As a participant in this Group Health Insurance Program, you have certain rights and responsibilities. By becoming familiar with them, you will be able to make the most of your health care.
You have the following rights
- Considerate, respectful care from all members of the health care system.
- Non-discriminatory treatment consistent with state and federal law.
- To change health plans annually.
- To a description of benefits presented in an understandable manner.
- To select a primary care physician and to have access to appropriate specialty care. You have the right to a referral to a non-plan specialist for covered services if there is not a plan specialist who is reasonably available to treat your condition.
- To have access to an OB/GYN provider.
- To a minimum hospital stay of 48 hours following a normal delivery of a child or 96 hours following a cesarean delivery. The physician, in consultation with the mother, may discharge the mother and baby prior to the expiration of the minimum stay.
- To have continuous and appropriate access to a medical provider as required by Wis. Stats. 609.24. This right only applies to medical providers that are listed in the available health plan's directory available during the annual open enrollment period.
- To have access to emergency care without prior-authorization from the health plan. If it is not reasonably possible to use an in-network hospital or facility, you have the right to obtain treatment at the nearest facility and have those charges covered by the health plan as if you did use an in-network hospital or facility.
- To participate with your medical provider in treatment decisions.
- To confidentiality of medical information and your Social Security number.
- To appeal any referral or claim denial through the health plan's grievance process. This review will be conducted in a timely manner. Grievances related to care that is urgently needed must be reviewed by the health plan within three (3) business days. If you have exhausted all levels of appeal available through the health plan, you may submit a complaint to ETF, in care of the Office of Legal Services.
You will need to submit an ETF Insurance Complaint Form (ET-2405). You also have the right to request a departmental determination if you believe that a health plan did not comply with its contractual obligations.
You have the following responsibilities
- To review the health benefits materials and information provided by your health plan during the annual open enrollment period. This information is important to determine if your health plan and/or your medical providers will continue to be available and whether your current health plan continues to best meet your needs for the following calendar year.
- To submit your application for coverage prior to the end of the enrollment period if you select a different plan during the open enrollment period.
- To select a primary care physician who will oversee your overall health care and to make a reasonable effort to establish a satisfactory patient-physician relationship.
- To become involved in your treatment options and/or treatment plan.
- To become knowledgeable about your health insurance coverage and your health plan provider, including covered benefits, limitations and exclusions, and the process to appeal coverage decisions. If you are covered under a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO), to also become knowledgeable about the health plan's rules regarding use of network providers, prior authorizations and referrals.
- To authorize the release of relevant personal or medical information necessary to determine appropriate medical care, to process a claim or to resolve a dispute.
- To notify your health plan by the next business day, or as soon as reasonably possible, if you receive emergency or urgent care from a non-plan provider.
- To promptly report any family status changes to your payroll representative (or ETF if you are a retiree or continuant). These changes include marriage, divorce, death, a birth or adoption, or a dependent child losing eligibility. You should also report address or name changes, a change in your primary care provider and Medicare eligibility.
- To respond to the health plan's annual questionnaire on eligibility for any adult dependent who may be disabled. Coverage for dependents could be lost if the questionnaire is not returned to the health plan or the review is not completed.
- To notify your health plan if you obtain or lose other health insurance – including Medicare.
- To submit claims to the health plan in a timely manner, if applicable.
- To use the health plan's internal grievance process to address concerns that may arise.
You agree to the following Terms and Conditions
If you elect to enroll in health insurance coverage through the State of Wisconsin Group Health Insurance Program, you agree to the following Terms and Conditions, as outlined in the Group Health Insurance Application/Change Form (ET-2301):
To the best of my knowledge, all statements and answers in this application are complete and true. I understand that if I provide false or fraudulent information, misrepresentation or fail to provide complete or timely information on this application, I may face action, including, but not limited to, loss of coverage, employment action, and/or criminal charges/sanctions under Wis. Stat. § 943.395.
- I authorize the Department of Employee Trust Funds to obtain any information from any source necessary to administer this insurance.
- I agree to pay in advance the current premium for this insurance, and I authorize my employer (the remitting agent) to deduct from my wages or salary an amount sufficient to provide for regular premium payments that are not otherwise contributed. The remitting agent shall send the premium on my behalf to ETF.
- I understand that eligibility for benefits may be conditioned upon my willingness to provide written authorization permitting my health plan and/or ETF to obtain medical records from health care providers who have treated me or any dependent(s). If medical records are needed, my health plan and/or ETF will provide me with an authorization form. I agree to respond to questions from health plans and ETF, including, but not limited to, audits, in a timely manner.
- I have reviewed and understand the eligibility criteria for dependents under this coverage and affirm that all listed dependents are eligible.
- I understand that children may be covered through the end of the month they turn 26. Children may also be covered beyond age 26 if they: have a disability of long standing duration, are dependent on me or the other parent for at least 50% of support and maintenance, and are incapable of self-support; or are fulltime students and were called to federal active duty when they were under the age of 27 years and while they were attending, on a full-time basis, an institution of higher education. I understand that it is my responsibility to notify the employer, or if I am a retiree or continuant to notify ETF, if there is a change affecting my coverage, including but not limited to, a change in eligibility due to divorce, marriage or an address change due to a residential move. Furthermore, failure to provide timely notice may result in loss of coverage, delay in payment of claims, loss of continuation rights and/or liability for claims paid in error. Upon request, I agree to provide any documentation that ETF deems necessary to substantiate my eligibility or that of my dependent(s).
- I understand that if there is a qualifying event in which a qualified beneficiary (me or any dependent(s)) ceases to be covered under this program, the beneficiary(ies) may elect to continue group coverage as permitted by state or federal law for a maximum of 18, 29, or 36 months, depending on the type of qualifying event, from the date of the qualifying event or the date of the notice from my employer, whichever is later. I also understand that if continuation coverage is elected by the affected qualified beneficiary(ies) and there is a second qualifying event (i.e, loss of eligibility for coverage due to death, divorce, marriage but not including non-payment of premium) or a change in disability status as determined by the Social Security Administration, continuation coverage, if elected subsequent to the second qualifying event, will not extend beyond the maximum of the initial months of continuation coverage. I understand that timely notification of these qualifying events must be made to ETF.
- I understand that if I am declining enrollment for myself or my dependent(s) (including spouse) because of other health insurance coverage, I may be able to enroll myself and my dependent(s) in this plan if I or my dependent(s) lose eligibility for that other coverage (or if the employer stops contributing toward that other coverage). However, I must request enrollment within 30 days after my or my dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if I have (a) new dependent(s) as a result of marriage, birth, acknowledgement of paternity, adoption, or placement for adoption, I may be able to enroll myself and my dependent(s) if I request enrollment within 30 days after the marriage or within 60 days after the birth, acknowledgement of paternity, adoption, or placement for adoption. To request special enrollment or obtain more information, I should contact my employer (or ETF if I am a retiree or continuant).
- I understand that I am responsible for enrolling in Medicare Parts A and B when I am first eligible and required by this coverage, and that as the subscriber I am responsible for ensuring my spouse and any other eligible dependents also enroll in Medicare Parts A and B when they are first eligible, to ensure proper coordination of benefits with Medicare. In the event I or any eligible dependent does not enroll in Medicare Parts A and B when first eligible and required by this group health insurance program, I understand that I will be financially liable for the portion of claims Medicare would have paid had proper Medicare enrollment been attained.
- I understand that if I enrolled in Medicare Advantage with an individual or family contract and subsequently I or my dependents cancel Medicare coverage, I and all covered dependents on the contract will be unenrolled from the Medicare Advantage plan and enrolled in the IYC Medicare Plus plan effective the date of loss of Medicare coverage. I understand that I will be financially liable for the portion of claims Medicare would have paid had proper Medicare enrollment been attained. I agree to abide by the terms of my benefit plan, as explained in any written materials I receive from ETF or my health plan, including, without limitation, the It’s Your Choice materials.