It's Your Choice 2019
Frequently Asked Questions
Below is detailed information regarding enrollment and plan change opportunities during and beyond the annual It’s Your Choice (IYC) open enrollment period, dependent eligibility, benefits and services, Medicare and termination of coverage.
This information is intended to provide understandable explanations of the Uniform Benefits Certificate of Coverage. In the event of any conflict between the terms of the IYC Health Plans Certificate of Coverage and the information contained in the Frequently Asked Questions section, the terms of the Certificate of Coverage shall control.
Each year ETF and the Group Insurance Board conduct an annual renewal process with health plans. The Board sets the requirements for the program and health plans decide whether they will participate. You may also want to see Frequently Asked Question 6 under the section Enrolling for Coverage that reads: Someone on my health plan is in the middle of medical treatment and we have to change health plans. What do I need to do?
Information about the Wisconsin Public Employers Group Health Insurance Program in this guide applies to the following individuals whose employer has elected this coverage:
The Marketplace, established under the Affordable Care Act (ACA), allows individuals to shop for health insurance outside of our program. This may be of interest to retirees who are paying premiums out-of-pocket. Note, premiums for Marketplace insurance cannot be paid out of sick leave credits or with any employer contribution. After evaluating the benefit levels of the Marketplace, it has been found that only platinum level plans are considered comparable coverage for the purposes of escrowing accumulated sick leave conversion credits. Visit healthcare.gov for more information.
Insurance Complaint Process
Each of the plans and the PBM participating in the Wisconsin Public Employers Group Health Insurance Program is required to have a complaint and grievance resolution procedure in place to help resolve participants' problems. 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 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 Wisconsin Public Employers Group Health Insurance Program, you have the right to request an administrative review through ETF if your health plan or PBM has rendered a decision on your grievance and it is not eligible for IRO review as described above. To initiate an ETF review, you may call or send a letter to ETF and request an ETF Insurance Complaint (ET-2405) form. Complete the complaint form and attach all pertinent documentation, including the plan's response to your grievance.
Please note that ETF's review will not be initiated until you have completed the grievance process available to you through the plan or PBM. After your complaint is received, it will be acknowledged and information may be obtained from the plan or PBM. An ETF ombudsperson will review and investigate your complaint and attempt to resolve your dispute with your plan or PBM. If the ombudsperson is unable to resolve your complaint to your satisfaction, you will be notified of additional administrative review rights available through ETF.
Adult Children: The Affordable Care Act (ACA) and 2011 Wisconsin Act 49 eliminated tax liability for the fair market value of health coverage for these dependents through the month in which they turn age 26, if eligible.
If the tax dependent status of your dependent over age 26 changes, please notify your employer (or for retirees and continuants, ETF).
No. Note, program benefits meet the minimum value standard for minimum essential health coverage under the ACA.
This opt-out incentive is available only to eligible State of Wisconsin employees. However, WPE employers may choose to offer a similar program.
Selecting a Health Plan
No, family members are limited to the plan selected by the subscriber.
No. If you elect family coverage for medical, you may only choose family coverage or choose to decline the Uniform Dental Benefit.
Similarly, if you elect individual coverage for medical, you may only choose individual coverage or choose to decline the Uniform Dental Benefit.
This can be a concern for members who travel and those with covered dependents living elsewhere, such as a college student living away from home. Consider the following when selecting a health plan:
If you are covered through an IYC Local Plan HMO, you are required to obtain allowable care only from providers in the IYC Local Plan HMO’s network. IYC Local Plan HMOs will cover emergency care outside of their service areas, but you must get any follow-up care to the emergency from providers in the IYC Local Plan HMO’s network. Do not expect to join an IYC Local Plan HMO and get a referral to a non-HMO physician. An IYC Local Plan HMO generally refers outside its network only if it is unable to provide needed care within the HMO.
If you are covered through a Preferred Provider Organization (PPO) such as WEA Trust or the IYC Access Plan, you have the flexibility to seek care outside a particular service area. However, out-of-network care is subject to higher deductible and coinsurance amounts.
Retirees only: If you or your dependents are covered through the IYC Medicare Advantage or IYC Medicare Plus, you have the freedom of choice to see any provider who accepts Medicare. UnitedHealthcare's Medicare Advantage-PPO 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
If eligible, you may enroll for individual or family coverage in any of the available health plans without restriction or waiting periods for preexisting medical conditions, provided you file an electronic or paper health application with your benefits/payroll/personnel office within the required enrollment period stated below:
There are no interim effective dates except as required by law. However, you may enroll for individual coverage within 30 days of your date of hire and change to family coverage if your electronic or paper application is received prior to the date the employer contributions begin.
If you cancel your policy prior to the date that the employer contribution starts, you may re-enroll in health insurance with the new coverage becoming effective on the first day of the month that employer contribution begins.
You cannot assume that the month when your first payroll deduction occurs is the month when your coverage begins. For further information on deductions, coverage and effective dates, contact your benefits/payroll/personnel office.
Important Information for Less Than Half-Time Employees:
The initial enrollment opportunity for most employees begins with their participation in the Wisconsin Retirement System. However, if you are a less than half-time employee, you have another enrollment period if:
If you apply for coverage within 30 days of one of these events, coverage will be effective on the later of the first of the month following the your new hire date, or the effective date of the increase in the employer contribution. Retroactive effective dates are not allowed. This does not provide an opportunity to change from individual to family coverage.
You may also enroll during the annual It's Your Choice open enrollment period for coverage to be effective January 1 of the following year.
Other Enrollment Opportunities
You may be able to get health insurance coverage if you are otherwise eligible under specific circumstances as described below:
The enrollment period begins on the date the other group health insurance coverage terminates because of loss of eligibility (for example, termination of employment, divorce, etc., but not voluntary cancellation of coverage) or the employer's premium contribution ends.
The It's Your Choice open enrollment period is the annual opportunity for eligible employees and retirees to select one of the many health plans offered by the Wisconsin Public Employers Group Health Insurance Program. The following list contains some of the most commonly asked questions about the enrollment period. You can also find information about key terms in the definitions section. Additional medical definitions are found in the online Certificates of Coverage.
The It’s Your Choice open enrollment period is an opportunity to change plans, change from family to individual coverage, enroll if you had previously deferred coverage, cancel your coverage or cancel the coverage for your adult dependent child. It is offered only to employees, surviving spouses and dependents and eligible retirees and continuants who are eligible under the Wisconsin Public Employers Group Health Insurance Program. Changes made become effective January 1 of the following year.
Eligible retirees are those who are currently insured, or were insured when they retired with an employer who offers the Wisconsin Public Employers Group Health Insurance Program. See Are there other enrollment opportunities available to me after my initial one expires?
Yes, coverage will be effective January 1 of the following year for all eligible dependents.
Making Changes During It's Your Choice Open Enrollment
If you decide to change to a different plan, you are encouraged
to make changes online using the myETF Benefits website, or you
may submit a paper application using the following instructions:
Note: If you plan to stay with your current plan for next year and you are not changing your coverage, you do not need to take any action.
Refer to the myETF Benefits System Instructions here.
Your changes will not be stored unless you click on the Submit button. You will need to log back in and make the changes again. To view what you submitted, click the myRequests button on the bottom of the myInfo page.
It’s Your Choice coverage changes are effective January 1 of the following year.
You may submit or make changes anytime during the It’s Your Choice open enrollment period, either online using the myETF Benefits website or by filling out a paper application. After that time, you may rescind, that is, withdraw your application (and keep your current coverage) by following these instructions before December 31:
Other rules apply when canceling coverage. For more information, see the Cancellation or Termination of Coverage section.
During the annual open enrollment period, you can add or drop coverage for yourself and/or your adult dependent children or do a spouse to spouse transfer of your health insurance coverage.
Layoff/Leave of Absence
Reinstatement of Coverage: If your health coverage lapses during your leave or layoff due to non-payment of premiums, you must submit a new application either electronically or via paper within 30 days of returning to payroll to reinstate prospectively the lapsed coverage. Coverage will be effective the first of the month after the application is received by your payroll office. If an It's Your Choice open enrollment period has occurred while you were on leave, you will be offered an enrollment opportunity upon your return. (See Question: Are there other enrollment opportunities available to me after my initial one expires?)
Lapsed coverage can also be reinstated for an employee who has been on a leave of absence, who is entitled to and applies for an immediate annuity. Coverage shall be effective the first day of the calendar month that occurs on or after the date the annuity application is approved by ETF, provided an application for health insurance has been received by that date either electronically or via paper.
If you occupy a seasonal or teaching position and do not receive pay between the end of one term of service and the beginning of another, your coverage may continue if you authorize a payroll deduction before your earnings are interrupted or make other provisions to pay premiums in advance.
Termination of Employment
Appealing a Discharge
If you are covered when you retire, the health benefit plan will automatically continue if your retirement annuity from the Wisconsin Retirement System begins within 30 days after employment ends. If you are eligible for Medicare, effective dates must be provided before coverage continues. (Those eligible for Medicare and enrolled in the IYC Access Health Plan or SMP will be switched to IYC Medicare Plus.) You must fill out the employer verification form and return it with your retirement application.
Note: If you are eligible for Medicare, you must be enrolled in the hospital (Part A), medical (Part B) and prescription drug (Part D) portions of Medicare at the time of your retirement.
Medicare Part D
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 suspended and you will no longer be eligible for health insurance as a retiree/annuitant. You will be eligible for health insurance as an active WRS employee through your WRS-participating employer if the employer is participating in an ETF health plan. Check with your employer to make sure you have other health insurance coverage available before you elect WRS participation.
You may also waive or terminate enrollment under Medicare until the first Medicare enrollment period after active WRS employment ceases. Your premium rates, while covered through active employment, will be the active employee contribution rates for your plan, not the Medicare rates.
When you subsequently terminate employment and resume your annuity, your eligibility for Wisconsin Public Employers Group Health Insurance Program coverage is once again dependent on you meeting the requirements for newly retired employees (that is, you must be insured under the Wisconsin Public Employers Group Health Insurance Program, and you must apply for an immediate annuity from the WRS).
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?
Your grandchildren born to your insured dependent children may be covered until the end of the month in which your insured dependent (your grandchild's parent) turns age 18. Your child's eligibility as a dependent is unaffected by the birth of the grandchild.
Note: If you are a retiree and cancel your health insurance coverage, you will not be able to re-enroll in this program.
Some things to note:
For subscribers whose premiums are being deducted on a post-tax basis, coverage can be changed at anytime.
Coverage will be effective on the beginning of the month following receipt of an electronic or paper application, or a later date specified on the application. (Note: WPE retirees who terminate their coverage may not re-enroll).
If your unmarried child has a physical or mental disability that is expected to be of long-continued or indefinite duration and is incapable of self-support, he or she may be eligible to be covered under your health insurance through our program.
You must work with your health plan to determine if your child meets the disabled dependent eligibility criteria. If disabled dependent status is approved by the health plan, you will be contacted annually to verify the adult dependent's continued eligibility.
If your child loses eligibility for coverage due to age or loss of student status, but you are now indicating that the child meets the disabled dependent definition, eligibility as a disabled dependent must be established before coverage can be continued. If you are providing at least 50% support, you must file an electronic or paper application with your employer to initiate the disability review process by the health plan. Your dependent will be offered COBRA continuation*.
If your disabled dependent child, who has been covered due to disability, is determined by the health plan to no longer meet their disability criteria, the health plan will notify you in writing of their decision. They will inform you of the effective date of cancellation, usually the first of the month following notification, and your dependent will be offered COBRA continuation*. If you would like to appeal the plan's decision, you must first complete the plan's grievance procedure. If the plan continues to deny disabled dependent status for your child, you may appeal the plan's grievance decision to ETF by filing an ETF Insurance Complaint (ET-2405) form. Note: If you are changing health plans, see also the Changing Health Plans section.
* Electing COBRA continuation coverage should be considered while his or her eligibility is being verified. If it is determined that the individual is not eligible as a disabled dependent, there will not be another opportunity to elect COBRA. If it is later determined that the child was eligible for coverage as a disabled dependent, coverage will be retroactive to the date they were last covered, and premiums paid for COBRA continuation coverage will be refunded.
Even though custody of your children may have been transferred to the other parent, you may still insure the children if the other dependency requirements are met.
Note: Dependents may only be covered once under both the State of Wisconsin Group Health Insurance Program and the Wisconsin Public Employers Group Insurance Program. In the event it is determined that a dependent is covered by two separate subscribers, the subscribers will be notified and will have 30 days to determine which subscriber will remove coverage of the dependent and submit an application to remove the dependent. The effective date will be the first of the month following receipt of the application. The health plan(s) will be notified.
Coverage for dependent children who are not physically or mentally disabled terminates on the earliest of the following dates:
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 Wisconsin Public Employers Group Health Insurance Program. Under federal law, if notification is not made within 60 days of the later of (1) the event that caused the loss of coverage, or (2) the end of the period of coverage, the right to continuation coverage is lost. A voluntary change in coverage from a family plan to a single plan does not create a continuation opportunity.
If your last dependent is losing eligibility, you must file an application to change to individual coverage.
There are other limited opportunities for coverage to be changed from individual to family coverage without restrictions as described below:
If an electronic or paper application is received by your benefits/payroll/personnel office for active employees (or ETF for retirees/continuants) within 30 days of the following events, coverage becomes effective on the date of the following event:
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 annuitants/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 Guide and Question: What if my spouse and I work for the same employer?)
Note: You may also change health plans when adding a dependent due to marriage. The subscriber will need to file an application within 30 days of the marriage with coverage effective with the new plan on the first day of the month on or following receipt of the application.
Birth/Adoption/Legal Guardianship/Dependent Becoming Eligible
If you have individual coverage, you can change to family coverage with your current health plan by submitting an application within 30 days of the date a dependent becomes eligible or within 60 days of birth, adoption or the date legal guardianship is granted.
Note: You may also change health plans if you, the subscriber, file an application within 30 days of a birth or adoption with coverage effective on the first day of the month on or following receipt of the application.
Single Mother or Father Establishing Paternity
Children born outside of marriage become dependents of the father on the date of the court order declaring paternity or on the date the "Voluntary Paternity Acknowledgment" (form DPH 5024) is filed with the Department of Health Services (or equivalent if the birth was outside the state of Wisconsin), or the date of birth with a birth certificate listing the father's name. The effective date of coverage will be the date of birth if a statement of paternity is filed within 60 days of the birth. If more than 60 days after the birth, coverage is effective on the first of the month following receipt of the electronic or paper application.
A single mother may cover the child under her health plan effective with the birth by submitting an application changing from single to family coverage, 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 employees or retirees, and each party is eligible for this health insurance in his or her own right and is insured under this program at the time of the divorce, each retains the right to continue this health insurance coverage, regardless of the divorce (unless the employer withdraws from this program).
Note for active employees: Failure to apply in a timely manner will limit enrollment to the annual It's Your Choice open enrollment period for coverage effective January 1.
Note for retirees: If you fail to enroll within 30 days of the date of divorce, you have no enrollment or continuation rights. You will not be able to re-enroll in this program.
Health insurance coverage will automatically continue for your covered surviving dependents. Continued coverage will be effective on the first of the month after your date of death. Surviving dependents may voluntarily terminate coverage by providing written notification to ETF and coverage will terminate on the last day of the month in which their written request is received by ETF.
If the surviving dependent(s) terminates coverage for any reason he or she may not re-enroll later.
Note: The survivors may not add persons to the policy who were not insured at the time of death.
If individual coverage was in force at the time of death, the monthly premiums collected for coverage months following the date of death will be refunded. No partial month's premium is refunded for the month of coverage in which the death occurred. Surviving dependents are not eligible for coverage.
If your employee premiums are deducted on a pre-tax basis under Internal Revenue Code Section 125, switching from family to individual coverage is not allowable unless there is an IRS qualified family status change such as divorce, marriage, birth or adoption. For example, all covered family members lose eligibility for health coverage or become eligible for and enroll in another group plan. (Group plans do not include Medicare or individual Medicare supplement policies.) However, you must check this with your employer or your Section 125 plan administrator. If any covered dependents remain eligible for coverage, a change from family to individual coverage is allowed only during the It's Your Choice open enrollment period.
If your premiums are deducted on a post-tax basis, you may change from family to individual coverage at anytime. The change will be effective on the first day of the month on or following receipt of your electronic or paper application by your benefits/payroll/personnel office (ETF for retirees and continuants). Switching from family to individual coverage when you still have eligible dependents is deemed a voluntary cancellation of coverage for all covered dependents and is not considered a "qualifying event" for continuation coverage.
Changing from individual to family coverage, regardless of whether your premiums are deducted on a pre- or post-tax basis, is only allowed during the It's Your Choice open enrollment period, or when you or an eligible dependent has a qualifying event that allows for family coverage. See the Question: "If I do not change from individual to family coverage during the It's Your Choice open enrollment period, will I have other opportunities to do so?".
Health Plan Information
All changes in coverage are accomplished by completing an approved electronic or paper application within 30 days after the change occurs. Employees should file an application through your benefits/payroll/personnel office to notify your plan of changes. Retirees and continuants should file with ETF. Failure to report changes on time may result in loss of benefits or delay payment of claims. (See Question: Which family changes need to be reported?):
Exception: If you change your primary care physician (PCP) or primary care clinic (PCC), you may contact your health plan for details.
You will receive identification cards from the health plan you select. If you lose these cards or need additional cards for other family members, you may request them directly from the health plan. Health plans are not required to provide you with a certificate describing your benefits. The It's Your Choice Uniform Benefits, 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 plan, and make sure you understand any requirements.
For the Access Plan and State Maintenance Plan (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 plan as soon as reasonably possible.
Only if the IYC Health Plan HMO has providers in the community in which the child resides. Emergency or urgent care services are covered wherever they occur. However, non-emergency treatment must be received at a facility approved by the health plan. Outpatient mental health services and treatment of alcohol or drug abuse may be covered. Refer to the It's Your Choice Uniform Benefits. Contact your health plan for more information.
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 It's Your Choice Uniform Benefits, 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 Local Health plans will pay nothing when non-emergency treatment is provided by physicians outside of the plan unless there is an authorized referral. Contact the health plans directly regarding their policies on referrals.
For emergency or urgent care, plans are required to pay for care received outside of the network, but it may be subject to usual and customary charges. This means the plan may not pay the entire bill and try to negotiate lower fees. However, ultimately the plan must hold you harmless from collection efforts by the provider. (See the Uniform Benefits definition of Emergency Care in the Certificate of Coverage online.)
Check your health plan's or Navitus's website for helpful information on selecting a provider. You can also call and inquire. If you do not select a medical PCP 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 to see if he or she will be available to you under your IYC Local Plan. Confirm this with the IYC Local Plan's provider directory. Even though your current physician may join an IYC Local Plan, he or she may not be available as your primary care physicians (PCP) just because you join that IYC Local Plan.
If you are enrolled in an IYC Local Plan HMO, you will need to find an in-network provider for your care unless you are a participant who is in her second or third trimester of pregnancy. Then you may continue to have access to your provider until the completion of postpartum care for yourself and the 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 plan is required to pay charges for covered services from these providers on a fee-for-service basis. Fee-for-service means the usual and customary charges the plan is able to negotiate with the provider while the member is held harmless.
Health plans will individually notify members of terminating providers (prior to the It's Your Choice open enrollment period) and will allow them an opportunity to select another provider within the plan's network.
Your provider leaving the plan does not give you an opportunity to change plans midyear.
All participants must designate a PCP or PCC. Your primary 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
Employers determine the amount they will contribute toward the premium under one of the two methods described here.
Note: Your employer may contribute any amount toward the premium for retired employees who continue group coverage.
No; all IYC Local Plans are required to offer the Uniform Medical Benefits (this excludes Medicare Plus). Premium rates and tier placement may vary because of many factors:
All group premium rates change at the same time: January 1 of each year. The monthly cost of all health plans will be announced during the annual It's Your Choice open enrollment period.
Active Employees: Premiums may be paid in advance. Therefore, initial deductions from your salary probably will occur about one month or more before coverage begins. If the initial deduction cannot occur that far in advance, then double deductions may be required initially so as to make premium payments current.
Retired Employees: Premium rates for retired employees are the same as for active employees (except that your premium will decrease when you or a dependent becomes covered by Medicare). The employer may, at its option, pay a portion or all of the premium. If you are paying your entire premium, it will be deducted from your monthly annuity. If the annuity is not sufficient to allow a premium deduction, you will be billed directly from your health plan. Warning: Your coverage will be canceled if you fail to pay your premium in a timely manner. You will not be able to re-enroll later.
If you are retired and have life insurance coverage through the Wisconsin Public Employers Group Life Insurance Program, you may be eligible to convert the present value of your life insurance to pay health insurance premiums. You must be at least age 67, or age 66 if your employer provides post-retirement life insurance coverage at the 50% level. If you make this election, your life insurance coverage will cease and you will receive credits in a conversion account equal to the present value of your life insurance. The present value ranges from about 44% to 80% of the amount, depending on your age. The life insurance company, Securian Financial Group, will pay health insurance premiums on your behalf from your conversion account until the account is exhausted. You will not receive any direct cash payment. You may file the election at anytime, and it will be effective no earlier than 61 days after ETF receives it. For more information and an election form, contact ETF.
No, but your employer may offer a similar program.
Each local government employer must choose whether to offer the Uniform Dental Benefit to employees. The benefits are the same for state and local employees who participate in the Uniform Dental Benefit plan. Please check with your employer to determine whether the Uniform Dental Benefit is available to you.
Preventive services are routine health care that includes check-ups, patient counseling and screenings to prevent illness, disease and other health-related problems. Federal law requires that specific preventive services performed by in-network providers be offered at no cost to you. You can find a list of these preventive services here.
A 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.
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 WPE (local government) program has OOPLs in place that apply to certain medical and prescription drug out-of-pocket costs. The federal government also enforces Maximum Out-of-Pocket (MOOP) limits that are much higher than the OOPLs of the State and WPE (local government) group health insurance programs. For any essential health benefit costs that do not stop at the program OOPL, the federal MOOP limits provide a safety net that does not allow you to incur any out-of-pocket expenses more than $6,850 individual or $13,700 family.
Note: For the group health insurance program, this only applies to Level 3 and Level 4 non-preferred prescription drugs.
A PBM is a third-party administrator of a prescription drug program that is primarily responsible for processing and paying prescription drug claims. In addition, it typically negotiates discounts and rebates with drug manufacturers, contracts with pharmacies and develops and maintains the drug formulary.
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 Wisconsin Public Employers Group health Insurance Program.
A formulary is a list of prescription drugs that are determined to be both medically effective and cost-effective by a committee of physicians and pharmacists.
Drugs are evaluated by the committee based on their effectiveness, side-effects, drug interactions and then cost. Drugs are reviewed on a continuous basis to make sure the formulary is kept up-to-date and that patient needs are being met.
You 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.
Log on at https://members.navitus.com to set up an account for the Navitus Portal, then click on Cost Compare to check the price of your drugs. For more detailed instructions, please see the Using Navi-Gate® for Members on ETF's website.
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 health plans that participate in the Wisconsin Public Employers Group Health Insurance Program have coverage options that are coordinated with Medicare, you will remain covered by the health plan you have selected even after you enroll in Medicare. Premium rates will decrease if Medicare covers you or a dependent, and you are retired. Medical and prescription drug coverage under the IYC Local Plans (health plans that offer Uniform Benefits for medical coverage) does not change. The health plan will simply not duplicate benefits paid by Medicare. However, if enrolled in the IYC Access Plan or SMP, your coverage will change to IYC Medicare Plus when you enroll in Medicare Parts A and B.
For all health plans, prescription drugs will continue to be covered through the Pharmacy Benefit Manager (PBM).
If you are not enrolled for all available portions of Medicare (A, B and D) upon retirement, you will be liable for the portion of your claims that Medicare would have paid beginning on the date Medicare coverage would have become effective.
For information about Medicare benefits, eligibility and how to enroll, contact your local Social Security Administration office or call 1-800-772-1213. In addition, the State Health Insurance Assistance Program (SHIP) has counselors in every state and several territories who are available to provide free one-on-one help with your Medicare questions or problems. The Wisconsin SHIP can be reached at 1-800-242-1060. Additional information and assistance can be found at www.dhs.wisconsin.gov/benefit-specialists/ship.htm. A list of SHIP programs outside of Wisconsin can be found at www.medicare.gov/contacts/staticpages/ships.aspx.
Important: When you receive your Medicare card, please send a photocopy to ETF immediately or your Medicare coordinated coverage may be delayed. If you become eligible for Medicare, your eligibility for COBRA coverage ends. Contact ETF for more information.
ETF does not require you and your dependents to enroll in Medicare until you, as the subscriber, terminate employment or health insurance coverage as an active employee ceases. (If you or your insured spouse is insured as an active employee under a non-state group plan, enrollment in Medicare may be deferred until retirement from that job.) At the time of your retirement, you and your dependents who are eligible for Medicare must enroll for the Part A (hospital) portion and Part B (medical) portion of Medicare. When you and/or your dependents enroll in Medicare Parts A and B, your group health insurance coverage will be integrated with Medicare and the monthly premium will be reduced.
In general, enrollment in Medicare Part D (prescription drug coverage) is voluntary; however, you may pay a penalty if you do not enroll when you are first eligible or are not covered by what Medicare considers creditable coverage. Regardless, Medicare Part D coverage is provided by the Wisconsin Public Employers (WPE) Group Health Insurance Program. Additional information about all parts of Medicare can be found in the following questions and answers.
If you become eligible for Medicare while on COBRA, your eligibility for COBRA coverage
ends. Contact ETF 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 employed by an employer that does not participate in the WPE group health insurance program, and has coverage as an active employee under that employer's group plan, enrollment in Medicare may be deferred until retirement from that job. Health insurance premiums will not be reduced until the employee retires and Medicare pays as primary.
For subscribers and their dependents with End Stage Renal Disease (ESRD): You will want to contact your local Social Security office, health plan, provider and Medicare to make sure you enroll in Medicare Part A and Part B at the appropriate time. The Wisconsin Public Employers Group Health Insurance Program will provide primary coverage during the 30-month coordination period for members with ESRD. You will want to decide if it would be beneficial to enroll in Part B during your initial or general enrollment opportunities to avoid later delayed Medicare enrollment and potential premium penalties after your 30-month coordination period ends.
Medicare Part D
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 health plan, please notify ETF and provide your dependent's Medicare information.
Individuals may choose to enroll in another Medicare Part D prescription drug plan; however, it is not recommended or required for your continued coverage under the Wisconsin Public Employers (WPE) group health insurance program.
If you choose to enroll in a different Medicare Part D plan, your health insurance premium for the WPE plan does not change, but your supplemental, wrap-around pharmacy coverage will be secondary to the other Medicare Part D plan. For more information, see Question: Does Medicare Part D affect my prescription drug coverage? Should I enroll? and Question: Will my health insurance premium go down if I enroll in a Medicare Part D prescription drug plan?
If Medicare is the primary insurance, your provider must submit claims to Medicare first. Once Medicare processes the claim(s), Medicare will send you a quarterly Medicare Summary Notice (MSN).
IYC Health Plan Medicare (health plans that offer Uniform Benefits
for medical coverage):
IYC Medicare Plus:
IYC Medicare Advantage:
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 to, 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 the WPE group health insurance program pharmacy benefits, will be considered secondary. You should be prepared to file the secondary claims manually through Navitus. Contact Navitus for more information on filing manual claims. Refer to the Medicare Part D Information section of the FAQs for more details.
Medicare Part B pharmacy claims are covered under the supplemental
wrap benefit. For specific information on Medicare Part B pharmacy
coverage and Part B claims processing, see the plan description
page for Navitus™ Health Solutions.
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 personcovered 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.
Since all health plans have coverage options that are coordinated with Medicare, you will remain covered by the health plan you selected after you are enrolled in Medicare, even though Medicare is the primary payor of your claims.
Note: For some benefits under It's Your Choice Health Plan Medicare and IYC 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 Wisconsin Public Employers Group Health Insurance Program are required to have Medicare Parts A, B and D, the IRMAA may impact you if you have higher income.
To determine if you will pay the additional premiums, Social Security uses the most recent federal tax return that the IRS provides and reviews your modified adjusted gross income. Your modified adjusted gross income is the total of your adjusted gross income and tax-exempt interest income.
Social Security notifies you in November about any additional premium amounts that will be due for coverage in the next year because of the IRMAA. You must pay the additional premium amount, which will be deducted from your Social Security check if it's large enough. Failure to pay may result in Medicare terminating your coverage. The IRMAA is paid to Social Security, not the Wisconsin Public Employers Group Health Insurance Program. It is not included in your Wisconsin Public Employers Group Health Insurance Program premium.
Additional information can be found in SSA Publication No. 05-10536 or by calling the Social Security Administration toll-free at 1-800-772-1213.
Medicare Part D Information
Medicare related prescription drug coverage will be provided by Navitus Health Solutions (Navitus) through a self-funded, Medicare Part D Employer Group Waiver Plan (EGWP) called the Navitus MedicareRx (PDP) plan. This plan is underwritten by Dean Health Insurance Inc. a federally-qualified Medicare contracting prescription drug plan. This affects Medicare-eligible participants covered under an annuitant contract enrolled in the WPE group health insurance program. As required by Uniform Pharmacy Benefits and IYC Medicare Plus, a supplemental wrap benefit is also included to mainly provide full coverage to WPE members when they reach the Medicare coverage gap, also known as the "donut hole." But the supplemental wrap benefit will also provide coverage at other times when the EGWP does not, such as during the Medicare Part D deductible and the initial coverage phases. Dean has been contracted with the Centers for Medicare and Medicaid Services since 2006, when Medicare Part D was first implemented to offer Medicare Part D prescription drug plans to employer groups.
Your group health insurance premium already includes the cost of this benefit. There is no separate premium that needs to be paid for this Medicare Part D coverage. It is important that you read and understand the information presented on the Navitus MedicareRx plan description page.
A Medicare Part D prescription drug plan (PDP) provides primary coverage of prescription benefits through Medicare. While enrollment in a PDP is voluntary, if you do not enroll when you are first eligible and do not have what Medicare considers creditable coverage, you may have to pay a penalty in the form of a higher PDP premium once you do enroll.
Under the Wisconsin Public Employers Group Health Insurance Program, after you become eligible for Medicare Part D, the following will happen:
When you are enrolled in the Navitus MedicareRx (PDP) plan you will be issued a new ID card that you will be required to use.
If you would like to maintain your current level of prescription drug benefits under our program, it is not necessary to enroll in another Medicare Part D plan. Nevertheless, participation in a Medicare Part D prescription drug plan is voluntary and you should carefully consider all options before making any kind of decision to enroll in a different Medicare Part D plan.
Also, if you are enrolled in Medicare and your modified adjusted gross income exceeds certain limits established by federal law, you may be required to pay an additional amount for your Medicare Part D coverage under the Navitus MedicareRx (PDP) plan. Please refer to the Question: What is the Social Security income-related monthly adjusted amount (IRMAA) and does it affect me? Please note that IRMAA is not unique to the Navitus medicareRx (PDP) plan. If you are required to pay the IRMAA, you would have to do so under any Medicare Part D plan.
No. Your health insurance premium includes both medical and prescription drug coverage. If you choose to 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 WPE group health insurance program. There is no partial refund of the WPE group health insurance premium if you choose to enroll in a different PDP. Navitus will coordinate coverage with Medicare and pay secondary claims after Medicare processes your prescription claims from the other Medicare Part D plan, minus the applicable copayments and coinsurance that are your responsibility. If you enroll in another Medicare Part D plan and you intend to stay in that program, notify ETF immediately. If ETF enrolls you in Navitus MedicareRx, you will be automatically disenrolled from your other plan by CMS.
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.
Each employer has the option to offer the Uniform Dental Benefit to employees and retirees. Please contact your employer to see if you have the Uniform Dental Benefit available to you.
If you are currently enrolled in Uniform Dental Benefits, and you do not waive these benefits during It's Your Choice open enrollment, you will automatically continue to be enrolled for the next year.
Cick on the enrollment tab above. You can also submit a paper application which you can download online, or request one from your payroll or benefits office.
For specific benefit details, view the Uniform Dental Benefit Certificate of Coverage. You may visit Delta Dental's website at www.deltadentalwi.com/state-of-wi or call Delta Dental directly at 1-844-337-8383.
Contact Delta Dental directly at 844-337-8383 or visit their website at deltadentalwi.com/state-of-wi to view the provider directories. 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 eligilble employees, retirees and their spouses enrolled in the group health insurance program. It provides services and resources through StayWell and rewards participants with a $150 cash incentive after completion of the StayWell health assessment, health screening and a 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 wellness program year deadline. 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 law. Only aggregate de-identified information will be shared with the group health insurance program or large employer groups. See the Equal Employment Opportunity Commission (EEOC) Notice Regarding Wellness Program and the StayWell privacy statement for more information.
Additional wellness incentives vary by health plan. Check with your health plan to learn more about additional incentives that may be available to you.
Yes, the Internal Revenue Service considers all incentives issued to you or your enrolled family members to be a fringe benefit of employment. Incentive payment information from StayWell and your health plan will be provided to your employer to be reported as taxable income and applicable deductions will be applied. No personal health information is shared with your employer, only the incentive payment amount. Retirees will 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.
Note: If your premiums are being deducted post-tax, you may cancel coverage at anytime. If your premiums are being deducted on a pre-tax basis, you may cancel coverage midyear only if you become eligible for and enroll in other group coverage or terminate employment.
Otherwise, you can only change health plans without restriction during each It's Your Choice open enrollment period and coverage will be effective the following January 1.
When you change health plans for any reason (for example, during an It's Your Choice open enrollment period or for a move from a health plan's service area), any annual health insurance benefit maximums under Uniform Benefits (such as durable medical equipment) will start over at $0 with your new plan, even if you change plans mid-year, with the exception of the prescription annual out-of-pocket maximum. If you are enrolled in the Uniform Dental Benefit, you will continue accumulating to the same benefit maximums as well.
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 3 months or more, will be permitted to enroll in the IYC Access Health Plan or an available IYC Local Plan that offers in-network providers near you, provided an electronic or paper application for such plan is submitted within 30 days after relocation. You will be required to document the fact that your application is being submitted due to a change of residence out of a service area.
If your relocation is temporary, you may again change plans by submitting an application within 30 days after your return. The change will be effective on the first of the month on or after your application is received by your employer or by ETF, but not prior to your return.
It is important that you submit your application to change coverage as soon as possible and no later than 30 days after the change of residence to maintain coverage for non-emergency services. The change in plans will be effective on the first day of the month on or after your application is received by your employer but not prior to the date of your move. If your application is received after the 30-day deadline, you will not be allowed to change plans until the following It's Your Choice open enrollment period or in certain situations. See Question: Are there other enrollment opportunities available to me after my initial one expires?
If you are confined as an inpatient (in a hospital, a skilled nursing facility or, in some cases, an Alcohol and Other Drug Abuse (AODA) residential center) or require 24-hour home care on the effective date of coverage with the new plan, you will begin to receive benefits from your new plan unless the facility you are confined in is not in your new plan's network. If you are confined in such a facility, your claims will continue to be processed by your prior plan as provided by contract until that confinement ends and you are discharged from the non-network hospital or other facility, 12 months have passed or the contract maximum is reached. If you are transferred or discharged to another facility for continued treatment of the same or related condition, it is considered one confinement.
In all other instances, the new plan assumes liability immediately on the effective date of your coverage, such as January 1.
Each health plan has the responsibility to determine whether or not a newly enrolled disabled dependent continues to meet the contractual definition of disabled dependent.
If you are a retiree, you may cancel at anytime. You must provide written, signed notification of cancellation to ETF.
An employee’s voluntary cancellation (or switching from family to individual coverage which is deemed voluntary cancellation for all insured dependents) requires written, signed notification to the employer denoting a cancellation of coverage. If your premiums are being deducted on a pre-tax basis under Internal Revenue Code Section 125, you may cancel coverage only if:
If your adult dependent child becomes eligible for and enrolled in other group health insurance coverage, and you want to drop coverage for him/her, you must submit an application electronically or via paper to your employer (to ETF for annuitants) within 30 days of the effective date of other coverage. In addition, you must submit proof of enrollment such as an ID card from that coverage. If this is your last dependent and you want to change to single coverage, you must note that on your application.
If your spouse becomes eligible for and enrolled in other group health insurance coverage and you want to change to individual coverage or cancel your family coverage, you must submit an application electronically or via paper to your employer (to ETF for retirees) within 30 days of the effective date of other coverage. In addition, you must submit proof of enrollment such as an ID card that lists all individuals covered under that plan. (Retirees, please see the first paragraph in this Frequently Asked Question for important information.)
If your premiums are being deducted post-tax, you may cancel at anytime.
Be aware that voluntary cancellation of coverage does not provide an opportunity to continue coverage for previously covered dependents as described in the Continuation of Health Coverage section. Cancellation affects both medical and prescription drug coverage.
No refunds are made for premiums paid in advance unless your employer (or ETF if you are no longer an employee of a participating local employer) receives your written, signed request on or before the last day of the month preceding the month for which you request the refund. Under no circumstances are partial month's premiums refunded. Once coverage terminates, you will be responsible for any claims inadvertently paid beyond your coverage effective dates.
Your coverage can only be terminated because:
Retirees only: Your coverage can be terminated because you:
Active employees should contact their benefits/payroll/personnel office, retirees should contact ETF for the date coverage will end.
When your employer's participation ends in this program, coverage will cease for all participants. This includes retirees, survivors and those who have continuation coverage. If the employer obtains group health insurance from another carrier, ask the employer if the new carrier will provide coverage for retirees, survivors and continuants.
When the employer terminates participation, you will not be eligible for continuation of health coverage.
Your COBRA continuation rights are described in the Federal/State Notifications section, under Helpful Info. Both you and your dependents should take the time to read that section carefully. This section provides additional information about continuation coverage.
You do not have to provide evidence of insurability to enroll in continuation coverage. However, coverage is limited to the plan you had as an active employee or covered dependent. (For example, if you change plans January 1 and your dependent loses eligibility December 31, that dependent would be eligible for COBRA from the plan you were enrolled in on December 31. An exception is made when the participant resides in a county that does not include a primary care physician for the subscriber's plan at the time continuation is elected. In that case, the participant may elect a different plan that is offered in the county where the participant resides.) You may select another plan during the It's Your Choice open enrollment period or if you move from the service area. If family coverage is in effect when continuation is first offered, each dependent may independently elect individual continuation coverage. A family of two may select two individual contracts at a lower cost than the premium for a family contract. The health plan will bill you directly.
There can be no lapse in coverage, so multiple premiums may be required.
A second qualifying event while on continuation will not serve to extend your period of continuation. Coverage will be limited to the original time period. At the end of the continuation period you will be allowed to enroll in a Marketplace or an individual conversion plan through the health plan.
Employees need to report this change to the benefits/payroll/personnel
office within 60 days of the dependent losing his/her eligibility
to ensure COBRA coverage is offered. Retirees and continuants
must contact ETF. Your
dependent will be entitled to 36 months of continuation coverage.
No, continuation coverage is identical to the active employee coverage. In most cases, you are eligible to maintain continuation coverage for 18 months from the month of the qualifying event. These events are termination of employment or reduction in work hours. Events such as death of employee, divorce or the loss of eligibility for a dependent child entitles the dependent to 36 months of coverage. You are allowed to change plans during the annual It's Your Choice open enrollment period or if the subscriber moves from the service area. However, your continuation coverage may be cut short for any of the following reasons:
If you or your covered dependent becomes eligible for Medicare, you may need to enroll in Medicare as soon as you are eligible. (See Question: When Must I Apply for Medicare?)
It may change, as you will pay the total premium amount, which includes both the employee and employer share. Contact your benefits/payroll/personnel office to obtain the total amount.
To cancel continuation coverage, send a signed, written notice to ETF. Include your name, Social Security number, birth date and address. ETF will forward your request to the health plan. Your coverage will be canceled at the end of the month in which ETF receives the request to cancel coverage.
If you move out of the service area (either permanently or temporarily for three months or more), you are eligible to change plans. (See Question: What if I have a temporary or permanent move from the service area?)
Your electronic or paper application to change plans must be postmarked within 30 days after your move. Because you are on continuation coverage, call the ETF Employer Communication Center at 608-266-3285 or toll free at 877-533-5020 or go online to obtain a Health Insurance Application/Change (ET-2301) form. Complete and submit the application to: Department of Employee Trust Funds, P. O. Box 7931, Madison, WI 53707-7931.
As required by law, you are eligible to apply for Marketplace or conversion coverage when group continuation coverage terminates. Contact the plan directly to make application for coverage. Marketplace or conversion coverage is available without a waiting period for preexisting conditions. The coverage and premium amount may vary greatly from plan to plan.
If the health plan automatically bills you for coverage that you do not want, simply do not pay the premium for the coverage.
If you reside outside of the IYC Local Plan service area at the time you apply for Marketplace or conversion coverage, you may only be eligible for an out-of-area policy through another insurance carrier. The benefits and rates of the plan are subject to the regulations in effect in the state in which you reside.
The Marketplace or conversion privilege is also available to dependents when they cease to be eligible under the subscriber's family contract. The request for Marketplace or conversion coverage must be received by the plan within 30 days after termination of group coverage. If you have questions, write or call the plan in which you are enrolled.
This page was last modified on: 9/13/2018 6:54:45 AM