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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. You may also want to see the Enrolling for Coverage frequently asked questions section. (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 the Wisconsin Public Employers Group Health Insurance Program?
Information about the Wisconsin Public Employers Group Health Insurance Program applies to the following individuals whose employer has elected this coverage:
- Active employees participating in the Wisconsin Retirement System.
- Retired employees who receive an annuity from the WRS (including a lump sum or disability annuity) and who are participants in the employer's group health plan.
- Insured employees who terminate employment after age 55 (age 50 for protectives) and who have 20 years of creditable service.
- The surviving insured spouse of an insured employee or an insured retiree.
- Employees of a Wisconsin Public Employer who do not participate in the WRS and who is a separate Social Security entity.
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 with any employer contribution. 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 Wisconsin Public Employers 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 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 Wisconsin Public Employers 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 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 the complaint 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. What are the tax implications for covering non-tax dependents (e.g., adult children)?
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).
8. Is the Wisconsin Public Employers 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.
9. Am I eligible for the state's opt-out incentive if I am covered under the Wisconsin Public Employers Group Insurance Program (WPE or “local” program)?
This opt-out incentive is available only to eligible State of Wisconsin employees. However, WPE employers may choose to offer a similar program.