Group Health Insurance
This is a brief overview of health insurance coverage available
to State and Local Government Employees and Annuitants. See the
Group Health Insurance Information pages below for more detailed
plan and premium rate information:
Health Insurance for State and Local Government
Employees
Who Can Be Covered Under Health Insurance As An
Eligible Dependent
Annual Dual-Choice Enrollment Period
Changes in Family Status
Changes in Health Insurance Plans
How to File a Complaint About Your Health Insurance
Continuation and Conversion Coverage
Health Insurance for Annuitants
State Employees Sick Leave Credits to Pay Health
Insurance Premiums
Age-65 Medicare Coverage
Annual Dual-Choice Enrollment Period and Changes
in Family Status
Local Annuitant Health Program
Health Insurance for State and Local Government
Employees
If you are a state employee, or if you are a local employee covered
by the Wisconsin Retirement System and your employer has elected
to participate in the state health insurance program, you are probably
eligible to enroll in one of the health insurance plans administered
by the Department of Employee Trust Funds. Check with your personnel
office to determine if you are eligible to enroll.
Depending upon where you live, the program allows you a choice
of two or more health care plans to choose from. You have a chance
to change plans once each year in the fall during the annual Dual-Choice
Enrollment period.
State employees may enroll in the health insurance program either:
-
Within 30 days of your hire (with coverage to be effective
on the first day of the month on or following receipt of the
application by your employer),
or
- Prior to becoming eligible for the employer contribution toward
premium (with coverage to be effective when you are eligible for
employer contribution). For most employees, this means prior to
the beginning of the third month after hire. However, if you were
previously covered under the Wisconsin Retirement System for at
least 6 months (and have not since taken a WRS benefit), you must
apply for health coverage within 30 calendar days of your first
day of employment. If you miss these enrollment periods you can
enroll in the State Standard plan at any time, subject to a 180-day
waiting period for pre-existing conditions.
Graduate assistants and local government employees should check
with their personnel office for more information regarding their
enrollment period.
There is also a special enrollment period if you are covered under
a qualifying health plan elsewhere and lose eligibility for that
coverage. In this case, you have 30 days from the loss of the other
coverage to enroll.
You may continue to be covered by the health insurance program
during an authorized leave of absence or during layoff, and you
can continue coverage after you retire if you meet the eligibility
criteria. If you die, your spouse and minor children are also eligible
to continue coverage under the program with the same benefits at
group rates, as long as they were insured dependents under your
family coverage at the time of your death. Your surviving spouse
may continue coverage for life, and your dependent children may
continue for as long as they meet the eligibility criteria for dependents.
They must file an application for continued coverage within 90 days
after your date of death.
Terminated employees, divorced spouses, or children who no longer
meet the definition of dependent may continue or convert their health
insurance under certain circumstances.
Who Can Be Covered Under Health Insurance
As An Eligible Dependent
If you select family coverage your eligible dependents are your
spouse and unmarried children. Children include those who are dependent
upon you or the other parent for at least 50% of their support and
are either your natural children, your stepchildren, your adopted
children, or are pre-adoption placements or legal wards who became
your wards before they turned age 19. Custody of your child is not
necessary if the other dependency requirements are met.
Eligibility for your unmarried dependent child ceases at the end
of the year in which the child turns age 19, except if the child
is a full-time student. For full-time students, eligibility ends
at age 25. If your child is incapable of self-support because of
a physical or mental disability which is expected to continue for
a long time, the age limits and student status requirements do not
apply.
Your grandchildren may also be covered, but only if your dependent
child is covered and is less than 18 years old. If coverage for
your child ends, coverage will end for the grandchild as well. Coverage
for the grandchild will also end at the end of the month your child
turns age 18. No other relatives are eligible for family coverage.
When a child is born to parents who are not married to each other,
the father may not claim the child as a dependent until a judicial
court has established paternity or until paternity has been acknowledged
by filing the Department of Health and Family Services Statement
of Paternity, form number DOH 5024.
Please review the "It's Your Choice" booklet, which can
be obtained from your payroll representative or this department
for additional information on eligible dependents.
Annual Dual-Choice Enrollment Period
The Dual-Choice Enrollment period is held in the fall of each year
for approximately 3 weeks. During this period, Employee Trust Funds
announces the new insurance plan rates for the upcoming year, and
the insurance carriers notify participants of any major changes
in service area or providers. If you are currently insured you can
change to a different plan, or you can change from single to family
coverage during the Dual-Choice Enrollment period. To make a change
you must submit a completed health insurance application to your
payroll representative before the end of the Dual-Choice Enrollment
period. The change will be effective the following January 1.
Refer to the "It's Your Choice" booklet issued during
the Dual-Choice Enrollment period for questions you may have about
the benefits offered by the various plan providers. The booklet
also includes other important information about the insurance program
for both new employees and those who have been insured under the
program for some time.
Changes in Family Status
You must submit a revised health insurance application showing
any change in your family status due to marriage, divorce, death,
or birth or adoption of a child to your payroll representative within
30 days of the change (60 days for birth or adoption).
If your change qualifies you for family coverage for the first
time, you may change to family coverage by submitting a completed
health insurance application to your payroll representative within
30 days of the change. You qualify for family coverage if you are
now married or now have a dependent who is eligible for coverage,
whether or not family coverage is in force.
If you miss this 30 day deadline, you can either change to family
coverage under the State Standard plan with a 180-day waiting period
for your dependents for preexisting conditions, or you will have
to wait until the Dual-Choice Enrollment period. However, if both
you and your spouse are State employees, you may change your single
plans into family coverage at any time.
For more information on changing your health insurance coverage,
please refer to your booklet entitled "It's Your Choice,"
or contact your payroll representative.
Changes in Health Insurance Plans
You may change your health insurance plan each fall during the
Dual-Choice Enrollment period, and the change will be effective
the following January 1st.
The only other time that you can change plans without limitation
is by applying to change within 30 days after moving out of your
health carrier's service area. If applying after 30 days, coverage
is limited to the Standard Plan. To make a change contact your payroll
representative for a Health Insurance Application.
How to File a Complaint About Your Health
Insurance
You must contact your health insurance plan representative about
initiating the grievance process. After the plan has issued its
final determination and the problem remains unresolved; then, and
only then, will the situation be reviewed by the Department of Employee
Trust Funds. To initiate the Department's review, you should complete an
Insurance Complaint Form (ET-2405) and return
it with copies of all relevant information, including all correspondence
from the insurance plan involving the complaint.
Continuation and Conversion Coverage
If you lose your group health insurance coverage under one of the
state or local health insurance plans administered by this Department,
you may be eligible to continue your coverage at group rates for
up to 36 months.
Continuation coverage is identical to the former coverage and you
pay the same group rate, however you will be required to pay the
entire amount since there will not be any employer contribution
toward the premium.
If you are eligible to continue coverage, you must contact the
health insurance subscriber's employer immediately. In most cases,
if the employer is not notified within 60 days of the event which
results in loss of coverage, the right to continuation coverage
will be lost.
At the end of the three-year continuation coverage period you will
be allowed to enroll in an individual conversion health plan. This
plan may offer coverage that differs from the group continuation
plan and may have increased premium costs.
Conversion coverage is available without providing evidence of
insurability, provided that group coverage was in effect for at
least 3 months before termination. Be sure the former employer has
your current home address as the plan will automatically bill you
for conversion coverage after your group coverage terminates. A
dependent who ceased to be eligible for coverage under the subscriber's
family contract may also elect an individual conversion contract.
The dependent must contact the plan within 31 days after termination
of group coverage.
For more information on continuation and conversion, please refer
to the booklet entitled "It's Your Choice" which is available
from your payroll representative or from this Department.
Health Insurance for Annuitants
This section provides a brief overview of health insurance topics
of interest to WRS annuitants. More detailed information is provided
in the brochure "Group Health
Insurance for Retirees" (ET-4112).
State Employees Sick Leave Credits to Pay
Health Insurance Premiums
As a state employee you earn hours of sick leave credit while you
are employed. When you retire these sick leave hours are converted
to credits to pay health insurance premiums. The amount available
to pay premiums is calculated by multiplying the number of accrued
sick leave hours times your highest hourly wage earned while employed
by the State. These sick leave credits can be used only to pay your
group health insurance premiums; they have no cash value.
At the end of each year we will send a statement to you that provides
the balance of your unused sick leave credits. Once your sick leave
credits are exhausted, premiums will be deducted each month from
your Wisconsin Retirement System annuity check. If your monthly
annuity payments are not large enough to cover the premiums, you
will be billed directly by the insurance carrier. The Department
of Employee Trust Funds will automatically change you to direct
pay status.
Age-65 Medicare Coverage
When you or your spouse turn age 65, you become eligible for federal
Medicare benefits. If you are retired, to be eligible to continue
your coverage under the group health insurance program, you must
enroll for Parts A and B of Medicare when you are first eligible.
We recommend that you contact your local Social Security Administration
office three months prior to turning age 65 to ensure a timely enrollment
in Medicare.
Approximately two months before your 65th birthday we will send
you a Medicare Eligibility Statement, which you must complete and
return to our office. After we receive this form, your group health
insurance coverage will be changed to a Medicare Supplement plan
and the amount of your monthly premium will be reduced. Your health
insurance carrier may send you new identification cards. You should
continue to use your old identification card until you receive the
new one. To ensure that you have the correct coverage and premium
rates, it is your responsibility to notify this office whenever
other family members included under your policy become eligible
for federal Medicare coverage.
Remember that you do not need to enroll in Medicare if you or your
spouse is still an active state employee.
Annual Dual-Choice Enrollment Period and
Changes in Family Status
Each fall there is a Dual-Choice Enrollment period of approximately
3 weeks. At this time, you may change your health insurance plan
to any other plan available. You may also change from single to
family coverage during this period. Any change in plan becomes effective
the following January 1. You will receive a booklet called "It's
Your Choice" from our Department prior to the Dual-Choice period.
This booklet will explain the available plans and their benefits
and an application to change your plan. Your application must be
received by the Department of Employee Trust Funds by the date shown
on the front of the "It's Your Choice" booklet.
Whenever there is a change in your family status that may affect
your health insurance, such as marriage, death, or divorce, you
should contact the Department of Employee Trust Funds as soon as
possible. In many cases, the department must receive the appropriate
application within 30 days of the change to avoid loss of coverage
or delays in the payment of claims.
If you move out of your health insurance provider's service area,
you must file an application to change providers within 30 days
of the move. You should contact the Department of Employee Trust
Funds for further information or specific forms.
Local Annuitant Health Program
The Local Annuitant Health Program is a health insurance plan available
to annuitants who are receiving a monthly benefit from the Wisconsin
Retirement System and are retired from a participating local employer.
The program offers two health plans; one for participants age 65
and over who are enrolled in Medicare Parts A and B, and one for
participants who are under age 65. Both plans are insured by Blue
Cross and Blue Shield United of Wisconsin.
The Local Annuitant Health Program allows you to enroll without
any restrictions if we receive your application for coverage within
60 days after you terminate employment. An open enrollment opportunity
also exists when you turn 65 or first enroll in Medicare Part B
and are over 65. If you do not apply within an open enrollment period,
you must provide evidence of insurability to enroll.
More detailed information may be found in the Local
Annuitant Health Program (ET-9019) brochure. You may also write
or call the Department of Employee Trust Funds and request a Local
Annuitant Health packet.
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