WRS News Online

ETF Ombudsperson Services: We Are Here to Help You

by Allen Angel, Vickie Baker, Liz Doss-Anderson, ETF Ombudsperson Services

Ombuds Team Photo
L to R: Liz Doss-Anderson, Allen Angel, Vickie Baker

For 25 years ETF Ombudsperson Services has been assisting Wisconsin Retirement System members with benefits-related problem resolution while providing overall education, guidance, and support. Benefits are getting more complicated, and with that comes your increasing responsibility to read, understand and ask questions.

Here is our best advice: Learn as much as possible about your benefits and always be a strong advocate for yourself and your family. For example:

  • Take time to review Department of Employee Trust Funds forms and publications, and other easily accessible online resources.
  • Watch an ETF webinar; offered at convenient times and on topics important to you.
  • Contact ETF’s Customer Service Call Center, where benefit specialists await your calls and emails.
  • If the issue is related to a health or pharmacy benefit claim or billing, first call your health plan or Navitus, the program’s pharmacy benefit manager.

Each year the It’s Your Choice open enrollment materials provide information on important health insurance changes for the coming year. These changes may affect your specific health plan or your health insurance benefits in general. Take time to review changes and use resources on ETF’s website, such as frequently asked questions . You may also want to attend a benefit fair in your area. But issues can arise and you may need our help resolving a complaint or making an inquiry on your behalf. An ETF Ombudsperson’s primary role is to act as an impartial and neutral party for equity, fairness and compliance with benefit program policies and insurance contracts.

In 2014 we received 1,018 complaints and inquiries, 61% of which stemmed from health plan decisions or other plan actions. Most of our member complaints and inquiries fall in the following categories: general program provisions and design, enrollment and eligibility, claims and billing issues, and non-covered services.

For example, we can assist or help educate when:

  • A prior authorization request for services has been denied.
  • You need clarification on what is covered or not covered under the health insurance contract.*
  • You don’t understand how the state’s sick leave conversion credit program works. (Note: Ask your employer if you have questions regarding the amount of sick leave/sick leave credits you have in your account).
  • Claims have not been processed correctly.
  • You have issues with enrolling a disabled dependent.
  • You would like to know how to file a grievance or request an independent review.
  • You are unsure about the transition to Medicare.

*Please remember that not every service you want or need is covered by your insurance.

There are many more topics and issues Ombudsperson Services can assist with – just as there is likely more that you can do to understand your benefits and advocate for yourself. Work with your health plan, Navitus and your employer – they have the important information that you need.

If your particular issues are outside the scope of our services, we can direct you to where you can express your concerns, whether it’s to your health plan, program administrators or the Group Insurance Board.

And remember: The It’s Your Choice open enrollment Period is just around the corner – October 5-30, 2015. Take the time to read, understand and ask questions so that you make the best health insurance decisions for you and your family in 2016.

To learn more, review the following:
Ombudsperson Services Program Brochure (ET-8935)
Ombudsperson Services Fact Sheet (ET-8934)
ETF Insurance Complaint Form (ET-2405)