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Health Plan Information

1. When and how must I notify my employer and my health plan of various changes?

All changes in coverage like those listed below are accomplished by completing an approved electronic or paper application within 30 days after the change occurs. Employees should file an application through their benefits/payroll/personnel office to notify their plan of changes. Retirees and continuants should file with the State of Wisconsin Department of Employee Trust Funds (ETF). Failure to report changes on time may result in loss of benefits or delay payment of claims (See the Dependent Information FAQs Question: Which changes need to be reported?).:

  • Change in health plan (for example, from Local Health Plan to Local Access Health Plan)
  • Change in plan coverage (for example, from individual to family)
  • Name change
  • Change of address or telephone number
  • Addition/deletion of a dependent to an existing family plan

Exception: If you change your primary care provider (PCP) or primary care clinic (PCC), you may contact your health plan for details.

2. How do I receive healthcare benefits and services?

You will receive identification cards from the health plan you select. You will receive separate identification cards from Navitus Health Solutions, the pharmacy benefit manager (PBM). If you lose these cards or need additional cards for other family members, you may request them directly from the health plan.

Health plans are not required to provide you with a certificate of coverage that describes your benefits. ETF provides the It's Your Choice (IYC) Uniform Benefits, Local Access Plan, Medicare Plus, and the Uniform Pharmacy Benefits Certificates of Coverage online. The IYC Medicare Advantage Evidence of Coverage is also available online.

Present your identification card to the hospital, physician, or pharmacist who is providing the service. Identification numbers are necessary for any claim to be processed or service provided.

Most of the health plans require that non-emergency hospitalizations be prior authorized and contact be made if there is an emergency admission. Prior authorizations may be required for high-tech radiology (for example, MRI, PET, CT scans) and for low back surgeries. Check with your plan, and make sure you understand any requirements.

For the Local Access Plan and State Maintenance Plan (SMP), it is recommended that you or your physician contact the health plan before you are admitted to a hospital unless it is an emergency. In an emergency, it is in your best interest to notify the plan as soon as reasonably possible.

3. Will a Local Health Plan HMO cover dependent children who are living away from home?

Only if the Local Health Plan HMO has providers in the community in which the child resides. Emergency or urgent care services are covered wherever they occur. However, non-emergency treatment must be received at a facility approved by the health plan. Outpatient mental health services and treatment of alcohol or drug abuse may be covered. Refer to the Uniform Benefits Certificate of Coverage (ET-2180) and Schedule of Benefits online at etf.wi.gov. Contact your health plan for more information.

4. How do I file claims?

It's rare that you would have to. Most of the services provided by health plans do not require filing of claim forms. However, you may be required to file claims for some items or services. All health plans require claims be filed within 12 months of the date of service, or if later, as soon as reasonably possible.

If you are enrolled in IYC Medicare Advantage, when you visit your provider, you must show your health plan's card. You do not need to show your Medicare card, but you should keep it in a safe place. Your provider will submit your claims directly to UnitedHealthcare (UHC).

5. How are my benefits coordinated with other health insurance coverage?

When you are covered under two or more group health insurance policies at the same time and both contain coordination of benefit provisions, insurance regulations require the primary carrier be determined by an established sequence. This means that the primary carrier will pay its full benefits first; then the secondary carrier would consider the remaining expenses (See the Coordination of Benefits Provision found in the It's Your Choice Uniform Benefits, Local Access Plan, or Medicare Plus Certificates of Coverage online. The IYC Medicare Advantage Evidence of Coverage is also available online.). Note that with coordination of benefits, the secondary carrier may not always cover all of your expenses that were not covered by the primary carrier.

6. If I meet my plan's out-of-pocket limit (OOPL), do I have to continue to pay copayments?

Once you reach your OOPL, you no longer have to pay most copayments. You will continue to pay copayments for certain level 3 and level 4 prescription drugs, and any other essential health benefit services that do not accumulate to the OOPL. If you are enrolled in the High Deductible Health Plan (HDHP), you do not have to pay for any copayments once you reach your OOPL.

There is a maximum out-of-pocket (MOOP) of $9,450/$18,900 which is the maximum you will pay for essential health benefits. Please see your Certificate of Coverage for information on which services apply to the OOPL and MOOP.

Provider Information

7. Does a Local Health Plan HMO cover care from physicians who are not affiliated with the health plan?

Most Local Health Plans will pay nothing when non-emergency treatment is provided by physicians outside of the plan unless there is an authorized referral or prior authorization. Contact the health plans directly regarding their policies.

For emergency or urgent care, plans are required to pay for care received outside of the network, but it may be subject to usual and customary charges. This means the plan may not pay the entire bill and try to negotiate lower fees. However, ultimately the plan must hold you harmless from collection efforts by the provider (See the Uniform Benefits definition of Emergency Care in the Uniform Benefits Certificate of Coverage (ET-2180) online.).

8. How do I choose a primary care provider (PCP), primary care clinic (PCC), or pharmacy that is right for me?

Check your health plan's or Navitus's website for helpful information on selecting a provider. You can also call and inquire. If you do not select a medical PCP or PCC, the health plan will select one for you and notify you.

If you're not sure a provider holds the same beliefs as you do, call the clinic or pharmacy and ask about your concerns. For example, you may want to ask about the provider's opinion about dispensing a prescription for oral contraceptives.

9. How do I know which providers are in-network providers?

See the Health Plan Search page online for more information on how to access or receive a provider directory. You may also contact the health plan to receive a printed copy of the provider directory. Neither ETF nor your employer maintains a current list of this information.

10. Can I change primary care providers (PCPs) or primary care clinics (PCCs)?

Contact your health plan to find out their requirements to make this change and when your change will become effective.

11. If my primary care provider (PCP) or other healthcare professional is listed with a Local Health Plan, can I continue seeing him or her if I newly enroll in that Local Health Plan?

If you want to continue seeing a particular physician (or psychologist, dentist, optometrist, etc.), contact that physician to see if he or she will be available to you under the Local Health Plan you are considering enrolling in. Confirm this with the Local Health Plan's provider directory. Even though your current physician may join a Local Health Plan, he or she may not be available as your PCP just because you join that Local Health Plan.

12. What happens if my provider leaves the plan midyear?

If you are enrolled in a Local Health Plan HMO, you will need to find an in-network provider for your care unless you are a participant who is in her second or third trimester of pregnancy. Then you may continue to have access to your provider until the completion of postpartum care for yourself and your baby. If you are enrolled in a Preferred Provider Organization (PPO) such as the Local Access Plan and you continue to see this provider, your claims will be paid at the out-of-network benefit level.

If a provider contract terminates during the year (excluding normal attrition or formal disciplinary action), and you are a participant in your second or third trimester of pregnancy, the plan is required to pay charges for covered services from these providers on a fee-for-service basis. Fee-for-service means the usual and customary charges the plan is able to negotiate with the provider while the member is held harmless.

Health plans will individually notify members of terminating providers (prior to the annual open enrollment period) and will allow them an opportunity to select another provider within the plan's network.

Your provider leaving the plan does not give you an opportunity to change plans midyear.

13. What if I need medical care that my primary care provider (PCP) or primary care clinic (PCC) cannot provide?

All participants must designate a PCP or PCC. Your primary PCP or PCC is responsible for managing your health care. Under most circumstances, they may refer you to other medical specialists within the health plan's provider network as he or she feels is appropriate. However, referrals outside of the network are strictly regulated for most health plans. Check with your health plan for their referral or prior authorization requirements.

In case of an injury that may fall under workers' compensation, you should utilize only providers in your health plan in case workers' compensation denies your claim.

Premium Contribution Tiering

14. How are health premium contributions determined?

Employers determine the amount they will contribute toward the premium under one of the two methods described here.

  1. Your employer pays between 50% and 88% of the premium rate of the average cost qualified plan in the employer's service area for either individual or family coverage for employees who are participants under the Wisconsin Retirement System (WRS).

    Your employer may pay as little as 25% of the premium for either individual or family coverage for an employee appointed to a position working less than 1,040 hours per year and who is a participating employee under the WRS.
     
  2. A three-tier health insurance premium option is available for your employer to choose from. Each health plan is assigned to one of three tiers based on the quality of care and relative efficiency with which it provides benefits. Health plans providing the most cost-effective, quality care (as determined by ETF) are assigned to Tier 1, moderately cost-effective plans to Tier 2, and the least cost-effective plans to Tier 3. Health plans in the same tier have been determined to be within certain thresholds in their level of providing cost-effective, quality care.

    The employee's required contribution to the health insurance premium for coverage is the same dollar amount for all health plans in the same tier, regardless of the total premium.

Note: Your employer may contribute any amount toward the premium for retired employees who continue group coverage.

15. Does a health plan with a higher premium or a higher tier offer more benefits?

No; all Local Health Plans are required to offer Uniform Medical Benefits (this excludes Medicare Plus). Premium rates and tier placement may vary because of many factors:

  • how efficiently the health plan is able to provide services and process benefit payments;
  • the fees charged in the area in which service is being rendered;
  • the manner in which the healthcare providers deliver care and are compensated within the service area;
  • and how frequently individuals covered by the health plan use the health plan.

16. How often will premium rates change?

All group premium rates change at the same time: January 1 of each year. The monthly cost of all health plans will be announced during the annual open enrollment period.

17. How do I pay my portion of the premium?

Active Employees

Premiums may be paid in advance. Therefore, initial deductions from your salary probably will occur about one month before coverage begins. If the initial deduction cannot occur that far in advance, then double deductions may be required initially to make premium payments current.

Retired Employees

Premium rates for retired employees are the same as for active employees (except that your premium will decrease when you or a dependent becomes covered by Medicare). The employer may, at its option, pay a portion or all of the premium. If you are paying your entire premium, it will be deducted from your monthly annuity. If the annuity is not sufficient to allow a premium deduction, you will be billed directly from your health plan. Warning: Your coverage will be canceled if you fail to pay your premium in a timely manner. You may not be able to reenroll later.

If you are retired and have life insurance coverage through the Wisconsin Public Employers Group Life Insurance Program, you may be eligible to convert the present value of your life insurance to pay health insurance premiums. You must be at least age 67 or age 66 if your employer provides post-retirement life insurance coverage at the 50% level. If you make this election, your life insurance coverage will cease and you will receive credits in a conversion account equal to the present value of your life insurance. The present value ranges from about 44% to 80% of the amount, depending on your age. The life insurance company, Securian Financial Group, will pay health insurance premiums on your behalf from your conversion account until the account is exhausted. You will not receive any direct cash payment. You may file the election at any time, and it will be effective no earlier than 61 days after ETF receives it. For more information, see the brochure Converting Your Group Life Insurance to Pay Health or Long-Term Care Insurance Premiums (ET-2325) or contact ETF for an election form.

Benefits/Deductible/Copayment/Coinsurance/Out-of-Pocket Limit

18. Does the $2,000 opt-out incentive offered to state employees apply to the Wisconsin Public Employers Group Health Insurance Program?

No, but your employer may offer a similar program.

19. Are the Uniform Dental Benefits available to local government employees?

Each local government employer must choose whether or not to offer the Uniform Dental Benefit to employees. Please check with your employer to determine if the Uniform Dental Benefit is available to you.

20. What are preventive services?

Preventive services are routine health care services that include check-ups, patient counseling, and screenings to prevent illness, disease, and other health-related problems. Federal law requires that specific preventive services performed by in-network providers be offered at no cost to you. You can find a list of these preventive services on the healthcare.gov Preventive health services page.

21. What is a deductible?

A deductible is the amount you must pay out-of-pocket for the full cost of certain covered healthcare services before your health plan begins to pay.

22. What is a copayment?

A copayment is a fixed amount you pay for certain covered healthcare services or prescription drugs, usually due at the time you receive the service.

23. What is coinsurance?

Coinsurance is your share of the costs of certain covered healthcare services or prescription drugs, calculated as a percent of the amount for the service or cost of the drug.

Example: If a diagnostic test costs $100 and you have met your deductible, your coinsurance payment of 10% would be $10 (10% of $100). The health plan pays the rest of the cost ($90).

24. What is an out-of-pocket limit (OOPL) and maximum out-of-pocket (MOOP) limit?

An OOPL is a plan provision that limits a member’s cost sharing. The OOPL is the maximum amount that a member will pay for most in-network, covered services during a plan year (same as calendar year). The WPE (local government) program has OOPLs in place that apply to certain medical and prescription drug out-of-pocket costs (See Changing Health Plans FAQs Question: If I change plans, what happens to any out-of-pocket maximums that may apply to services I've received?).

The federal government also enforces MOOP limits that are much higher than the OOPLs of the state and WPE (local government) group health insurance programs. For any essential health benefit costs that do not stop at the program OOPL (for example, adult hearing aids), the federal MOOP limits provide a safety net that does not allow you to incur any out-of-pocket expenses after the MOOP is met. The Group Insurance Board selected $9,450 individual or $18,900 family as the program's MOOP.

Note: For the group health insurance program, the MOOP typically only applies to Level 3 and Level 4 non-preferred prescription drugs. For members in the High Deductible Health Plan (PO7/17), the OOPL is the most you will pay for claims. It acts as the MOOP.