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Members

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.