Wisconsin DETF - Hot Topic

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Department of Employee Trust Funds - Hot Topic
September 14, 2004 (revised November 15, 2004)

New Health Insurance Options for Local Governments

Local government employers will have three new health insurance program options available in 2005. These options, which include a combination of higher deductibles and/or a preferred provider plan (PPP) option for the fee-for-service standard plan, will allow employers additional flexibility in offering less costly health insurance plans.

With the new options available, employers can select from one of the options listed below. Click on the option that interests you to go to premium rate and benefit information:

Traditional HMO Option paired with the Classic Standard Plan (Current benefit)
Traditional HMO Option paired with the Standard PPP (New option)
Deductible HMO Option paired with the Deductible Standard Plan (New option)
Deductible HMO Option paired with the Deductible Standard PPP (New option)

The new Deductible HMO Option has an overall deductible of $500 individual / $1000 family per calendar year on all HMO type plans for medical services. (Note the deductible does not apply to pharmacy benefits.) Once the deductible has been met, the benefits will be administered as described for each plan. The premium rates for the deductible option average 10% below traditional option rates

The new Standard PPP and Deductible Standard PPP options are alternatives to the Classic Standard Plan (fee-for-service indemnity plan now offered to employees) and the new Deductible Standard Plan (fee-for-service indemnity plan option for the deductible HMO option), respectively. The PPP options allow participants to see any provider of their choice. However, unlike the Classic Standard Plan and Deductible Standard Plan, the PPP options have different deductible and coinsurance requirements depending on whether participants use an in-network or an out-of-network provider. The premium for the PPP options is lower than the Classic Standard Plan and Deductible Standard Plan. All Standard Plan options are administered by Blue Cross and Blue Shield of Wisconsin (BCBSWI).

For your quick reference, comparisons of the non-Medicare and Medicare benefits are shown below. Click on any of the options listed above for premium rate information.

Non-Medicare Benefits	Traditional HMO-Classic Standard Plan	Traditional HMO-Standard PPP	Deductible HMO- Deductible Standard Plan	Deductible HMO-Standard PPP Deductible
Standard Plan Option Benefit:
Deductible (Unless otherwise noted, it is an overall deductible)	$250 Individual / $500 Family (Major Medical*)	In-Network: $250 Individual/ $500 Family Out-of-Network: $500 Individual/ $1000 Family	$500 Individual/ $1000 Family	In-Network: $500 Individual/ $1000 Family Out-of-Network: $1000 Individual/ $2000 Family
Coinsurance	80% / 20% (Major Medical*)	In-Network: 90% / 10% Out-of-Network: 70% / 30%	80% / 20%	In-Network: 80% / 20% Out-of-Network: 70% / 30%
Annual out-of-pocket maximum (Includes deductible & coinsurance)	$1250 Individual/ $2500 Family (Major Medical*)	In-Network: $1000 Individual $2000 Family Out-of-Network: $2000 Individual $4000 Family	$2000 Individual/ $4000 Family	In-Network: $2000 Individual / $4000 Family Out-of-Network: $4000 Individual / $8000 Family
HMO-Type Benefit:
HMO-type benefit	Uniform Benefits	Uniform Benefits	$500 Individual/ $1000 Family After deductible is met, Uniform Benefits apply.	$500 Individual/ $1000 Family After deductible is met, Uniform Benefits apply.

Medicare Benefits	Traditional HMO-Classic Standard Plan	Traditional HMO-Standard PPP	Deductible HMO-Deductible Standard Plan	Deductible HMO-Standard PPP Deductible
Standard Plan Option Benefit:
Deductible (Unless otherwise noted, it is an overall deductible.)	$150 Individual/ $300 Family (Major Medical*)	In-Network: $150 Individual/ $300 Family Out-of-Network: $300 Individual/ $600 Family	$500 Individual/ $1000 Family	In-Network: $500 Individual / $1000 Family Out-of-Network: $1000 Individual / $2000 Family
Coinsurance	80% / 20% (Major Medical*)	100% / 0%	100% / 0%	100% / 0%
Annual out-of-pocket maximum (Includes deductible & coinisurance)	$1150 Individual/ $2300 Family (Major Medical*)	In-Network: $150 Individual/ $300 Family Out-of-Network: $300 Individual/ $600 Family	$500 Individual/ $1000 Family	In-Network: $500 Individual / $1000 Family Out-of-Network: $1000 Individual/ $2000 Family
HMO-Type Benefit:
HMO-type benefit	Uniform Benefits	Uniform Benefits	$500 Individual/ $1000 Family After deductible is met, Uniform Benefits apply.	$500 Individual/ $1000 Family After deductible is met, Uniform Benefits apply.

*Only applies to major medical services, for example, durable medical equipment, physical/speech/ occupational therapy, medical services and supplies, cardiac rehabilitation, and total extraction and replacement of teeth.

Local government employers currently participating in the Group Health Insurance Program are enrolled in “Traditional Option – Classic Standard Plan” and only need to file a new resolution if they wish to select one of the new options for their employees and annuitants. Employers joining the program must select the benefit option when filing the initial resolution. Employers may not split its group between the options.

For more information on the WPE Group Health Insurance Program, contact ETF, Division of Trust Finance & Employer Services, P.O. Box 7931, Madison, WI 53707-7931. Call (608) 267-2198 or FAX (608) 266-5801. Information about Health Insurance and other benefit programs is also available on our Internet site at etf.wi.gov.