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1. Why do changes to the health plans and benefits happen?
Each year ETF and the Group Insurance Board (Board) conduct an annual renewal process with health plans. The Board sets the requirements for the program and health plans decide whether they will participate. (See question: Someone on my health plan is in the middle of medical treatment and we have to change health plans. What do I need to do?)
2. Who is eligible for State of Wisconsin group health insurance?
Information about the State of Wisconsin Group Health Insurance Program applies to the following individuals:
The Following Will Be Considered Active Employees:
Eligible State Employees (Hereafter called "state" in this guide section.)
- Active state and university employees participating in the Wisconsin Retirement System.
- Elected state officials.
- Members or employees of the legislature.
- Certain visiting faculty members in the University of Wisconsin System.
- Blind employees of the Workshop for the Blind (Wiscraft or Beyond Vision).
- Employees on leave of absence who continue their insurance.
Eligible Graduate Assistants (Hereafter called "Grad" in this section.)
- Graduate Student Assistants (Research Assistants, Fellows, Advanced Opportunity Fellows, Scholars, Trainees, Teaching Assistants and Project/Program Assistants) holding a combined one-third (33%) or greater appointment of at least one semester for academic year (nine month) appointments or six months for annual (twelve month) appointments.
- Employees-in-Training (Research Associates, Post-Doctoral Fellows, Post-Doctoral Trainees, Postgraduate Trainees 1 through 7, Interns (non-physician), Research Interns, Graduate Interns/Trainees holding a combined one-third time (33%) or greater appointment of at least one semester for academic year (nine month) appointments or six months for annual (12 month) appointments.
- Short-Term Academic Staff who are employed in positions not covered under the WRS and who are holding a fixed-term terminal, acting/provisional or interim (non UW-Madison) appointment of 28% or more with an expected duration of at least one semester but less than one academic year if on an academic year (nine month) appointment or have an appointment of 21% or more with an expected duration of at least six months but less than 12 months if on an annual (12 month) appointment.
- "Visiting" Appointees (e.g., Visiting Professors, Visiting Scientists, Visiting Lecturers) may be eligible for the health insurance benefits described in this guide. If you hold a "visiting" appointment, contact your benefits/payroll office for more information.
The Following Will Be Considered Former Employees:
Eligible State Annuitants and Continuants (Hereafter called "retirees" in this section.)
- Retired state employees who are enrolled at the time of retirement and whose retirement annuity from the WRS begins within 30 days after employment ends.
- Insured employees who terminate employment and have 20 years of WRS-creditable service are eligible to continue the State of Wisconsin Group Health Insurance Program even if the annuity is deferred if a timely application is submitted.
- State employees receiving a WRS disability benefit.
- The following former state employees who are not covered under the State of Wisconsin Group Health Insurance Program may apply for coverage (See Question, What if I didn't have health insurance coverage at retirement or my coverage later lapsed?):
- Retired state employees receiving a WRS retirement annuity or a lump sum benefit under Wis. Stat. § 40.25(1); or
- Terminated state employees with 20 years of WRS-creditable service who remain as inactive WRS participants and are not eligible for an immediate annuity.
3. What is the health insurance marketplace and is it an option for me?
The Marketplace, established under the Affordable Care Act (ACA), allows individuals to shop for health insurance outside of our program. This may be of interest to retirees who are paying premiums out-of-pocket. Note: Premiums for Marketplace insurance cannot be paid out of sick leave credits or with any employer contribution. After evaluating the benefit levels of the Marketplace, it has been found that gold and platinum level plans are considered comparable coverage for the purposes of escrowing accumulated sick leave conversion credits. Visit healthcare.gov for more information.
Insurance Complaint Process
4. What if I have a complaint about my health plan, dental plan or Pharmacy Benefit Manager (PBM)?
Each of the plans and the PBM participating in the State of Wisconsin Group Health Insurance Program is required to have a complaint and grievance resolution procedure in place to help resolve participants' problems. Contact your plan or the PBM to get information on how to initiate this process. You must exhaust all of your appeal rights through the plan or the PBM first in order to pursue review through an External Review/Independent Review Organization (IRO) or through ETF and the Group Insurance Board. If the plan upholds its denial, it will state in its final decision letter your options if you wish to proceed further. If you continue to be dissatisfied with the outcome, you may contact ETF's Ombudsperson Services at 877-533-5020 ext. 17947 or email firstname.lastname@example.org.
5. What if my health plan, dental plan, or PBM upholds a denial that is based on medical reasons, such as "medical necessity"?
Depending on the nature of your complaint, you may be given rights to request an external or independent review through an outside organization. This option becomes available when a plan or PBM has denied services as either not medically necessary or experimental. For more information, you may contact ETF's Ombudsperson Services at 877-533-5020 ext. 17947 or email email@example.com. Note: If you choose to have an independent review organization (IRO) review the plan or PBM's decision, that decision is binding on both you and your plan or PBM except for any decision regarding a rescission of coverage. Apart from this exception, you have no further rights to a review through the ETF or the courts once the IRO decision is rendered.
6. What if my health plan, dental plan, or PBM upholds a denial that is not eligible for IRO, such as a denial based on contract interpretation?
As a member of the State of Wisconsin Group Health Insurance Program, you have the right to request an administrative review through ETF if your health plan or PBM has rendered a decision on your grievance and it is not for reasons eligible for IRO review as described above. For more information, you may contact ETF's Ombudsperson Services at 877-533-5020 ext. 17947 or email firstname.lastname@example.org. To initiate an ETF review, you may send a letter to ETF and request an ETF Insurance Complaint (ET-2405) form. Complete this form and attach all pertinent documentation, including the plan's response to your grievance.
Please note that ETF's review will not be initiated until you have completed the grievance process available to you through the plan or PBM. After your complaint is received, it will be acknowledged and information may be obtained from the plan or PBM. An ETF ombudsperson will review and investigate your complaint and attempt to resolve your dispute with your plan or PBM. If the ombudsperson is unable to resolve your complaint to your satisfaction, you will be notified of additional administrative review rights available through ETF.
7. Are my health insurance premiums deducted from my paycheck on a pre-tax or post-tax basis?
The health insurance premiums for employees are automatically deducted from your paycheck on a pre-tax basis. This is often referred to as Automatic Premium Conversion. This means that you save on federal and state income tax, and FICA taxes (Social Security and Medicare taxes). This is a permanent tax exclusion, no taxes will be owed at a later date.
Important Note: When premiums are deducted on a pre-tax basis, Internal Revenue Code regulations governing premium conversion restrict changes that can be made to your health insurance benefits during the plan year. You may not make changes or cancel your participation in the health plan during the plan year unless your decision to do so is a result of a qualifying change in status event and is allowed by the health plan rules. For more information, see the Life Change Event Guide and Question: What are my coverage options if my spouse is also a state of Wisconsin or participating Wisconsin Public Employer (WPE) employee or state retiree?
If you wish to pay your premiums on a post-tax basis, you may fill out an Automatic Premium Conversion Waiver/Revocation of Waiver (ET-2340) form and return it to your payroll/benefits office before the end of the year. Post-tax premium deductions will begin with the January deduction. Once you have filed a waiver, it will remain in effect for future plan years unless you file another Automatic Premium Conversion Waiver/Revocation of Waiver (ET-2340) form to revoke the waiver.
Retirees: Since your premiums are not taken from a paycheck, they are considered post-tax.
The Affordable Care Act (ACA) and 2011 Wisconsin Act 49 eliminated tax liability for the fair market value of health coverage for adult children through the month in which they turn age 26, if eligible.
If the tax dependent status of your dependent over age 26 changes, please notify your employer (or for retirees and continuants, ETF.)
9. Is the State of Wisconsin Group Health Insurance Program grandfathered under the Affordable Care Act?
No. Note, program benefits meet the minimum value standard for minimum essential health coverage under the ACA.