first day of the month on or following receipt of the application.
Birth/Adoption/Legal Guardianship/Dependent Becoming Eligible
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 electronic or paper application.
Single Mother or Father Establishing Paternity
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 on 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, along with a birth certificate, adoption order, or other documentation indicating guardianship over the child.
Upon Order of a Federal Court Under a National Medical Support Notice
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 state or university employees or retirees, and each party is eligible for state health insurance in his or her own right and is insured under the state health plan at the time of the divorce, each retains the right to continue state health insurance coverage regardless of the divorce.
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 and continuants: Failure to apply in a timely manner will delay the effective date of coverage.
Medicare Eligibility: Please refer to the Medicare information in this FAQ for details regarding Medicare eligibility and enrollment requirements.
Death: (State and retirees only) 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 State of Wisconsin Group Health Insurance Program at group rates. The dependent children may continue coverage until eligibility ceases if they:
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 it will terminate on the last day of the month in which their written request is received by ETF.
Note: Survivors may not add persons to the policy who were not insured at the time of death unless the survivor is also a state employee and eligible for the insurance in his or her own right.
If family coverage was in force at the time of death, any unused sick leave credits in the deceased employee's account are available to the surviving dependents for premium payments. If sick leave credits are escrowed, the surviving dependents may continue to escrow the credits or may apply to convert the credits to pay health insurance premiums.
Note: 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.
(Grad only) If family coverage was in force at the time of death, the covered surviving dependents are then eligible for COBRA Continuation. (See Question: Who is eligible for continuation?).
If your employee premiums are deducted on a pre-tax basis under Internal Revenue Code Section 125 rules, 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.) 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 employee premiums are deducted on a post-tax basis or you are a retiree, 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.
(State only) Please Note: If you have individual coverage and you should die, your sick leave credits will not be available for use by your surviving dependents.
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 enrollment period, or when you or an eligible dependent has a qualifying event that allows for family coverage. See 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?
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 health 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?):
Exception: If you change your primary care physician (PCP) or your primary care clinic (PCC) , you may contact your health plan.
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 IYC Health Plans, Access Plan, Medicare Advantage 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 health plan, and make sure you understand any requirements.
For the IYC Access Health Plan and SMP, it is recommended 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 health 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 IYC Health Plans Certificate of Coverage. Contact your health plan for more information.
It's rare that you would have to. 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.
If you are enrolled in Medicare Advantage, when you visit your provider, you must show your health plan's card. You do not need to show your Medicare card, but you should keep it in a safe place. Your provider will submit your claims directly to UnitedHealthcare.
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 IYC Health Plans, Access Plan, Medicare Advantage 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, which is the maximum you will pay for essential health benefits. Please see your Certificate of Coverage for information on which services apply to the OOPL and MOOP.
Most IYC Health Plans will pay nothing when non-emergency treatment is provided by physicians outside of the health plan unless there is an authorized referral. Contact the health plans directly regarding their policies on referrals.
For emergency or urgent care, health 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 health plan may not pay the entire bill and try to negotiate lower fees. However, ultimately the health plan must hold you harmless from collection efforts by the provider. (See the definition of Emergency Care in the IYC Health Plans Certificate of Coverage.)
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 or PCC, 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's office to see if he or she will be available to you under your IYC Health Plan or IYC HDHP HMO. Confirm this with the IYC Health Plan or IYC HDHP HMO's provider directory. Even though your current physician may join an IYC Health Plan or IYC HDHP HMO, he or she may not be available as your PCP just because you join that IYC Health Plan or IYC HDHP HMO.
If you are enrolled in an IYC Health Plan HMO or IYC HDHP HMO, you will need to find an in-network provider for your care. If you are in your second or third trimester of pregnancy, then you may continue to have access to your provider until the completion of postpartum care for yourself and your baby. 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 health 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 health 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 health plan's network.
Your provider leaving the plan does not give you an opportunity to change health plans midyear.
A participant must designate a PCP or PCC. Your PCP or PCC is responsible for managing your health care. Under most circumstances, they 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
(State and Grad only) For eligible employees, the employer contribution is determined either through collective bargaining or through the applicable compensation plan.
The three-tier health insurance program was implemented as an innovative approach that holds costs down as it creates incentives for health plans to reduce their costs to the state, and encourages employees in the state to choose the health plans that are most efficient in providing quality health care. Each health plan is rated and placed in a tier based on providing the most cost-effective, quality care (as determined by ETF). Health plans in the same tier have been determined to be within certain thresholds in their level of providing cost-effective, quality care.
(State and Grad only) No, all plans are required to offer the Uniform Medical Benefits. Premium rates and tier placement may vary because of many factors:
Also, members who enroll in the Uniform Dental Benefit plan will have a slightly higher premium than members who decline dental.
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 It's Your Choice open enrollment period.
(State and Grad only) No. The Group Insurance Board requires that plans demonstrate high quality in order to be in the program. This is verified by our collection of data from the Consumer Assessment of Health Plans (CAHPS) survey, the Health Plan Employer Data and Information Set (HEDIS) and other quality measures.
(State and Grad only) Premiums are deducted from your paycheck. If you have questions, contact your employer. Note: If eligible, your premiums will automatically be deducted from your payroll check on a pre-tax basis unless you choose otherwise.
(Retirees only) 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). However, the state does not pay any portion. Your premiums are post-tax.
Your monthly premiums will be paid in one of the following ways:
(Retirees only) You do not have to use your sick leave credits to pay your health premiums if:
Note: You can unescrow your sick leave once a year during the It's Your
Choice open enrollment period. (See Sick
Leave Conversion Credit Program (ET-4132) brochure for detailed
A deductible is the amount you must pay out-of-pocket for the full cost of certain covered health care services before your health plan begins to pay.
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.
Example: paying a copayment of $15 for a primary care visit.
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 most in-network, covered services during a plan year (same as calendar year).
The State and WPE (local government) programs have 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 of Wisconsin and WPE Group Health Insurance Programs. For any essential health benefit costs that do not stop at the program OOPL, the federal MOOP provides 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 State of Wisconsin Group Health Insurance Program, this only applies to Level 3 and Non-Preferred Level 4 prescription drugs.
The medical deductible is $250 per individual and $500 per family for the It’s Your Choice Health Plan. Keep in mind that certain preventive services are covered at 100%. Office visit copayments and prescription drug costs are not subject to the deductible and do not apply towards meeting the deductible.
Note: You can find complete deductible and benefit information for your plan online, under the Compare Benefits tab.
All eligible medical charges are subject to the annual deductible. There are three exceptions:
These visits are not subject to the deductible, but any additional services you receive (e.g., lab work or testing) may be subject to the deductible and any applicable coinsurance.
No. There is no deductible associated with covered services under the Uniform Dental Benefit, including for the high deductible health plan (HDHP) option.
No, but any additional services you receive (e.g., lab work or testing) may be subject to the deductible and any applicable coinsurance.
* If all prenatal visits are billed as a package at the end of pregnancy, then deductible and 10% coinsurance apply. Check with your doctor’s office for more information.
Yes, office visit copayments are applied to the annual OOPL.
Yes. After the deductible is met, a 10% coinsurance will be charged for all non-copayment related services beyond the charge for the office visit.
Exception: A 20% coinsurance applies to covered durable and disposable medical equipment, certain hearing aids and cochlear implants.
The medical deductible is $1,500 per individual and $3,000 per family for the It's Your Choice High Deductible Health Plan. The only services covered before your deductible is met are preventive services; these are covered by the plan at 100%.
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.
No. These preventive services are covered at no cost to you, as long as the services are provided by an in-network provider. Therefore, they do not apply to the deductible, including under the It’s Your Choice High Deductible Health Plan (HDHP). You can find a list of these preventive services here.
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, they typically negotiate discounts and rebates with drug manufacturers, contract with pharmacies and develop and maintain the drug formulary.
A PBM also provides programs designed to help members maintain or improve their overall health by working closely with the member and their doctor to ensure the drugs members take are safe and effective.
Navitus Health Solutions is the PBM for the State of Wisconsin 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 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 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.
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. For non-Medicare members, Level 3 drugs that are prescribed by your doctor as "dispense as written" may cost you even more. See Why did I get a generic drug instead of a brand name drug?
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 tool on their website that will tell you how much your drugs will cost at the specific pharmacy you go to.
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.
To provide you with the best value, the uniform pharmacy benefits requires that higher cost brand name drugs be replaced by lower cost generic equivalent or alternative drugs that have been proven to work like the brand name drug. In most cases the brand name drug will not be a preferred drug on the formulary. If you cannot take the generic drug for medical reasons, your doctor will have to request an exception to coverage from Navitus.
Some doctors write prescriptions as "DAW-1," or "dispense as written." This means the pharmacist will fill the brand name drug as written on the prescription and will not substitute an available generic equivalent. You will pay more for "DAW-1" brand name Level 3 drugs unless you cannot take a the generic equivalent drug due to a medical need. If you have a medical need, your doctor must submit an FDA MedWatch form for the prescription. Your doctor can contact Navitus for the form. Without the form, you will pay the 40% coinsurance plus the cost difference between the brand name drug and its generic equivalent. With the form, you will pay a 40% coinsurance (with a limit of $150).
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 insured under active employee coverage, these requirements to enroll for Medicare coverage are deferred for you and your dependents until the termination of employment. Because all plans that participate in the State of Wisconsin Group Health Insurance Program have coverage options that are coordinated with Medicare, you will remain covered by the 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. The plan will not duplicate benefits paid by Medicare. However, if enrolled in the IYC Access Health Plan or SMP, your coverage will change to the Medicare Plus plan when you enroll in Medicare Parts A and B. For all health plans, prescription drugs will continue to be covered.
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 http://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 the 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.
(State and Retirees only) ETF does not require you and your dependents to enroll in Medicare until you, 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 State of Wisconsin 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 while on COBRA, your eligibility for COBRA coverage ends. Contact ETF for more information.
(Grad only) There is no Medicare reduced rate available to those enrolled in the Graduate Assistant program.
(State and Retirees only)
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
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 insured as an active employee under a non-state 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 State of Wisconsin 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
Please note that the Navitus MedicareRx (PDP) plan is not available in the U.S. Territories, except for the Puerto Rico. If you live in one of the other U.S. Territories you must enroll in another Medicare Part D Plan. You will still have the wrap benefit available as secondary coverage.
Before Navitus can report your enrollment in Medicare Part D to Medicare, they need to have either your Medicare Health Insurance Claim (HIC) number or your Medicare Beneficiary Identifier (MBI) 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 are retired and cover a Medicare-eligible spouse or disabled dependent on your plan, please notify ETF and provide your spouse's or 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 State of Wisconsin Group Health Insurance Program.
If you choose to enroll in a different Medicare Part D plan, your health insurance premium for the state plan does not change, but your supplemental, wrap-around pharmacy coverage will be secondary to the other Medicare Part D plan. (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?
(Annuitants only) 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).
Health Plan Medicare:
You must be enrolled in Medicare Parts A and B to be eligible for the IYC Medicare Advantage plan. You should keep your Medicare card in a safe place, but you should not show it when you receive health care services, as the the IYC Medicare Advantage plan will be primary for your service. See question: If I have Medicare as my primary coverage, how are my benefits coordinated?
Pharmacy Benefit Manager:
However, if you choose, or are required to enroll in a Medicare Part D plan other than the Navitus MedicareRx (PDP) plan, your supplemental wrap coverage, which is part of your State of Wisconsin Group Health Insurance Program pharmacy benefits will be considered secondary. You should be prepared to file the secondary claims manually through Navitus. Contact Navitus or visit their website for more information on filing manual claims. Refer to the Medicare Part D Information section for more details.
Medicare Part B pharmacy claims are covered under the supplemental wrap coverage benefit. For specific information on Medicare Part B pharmacy coverage and Part B claims processing, see the plan description page for Navitus™ Health Solutions.
(Retirees only) Medicare Cross-over is designed to eliminate some of the paperwork involved in filing medical claims. Some plans have an agreement with Medicare to crossover claims for any services that Medicare processed as primary. Medicare will automatically forward your Medicare Summary Notice (MSN) to those plans for services you receive throughout the United States. Claim forwarding is automatic for each person covered under Medicare when a plan participates in Medicare Cross-over. You do not need to complete a form or contact a plan to take advantage of crossover. Please contact your health plan for further information.
(Retirees only) Since all state health plans have coverage options that are coordinated with Medicare, you will remain covered by the plan you selected after you are enrolled in Medicare, even though Medicare is the primary payor of your claims.
Note: For some benefits under Health Plan Medicare and Medicare Advantage, 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 State of Wisconsin 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 State of Wisconsin Group Health Insurance Program. It is not included in your State of Wisconsin Group Health Insurance Program premium.
Additional information can be found in SSA Publication No. 05-10536 or by calling the SSA 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 State of Wisconsin Group Health Insurance Program. As required by Uniform Pharmacy Benefits and IYC Medicare Plus, a supplemental wrap benefit is also included to mainly provide full coverage to State 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 (CMS) 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. It is available online under the Available Plans page or on paper by calling ETF.
(Retirees only) 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 State group health insurance program, after you become eligible for Medicare Part D the following will happen:
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.
(Retirees only) No. Your health insurance premium includes both medical and prescription drug coverage. If you choose, or are required 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 State of Wisconsin Group Health Insurance Program. There is no partial refund of the State of Wisconsin Group Health Insurance Program 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 may be automatically disenrolled from your other plan by CMS.
The Group Insurance Board selected UnitedHealthcare to administer the It’s Your Choice Medicare Advantage plan, a new plan option under the State of Wisconsin Group Health Insurance Program.
ETF’s Medicare Advantage Plan is a group insurance plan; most plans that are advertised on TV or in magazines are individual plans. Group insurance plans are purchased by an organization on behalf of a group. Individual plans are purchased by individuals for themselves or their family, either through an insurance company or a broker.
With a group Medicare Advantage plan, the state can negotiate plan enhancements that are not available via individual Medicare Advantage plans. For example, a group Medicare Advantage plan offered through ETF would not be subject to the prescription drug coverage gap, otherwise known as the “donut hole.” The It’s Your Choice Medicare Advantage plan will provide the Uniform Benefits, set by the Group Insurance Board each year. The prescription drug benefits will continue to be offered through Navitus.
The It’s Your Choice Medicare Advantage plan will cover the same uniform set of benefits as most of the other Medicare-coordinated plans ETF offers. However, UnitedHealthcare will offer some specialized services such as optional in-home preventive visits and SilverSneakers, a gym membership program.
The medical benefits will be a lot like the other Medicare-coordinated benefits offered by the program, but with Medicare Advantage, you can see any doctor nationwide who accepts Medicare and is willing to treat you and bill UnitedHealthcare. ETF will release medical benefit comparisons for It’s Your Choice open enrollment in the fall.
The It’s Your Choice Medicare Advantage plan is a “passive” Preferred Provider Organization, or PPO, meaning you are not restricted to using network doctors, hospitals and other health care providers. You can see any provider that accepts Medicare and is willing to treat you and bill UnitedHealthcare. For services covered by the group health insurance program, you can continue to see your doctors if they have not opted out of Medicare and agree to see you. Both nationally and in Wisconsin, less than 1% of providers have opted out of Medicare.
No. This is a national plan that allows you to see doctors and hospitals around the nation, whether they are in-network or out-of-network. This plan will travel with you and your covered dependents throughout the United States. The service area is all counties in all 50 U.S. states, the District of Columbia and all U.S. territories.
You will have worldwide coverage for emergency and urgently needed care. You may need to pay the entire claim when receiving care and then submit the claim to UnitedHealthcare for reimbursement after returning to the U.S.
No. You will only use the UnitedHealthcare Group Medicare Advantage ID card for all covered medical services. You should put your Medicare card somewhere for safe keeping. It is important that you use your UnitedHealthcare ID card each time you receive medical services. Because UnitedHealthcare pays all claims directly, the claims no longer go to Medicare first. By always showing your UnitedHealthcare ID card, you will ensure your claims get processed correctly, timely and accurately.
You will continue to use your Navitus card when you fill your prescriptions.
Your prescription drug coverage will continue to be provided by Navitus.
No. All Medicare-coordinated plan options through the group health insurance program offer the same pharmacy benefit administered by Navitus. The plans have the same formulary, in-network pharmacies, mail-order program and cost sharing. There is no coverage gap, or “donut hole” to worry about.
A retiring individual who is not eligible for Medicare will stay on his or her current plan. When the retiree turns 65 or otherwise becomes eligible for Medicare, he or she will move to the Medicare version of the plan they are currently enrolled in. A participant can change plans during the annual It’s Your Choice open enrollment period each fall.
When a retiree turns 65 and becomes eligible for Medicare, he or she will move to the Medicare version of the plan they are currently enrolled in. The retiree’s existing coverage will remain the same for any dependent under age 65 until he or she becomes eligible for Medicare.
Note: ETF members are only eligible for an It’s Your Choice Medicare Advantage plan if all members on the family plan are enrolled in Medicare Parts A and B.
Yes. You have an opportunity to change plans each fall during the It’s Your Choice open enrollment period.
Yes. As is the case today, when retirees turn age 65 or first become eligible for Medicare, they must enroll in Medicare Parts A and B. Under the It’s Your Choice Medicare Advantage Plan, retirees must pay or continue to pay their monthly Part B premium. Retirees who stop paying their Part B monthly premium will be moved from this plan to the It’s Your Choice Medicare Plus plan.
Yes. You will retain all the rights and privileges of traditional Medicare. Under the It’s Your Choice Medicare Advantage plan, your medical claims will be paid directly by UnitedHealthcare.
The monthly premium rates will be released before the It’s Your Choice open enrollment period, along with the premium rates for all State Group Health Insurance Program plan options.
Note: On May 16, 2018, the Group Insurance Board set the medical rate of $103.82 for the group Medicare Advantage plan for 2019, but the total monthly premium is to be determined, once pharmacy benefits, dental benefits and administrative fees are known.
There will be no difference in how premiums are paid.
Most state retirees use accumulated sick leave credits to pay their health insurance premiums. After all sick leave credits have been used, monthly premiums are then deducted from the annuity check. If the annuity payment is not large enough to cover the monthly health insurance premium, the health plan can be paid directly.
The answer lies in how the federal government reimburses for Medicare-covered services. Under the current structure, traditional Medicare pays pre-set amounts for specific services, regardless of the patient involved. Under a Medicare Advantage plan, the federal government recognizes that some individuals have health risk factors that make them likely to need additional services. Medicare reimburses more for those patients and enhances payments to the Medicare Advantage plan based on how well it meets standards for quality and member satisfaction. Medicare Advantage plans have an incentive to make sure all members get the care they need. By optimizing federal reimbursement through the Medicare Advantage plan, the State can achieve savings while maintaining the same level of covered services for its retirees.
ETF and UnitedHealthcare are developing educational materials that will be available before the next It’s Your Choice open enrollment period. We will mail information to members, host in-person information meetings and offer online learning resources.
The results of the recent survey of Medicare members affirmed the recommendation of the Medicare Advantage evaluation committee. The key findings of the survey were:
The committee and ETF staff recommended the addition of a nationwide Medicare Advantage plan that is comparable to other Medicare-coordinated plans, but with a lower monthly premium. The new option will be available for the 2019 benefit year.
No. This is a custom Group Medicare Advantage PPO plan designed exclusively for the Wisconsin Department of Employee Trust Funds. This plan is different and should not to be confused with individual UnitedHealthcare Medicare Advantage plans that might be available in the area.
All state employees and retirees who elect medical coverage through the State of Wisconsin Group Health Insurance Program are eligible. If you are currently enrolled in Uniform Dental Benefits, and you do not decline these dental benefits during It's Your Choice open enrollment, you will automatically continue to be enrolled for the next year.
Click on the Enrollment tab. You can also submit a paper application, which you can download online, or request from your payroll or benefits office.
Contact Delta Dental directly at 1-844-337-8383 or visit their website at www.deltadentalwi.com/state-of-wi to view the provider directories. Delta Dental PPO and Delta Dental Premier providers are all considered in-network for the Uniform Dental Benefits Plan.
No. If you elect family medical coverage with dental, you will be enrolled in the family dental coverage. Similarly, if you elect individual medical coverage with dental, you will be enrolled in the individual dental coverage.
The Uniform Dental Benefit uses the Delta Dental PPO and the Delta Dental Premier networks. You may use a dentist who participates in either network. ETF encourages you to check whether your dental provider is in-network before receiving dental services. There is no benefit for out-of-network providers. Please visit www.deltadentalwi.com/state-of-wi to search for in-network providers.
No. See the deductible questions for more information.
All covered services, copayments and/or coinsurance will be outlined in the Uniform Dental Benefit Certificate. Any changes to the covered dental services, copayments and/or coinsurance will be noted in the It’s Your Choice open enrollment materials and in Delta Dental’s benefit materials.
The Well Wisconsin Program is available to eligible 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 well-being 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 program activities by the wellness program year deadline.
ETF previously communicated plans to move the program incentive from a gift card to a premium reduction in 2019 for active state employees. However, this transition will not occur for 2019. Participation in 2018 will not affect premium rates in 2019. All participants will continue to receive the $150 gift card upon completion of the program steps. Visit wellwisconsin.staywell.com or call 1-800-821-6591 to learn more.
Yes. All of the information you provide to StayWell will be kept strictly confidential as required by federal lawl. 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 see taxes removed from their total gift card amount and 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.
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:
See the Life Change Event Guide for more information.
When you change health plans for any reason (for example, during an It's Your Choice open enrollment period or for a move from a 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. You will continue accumulating to the same benefit maximums under the Uniform Dental Benefit plan as well.
If you move between two options offered by the same health plan carrier, your benefit maximums and out of pocket limits will continue to accumulate.
A subscriber who moves out of a service area (for example, out of the county), either permanently or temporarily for three months or more, will be permitted to enroll in the IYC Access Health Plan or an available alternate plan offered under the IYC Health Plans 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.
(State and Grad only) It is important that you submit your electronic or paper 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.
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, twelve 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.)
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 you are a retiree, you may cancel at any time. You must provide written, signed notification of cancellation to ETF.
If your premiums are being deducted on a pre-tax basis, you may cancel coverage only if:
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 individual 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.
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 a state employee) 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:
(State and Grad only) Your coverage can be terminated because your eligibility for coverage ceases (for example, termination of employment).
(Retirees only) Your coverage can be terminated because you:
Active employees should contact their benefits/payroll/personnel office
(retirees and continuants should contact
ETF) for the date coverage will end.
(State and Retirees only) If you terminate state employment and you are not enrolled for health insurance or subsequently terminate coverage, you may enroll for individual or family coverage if you are:
If you are eligible, you must submit an electronic or paper application to enroll during the It's Your Choice open enrollment period and may select any offered health plan. Surviving dependents are not eligible for this enrollment.
(State only) Yes. Under certain circumstances, your accumulated unused sick leave can be converted to credits to pay for health insurance premium if you are:
The rules governing eligibility are described in ETF publications Sick Leave Credit Conversion Program (ET-4132), Group Health Insurance (ET-4112), Information for Retirees (ET-4116) and Your Benefit Handbook (ET-2119).
Your COBRA continuation rights are described in the Federal/State Notifications Section, under the Helpful Info tab. Both you and your dependents should take the time to read that section carefully. This section provides additional information about continuation coverage.
(State and Grad only)
Note: Continuation coverage time limits do not apply to state and university
employees who terminate with 20 years of Wisconsin Retirement System-creditable service and remain
a Wisconsin Retirement System (WRS) participant. They can continue the group health insurance for life
even if they don't take an immediate annuity. To continue, an application
must be received before coverage lapses.
You will need to report this change to your benefits/payroll/personnel office (or ETF for retirees and continuants) within 60 days of your dependent losing his/her eligibility to ensure COBRA coverage is offered. Your dependent will be entitled up 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:
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?)
If you are an active employee, your premium 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.
If you are a retiree or continuant, you will want to refer to the full premium rates.
To cancel continuation coverage, send a signed, written notice to ETF. Include your name, ETF ID or Social Security number, date of birth 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 608-266-3285 or toll free at 877-533-5020 to obtain a Group Health Insurance Application/Change Form (ET-2301). 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 conversion coverage that you do not want, simply do not pay the premium for the coverage.
If you reside outside of the IYC Health Plan HMO 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.
It is a health plan that, under federal law, has a minimum annual deductible and a maximum annual out-of-pocket limit set by the IRS. An HDHP does not pay any health care costs until the annual deductible has been met (with the exception of preventive services mandated by the Patient Protection and Affordable Care Act). The plan is designed to offer a lower monthly premium in turn for more shared health care costs by the member.
To be eligible for an HDHP, you must be enrolled in the state sponsored Health Savings Account (HSA) and:
Yes. Under Wisconsin statute for public (state) employees, the High Deductible Health Plan (HDHP) with a state sponsored Health Savings Account (HSA) benefit option requires dual enrollment in both the HDHP and HSA benefit options.
The following are not eligible for the It’s Your Choice High Deductible Health Plan:
Disqualifying other health coverage is coverage under any other health plan that is not an HDHP and which provides health care coverage prior to meeting the deductible. Below are examples of other health coverage that pays for out-of-pocket health care expenses before you would meet your HDHP deductible:
Yes. There are a number of exceptions to the rule of requiring HDHP coverage for an HSA and no other health coverage. Exceptions include:
No. Insurance for liability under workers’ compensation laws, liability for ownership or use of property, will not disqualify an individual.
No. Coverage for specified disease or illness, such as, cancer, diabetes, asthma, is allowed in addition to HDHP and HSA coverage without impacting eligibility.
Note: The insurance industry sells insurance that appears to satisfy the specified disease exception, but actual coverage is not for a disease. You should check with your disease or illness insurance provider to make sure your disease or illness coverage is compatible with both an HDHP and HSA.
Yes. Hospital insurance that pays a fixed amount per day for a hospitalization is allowed and does not disqualify you for the HDHP HSA benefit option.
Some critical illness insurance plans are designed to be compatible with HDHPs and HSA eligibility and others are not. A critical illness insurance plan that pays the HDHP deductible amount are not allowed. You should check with your critical illness insurance provider on if your plan is compatible with HDHP and HSA.
Yes. You would have other health coverage that disqualifies you for the It’s Your Choice High Deductible Health Plan and HSA benefit option.
No. The law and rules only look at the eligibility of the subscriber. You are not made ineligible for the HDHP and HSA benefit option because your spouse is ineligible, as long as you are not covered underneath your spouse’s traditional health coverage.
No. In determining eligibility, only your coverage matters. The health coverage of your dependent child does not impact your eligibility for family coverage in the HDHP and HSA benefit option.
Yes, unless the HRA meets one of the exceptions:
Yes. Your health care FSA coverage will make you ineligible for the HDHP and HSA benefit option. Your Health Care FSA is considered another health plan because you can use the money in your Health Care FSA for general health care expenses prior to meeting your HDHP deductible.
Yes. The industry uses a few different names to describe a Health Care FSA including: Flexible Spending Account (FSA), Medical Flex Plan, Flexible Spending Arrangement, Medical Reimbursement Plan, etc. Any plan that provides coverage for health care expenses prior to meeting the HDHP deductible, would disqualify you for the HDHP and HSA benefit option.
Generally, yes. If your spouse’s Health Care FSA can be used to pay for your medical expenses prior to meeting the HDHP deductible, then this makes you ineligible.
No. The rule disqualifying you when your spouse is covered by a Health Care FSA assumes the Health Care FSA can also be used for you. Given the popularity of HSAs and their growth, some plan documents are drafted to allow the individuals the choice of whether or not to cover their spouse. If your spouse’s Health Care FSA cannot be used for you, then you do not have other health coverage and will not disqualify you.
No. In order to remain eligible, your spouse’s Health Care FSA plan document must provide an option to exclude you from your spouse’s Health Care FSA coverage.
Yes. If you are covered under a Health Care FSA, you are not eligible for the HDHP and HSA benefit option. This answer remains the same if the only reason you have Health Care FSA coverage is because of a carryover of unused Health Care FSA funds. Leftover funds may, however, be rolled into a Limited Purpose FSA, which is HSA-compatible and not disqualifying. See Question 21 in this section.
The Internal Revenue Service, outlined three options that will allow you to gain eligibility on the first day of the next year:
The State of Wisconsin sponsored Health Care FSA follows option two. If you newly enroll in the It’s Your Choice High Deductible Health Plan and Health Savings Account benefit option, your eligible Health Care FSA funds will automatically carry over from your Health Care FSA to an LPFSA.
A deductible is the fixed amount that you must pay before your insurance begins to make payments for covered medical services. For example, if you have a $1500 deductible, you must incur $1500 in covered medical expenses (for which you are responsible for paying) before your insurance pays anything (with the exception of preventive services mandated by the Patient Protection and Affordable Care Act).
Health plans will provide you with periodic explanation of benefit statements that will provide this information. While it’s always a good idea to keep track of your out-of-pocket medical expenses, you can check with your health plan to determine where you are in meeting your deductible.
Yes, the prescription benefits remain the same, with the exception of an added deductible. Certain prescription drugs that are considered preventive medications are provided with "first-dollar" coverage under the HDHP, meaning that your benefits pay for these drugs before you meet your deductible. In other words, your deductible does not apply to these certain preventive drugs and you will not have to pay for the full cost of the drug. You will still have to pay the copayment on these preventive medications in most cases; however, there are also some drugs which are covered at 100% by federal law, meaning you will not have to pay the copayment on these specific drugs. You can find the lists of preventive prescription drugs that are paid with "first-dollar" coverage and those that require no copayment under federal law on the It’s Your Choice website.
An HDHP must meet certain requirements, including the minimum amount of the deductible and maximum out-of-pocket limit, as set by the IRS.
Yes, examples of covered services before the deductible is met include: in-network preventive medical services and certain preventive prescription drugs. A list of preventive medical services covered at 100% is available at Healthcare.gov (https://www.healthcare.gov/coverage/preventive-care-benefits/). See question 55 for more information about preventive prescription drugs.
No, the amount you pay for medical claims submitted to your health plan and prescription drug claims submitted to the Pharmacy Benefit Manager (PBM), both count towards a single deductible.
Your health plan and the PBM, share your claims data in order to account for all the costs you pay. The combined amount is applied to your deductible. However, be aware that claims processing for prescription drugs is nearly instantaneous when you receive your prescriptions, but medical claims processing takes more time. As such, there may be times when you have actually met your deductible but your health plan and the PBM are not aware of it. Retroactive adjustments and refunds for costs you paid after reaching your deductible will occur.
No, you only have to incur the claims. You are still responsible for payment, but your deductible is considered to be met once you receive the service and it is billed to the health plan.
Yes, you will have an insurance ID card the same as you would under any of the other health plan options.
You can use your sick leave credits to pay for your premium only. These credits cannot be transferred to your HSA.
No, the Uniform Dental Benefit is now separate from the medical and prescription drug benefits. There is no deductible associated with the Uniform Dental Benefit plan.
No, the deductible and OOPL amounts are not changing for the HDHP for 2019.
An HSA is an account established by an individual to pay for health care. To set up an HSA, the individual must be covered by a federally qualified HDHP. HSAs are owned by the individual, balances roll over from year to year, and the funds are portable, meaning the employee keeps them if they leave the HDHP plan or state service. The funds in an HSA can be used to pay for qualified medical expenses that are not covered by your health plan, and can be saved for future expenses on a pre-tax basis. The funds can also be invested. Contact TASC for investment options. See question #12 for more information.
A participant is only eligible for an HSA if they are enrolled in a federally qualified HDHP. A participant may not enroll in both an HSA and a regular health care FSA at the same time, although the FSA can be converted to an allowed Limited Purpose Flexible Spending Account (LPFSA). Both types of accounts allow a participant to set aside money pre-tax to pay for healthcare expenses, however, there are some key differences shown in the table below:
No, you choose how you pay for your deductible.
Check out this list of qualified expenses.
Yes, some of the expenses include: cosmetic surgery, over-the-counter medications, insurance premiums, and family or marriage counseling. This a list of qualified expenses.
Yes, you cannot enroll in a state sponsored HSA through your employer unless you are enrolled in the High Deductible Health Plan.
Anyone can contribute money to your HSA. Your employer can make pre-tax contributions to your HSA. You can also choose to contribute tax-free dollars through your payroll. Any others who choose to contribute to your account would do so on an after-tax basis, although you would be able to deduct the contribution from your gross income on your tax return.
Yes, Contributions made to an HSA by a family member on behalf of an eligible individual are deductible by the eligible individual in computing adjusted gross income. The contributions are deductible whether or not the eligible individual itemizes deductions.
Yes, you can arrange this through your payroll office. When you complete the HSA enrollment process, you will have the option to choose a pre-tax paycheck deduction amount. Note: LTEs are not able to contribute to an HSA through payroll deduction.
Yes, the limits are available online in the IYC HSA Information section. The IRS updates the annual limits each year, so the limit in future years may be different. All contributions, including those made by your employer or another person, are combined when applying the contribution limit.
No, your HSA balance will roll over from year to year.
Yes, your HSA balance earns interest. You can also choose to invest a portion of your HSA balance once you have a $2,000 balance in your account. More information is available at www.tasconline.com.
Yes, the contributions made by your employer are not taxable income. This money is yours, tax-free, as long as you spend it on qualified medical expenses. You can also make pre-tax contributions to your HSA, contact your payroll office to arrange.
Yes, as long as you use the funds to pay for qualified medical expenses, you can pay for any family member who is a tax dependent on your tax return. You may also use the funds for medical expenses incurred by your child who is claimed as a tax dependent by his/her other parent.
The IRS views spouses as one tax unit, even if filing as "married filing separately", so if either spouse is eligible for a family contribution limit, that is intended to cover both spouses. The IRS suggests that the family limit be split evenly between the spouses, unless a separate allocation is desired.
The money in the HSA belongs to you. You can continue to use the money in your HSA to pay for qualified medical expenses, but you can no longer make contributions to the account unless you are enrolled in another HSA eligible HDHP.
You can withdraw money at any time if it’s used for qualified medical expenses. However, if you withdraw money for other purposes, your withdrawal will be subject to income tax (if the contribution was pre-tax) and a 20% penalty.
You can keep your HSA open as long as you choose. This is your account. Your new employer may or may not contribute to this HSA. Once you leave state service you are responsible for any account maintenance fees.
You can continue to use your account tax-free for qualified medical expenses. Once you turn age 65, you can also use your account to pay for things other than medical expenses. If used for other expenses, the amount withdrawn will be taxable as income but will not be subject to any other penalties. Individuals under age 65 who use their accounts for non-qualified medical expenses must pay income tax and a 20% penalty on the non-qualified withdrawal.
The HSA is an asset that is treated like any other. The HSA may be transferred between two divorcing parties as part of the divorce agreement. Either parent may use HSA funds to cover their children's eligibility expenses under IRS Regulation and it does not matter which parent considers the children to be dependents for income tax purposes or which parent maintains physical custody of them.
No, only expenses incurred after establishing your HSA.
Yes, you can use your HSA to pay for any qualified medical expenses from any provider.
Yes, as long as you are not currently eligible for or enrolled in Medicare.
It depends. You can have a limited-purpose Health Care FSA, which only allows you to pay for qualified vision, dental and post-deductible expenses. However, the IRS prohibits you from having a general-purpose Health Care FSA and an HSA at the same time because they have almost identical qualified medical expenses, and because the IRS considers a Health Care FSA to be “other health insurance coverage”. It is permissible to still have a dependent day care FSA when you have an HSA.
You can enroll in the HDHP for the next plan year if you are enrolling during It’s Your Choice (open enrollment period). You will be required to spend out any remaining FSA funds before the HDHP can take effect and before you are eligible to open an HSA. In some cases your FSA funds may be converted to a limited-purposed FSA, check with your employer on this.
Your HSA would transfer to your beneficiary tax-free.
It is recommended that you keep your receipts. If you are audited by the IRS, you may need to explain any funds you used from your HSA.
For information on available plans, open enrollment and benefits, please view Supplemental Benefit Plans.
Eligible members may enroll in any of the supplemental benefits during the It's Your Choice open enrollment period.
A member can also enroll, cancel or change supplemental coverage during a specific qualifying events (birth/adoption, marriage, divorce, ect.). View the list qualifying events.
There are two supplemental dental options available for you, the Delta Dental PPOSM-Select Plan and the Delta Dental PPO Plus PremierTM-Select Plus Plan. Learn more about the supplemental dental plans.
No. The two supplemental dental plans cover many of the same services but at different levels of coverage.
The Select Plan covers dental services at 50% and the Select Plus Plan covers those same services 60%-80% and includes a $1,500 individual lifetime maximum for orthodontic services.
Yes! If you wish to continue supplemental dental coverage for 2019, you must select a different plan during the It's Your Choice open enrollment period. See the 2019 supplemental dental plans.
If you currently have supplemental vision insurance through ETF with a provider other than VSP you will need to select a new provider during the It's Your Choice open enrollment period. VSP will be the only State of Wisconsin supplemental vision insurance provider in 2019. View VSP's supplemental vision benefits.
If you have a supplemental insurance plan through a vendor that will no longer be with the State of Wisconsin in 2019 and you do not select a different supplemental plan during the It's Your Choice open enrollment period, you will not have supplemental insurance for 2019. You cannot add coverage after open enrollment unless you experience a qualifying life event.
In early 2018 the Group Insurance Board (GIB) asked for proposals from vendors who wanted to offer long-term care insurance to State of Wisconsin employees and retirees during 2019. The GIB received one proposal. The proposal that was received did not meet the ETF’s long-term care standards criteria.
No, you are not going lose your long-term care insurance coverage. The change only effects those looking to purchase new plans in 2019.
There will be no change. Retirees will still be able to pay their premiums on long-term care insurance policies, that were purchased from an ETF approved vendor at the time of sale, with funds received from converting their Basic group life insurance coverage.
This change does not stop any state employee or retiree from purchasing long-term care insurance. The only change this means to employees and retirees who have not purchased a long-term care policy is they are not eligible to convert their Basic Group Life Insurance Coverage to pay premiums for long-term care insurance.
The Wisconsin Office of the Commissioner of Insurance (OCI) has some helpful information on what to look for when purchasing long-term care insurance and a listing of registered long-term care insurance agents.
The State of Wisconsin has entered a joint effort between the federal Medicaid Program, long-term care insurers to form the Wisconsin Long-Term Care Insurance Partnership Program.
If you are a state employee: You may be eligible to receive $2,000 from your employer if you opt out of state group health insurance program coverage. To be eligible you cannot have opted out in 2015, meaning you must have been covered through the last day of 2015 if you were eligible for coverage and an employer contribution and you also cannot be covered under the state group health insurance program as a dependent. You are required to submit a paper Group Health Insurance Application/Change (ET-2301) form during It’s Your Choice open enrollment to receive the opt-out incentive for 2018. Some employees may be able to elect the opt-out incentive electronically; check to see if your employer allows this.
No, incentive payments will be spread out over all applicable pay periods in the year.
No, not as the law is currently written.
This opt-out incentive is available only to eligible State of Wisconsin employees.
Yes, as long as you meet the other eligibility requirements, you can receive the $2,000 opt-out incentive for each year that you opt out. You must submit a paper Group Health Insurance Application/Change (ET-2301) form each year during It's Your Choice open enrollment in order to receive the incentive for the following year. Some employees may be able to elect the opt-out incentive electronically; check to see if your employer allows this.
Yes, and it will appear on employees’ W-2 statements. The incentive payment is not considered Wisconsin Retirement System (WRS) earnings.
The eligibility criteria for sick leave conversion for state employees remains the same. You must be in the State Group Health Insurance Program to be able to convert unused sick leave time to credits that can be used to purchase health insurance at retirement. Keep in mind, if you opt-out of the health insurance program and unfortunately pass away, your unused sick leave time will not be eligible to be converted to sick leave credits by your dependent like it would if you passed away and had family health insurance coverage. Please see the Sick Leave Conversion Credit Program (ET-4132) brochure for more information on eligibility requirements related to retirement and death benefits for spouse and dependents.
No, being covered as a dependent under a state family plan is not the same as having opted-out in 2015, which would disqualify you or your spouse.
Yes, you are not eligible for the opt-out incentive if you were eligible for an employer contribution through the state and you waived state coverage.
This page was last modified on: 3/21/2019 5:20:46 PM