If you are eligible for Medicare, you must be enrolled in the hospital (Part A) and medical (Part B) portions of Medicare at the time of your retirement. If you are an active employee, the requirement to enroll for Medicare coverage is deferred for you and your dependents until the termination of your employment. Because all plans that participate in the State of Wisconsin Group Health Insurance Program have coverage options that are coordinated with Medicare, you will remain covered by the plan you have selected even after you enroll in Medicare.
Premium rates will decrease if you or a dependent are eligible for Medicare and you are retired. Medical coverage under the It's Your Choice (IYC) Health Plans (health plans that offer Uniform Benefits) does not change. The IYC Medicare Advantage plan also offers Uniform Benefits. The health plan will not duplicate benefits paid by Medicare. However, if enrolled in the Access Plan or State Maintenance Program (SMP), your coverage will change to the Medicare Plus plan (a Medicare supplement) when you enroll in Medicare Parts A and B.
For all health plans, prescription drugs will continue to be covered through the Pharmacy Benefit Manager (PBM). For members with Medicare, this is your Part D Plan.
If you are not eligible for and enrolled in all available portions of Medicare (A, B, and D) upon retirement you will be liable for the portion of your claims that Medicare would have paid beginning on the date Medicare coverage would have become effective. The only exception is under the IYC Medicare Advantage plan. If you are not enrolled in both Medicare Parts A and B, you are not eligible for IYC Medicare Advantage.
For information about Medicare benefits, eligibility, and how to enroll contact your local Social Security Administration office or call 1-800-772-1213. In addition, the State Health Insurance Assistance Program (SHIP) has counselors in every state and several territories who are available to provide free one-on-one help with your Medicare questions or problems. The Wisconsin SHIP can be reached at 1-800-242-1060. Additional information and assistance can be found on their website. Information about SHIP programs outside of Wisconsin can be found at https://www.medicare.gov/talk-to-someone.
1. What do I need to do when my spouse or I become eligible for Medicare?
Important! When you receive your Medicare card, please send a photocopy to the Wisconsin Department of Employee Trust Funds (ETF) immediately or your Medicare-coordinated coverage may be delayed.
If you become eligible for Medicare your eligibility for COBRA coverage ends. Contact ETF for more information.
State and Retirees only: ETF does not require you and your dependents to enroll in Medicare until you, the subscriber, terminate employment or health insurance coverage as an active employee ceases (If you or your insured spouse is insured as an active employee under a non-state group plan, enrollment in Medicare may be deferred until retirement from that job.). At the time of your retirement, you and your dependents who are eligible for Medicare must enroll for the Part A (hospital) portion and Part B (medical) portion of Medicare. When you and/or your dependents are retired and eligible for Medicare Parts A and B, your group health insurance coverage will be integrated with Medicare and the monthly premium will be reduced.
In general, enrollment in Medicare Part D (prescription drug coverage) is voluntary, however, you may pay a penalty if you do not enroll when you are first eligible or are not covered by what Medicare considers creditable coverage. Regardless, Medicare Part D coverage is provided by the State of Wisconsin Group Health Insurance Program. Additional information about all parts of Medicare can be found in the following questions and answers.
Grads only: There is no Medicare reduced rate available to those enrolled in the Graduate Assistant program.
2. When must I apply for Medicare?
State and Retirees only:
Medicare Part A
Most people become eligible for Medicare upon reaching age 65. Individuals determined to be disabled by the Social Security Administration (SSA) become eligible after a 24-month waiting period.
If you or your spouse are actively working and are not enrolled in a High Deductible Health Plan (HDHP) when you become eligible, you may want to consider enrolling in Medicare Part A as it may cover hospital services if your health plan denies them. There is no premium for Medicare Part A. Subscribers who have Medicare Part A are ineligible for the state's HDHP.
Medicare Part B
The requirement to enroll in Medicare Part B coverage is deferred for active employees and their dependents until the subscriber's termination of their Wisconsin Retirement System-covered employment, through which active employee health insurance coverage is provided.
If you have terminated employment, are a surviving dependent, or are a COBRA/continuant and are eligible for coverage under the federal Medicare program, you must immediately enroll in both Part A and Part B of Medicare unless you are otherwise employed and have health insurance coverage through that employment. If you do not enroll for all available portions of Medicare upon retirement, you will be liable for the portions of your claims that Medicare would have paid beginning on the date Medicare coverage would have become effective. The only exception is under the IYC Medicare Advantage plan. If you are not enrolled in both Medicare Parts A and B, you are not eligible for IYC Medicare Advantage.
If you or your insured spouse is insured as an active employee under a non-state group plan, enrollment in Medicare may be deferred until retirement from that job. Health insurance premiums will not be reduced until the employee retires.
For subscribers and their dependents with End Stage Renal Disease (ESRD): You will want to contact your local Social Security office, health plan, provider, and Medicare to make sure you enroll in Medicare Part A and Part B at the appropriate time. The State of Wisconsin Group Health Insurance Program will provide primary coverage during a 30-month coordination period for members with ESRD. You will want to decide if it would be beneficial to enroll in Part B during your initial or general enrollment opportunities to avoid later delayed Medicare enrollment and potential premium penalties after your 30-month coordination period ends.
Medicare Part D
U.S. resident retired members and their spouses and/or dependents that participate in the State of Wisconsin Group Health Insurance Program who are Medicare enrolled will be automatically enrolled in the Navitus MedicareRx Prescription Drug Plan (PDP). This plan is offered by Navitus Health Solutions and underwritten by Dean Health Insurance Inc., a federally-qualified Medicare contracting prescription drug plan. Prescription drug coverage under this program is Medicare Part D coverage and a portion of your monthly health insurance premium applies to this coverage.
Please note that the Navitus MedicareRx (PDP) includes all 50 states and Puerto Rico. The service area excludes most U.S. Territories, such as the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. If you live outside the service area you must enroll in another Medicare Part D Plan. You will still have the wrap benefit available as secondary coverage.
Before Navitus can report your enrollment in Medicare Part D to Medicare they need to have your Medicare Beneficiary Identifier (MBI) number and Parts A and B effective dates. In most cases, ETF will request this information from you two to three months in advance of your 65th birthday by sending you a Medicare Eligibility Statement (ET-4307). ETF will then provide the information to Navitus. Please complete and return this form as soon as possible to ensure you receive the benefits you are eligible for and your claims are paid properly.
If you do not receive the Medicare Eligibility Statement (ET-4307) at least one month before your 65th birthday please contact ETF.
If you are retired and cover a Medicare-eligible spouse or disabled dependent on your plan please notify ETF and provide your spouse's or dependent's Medicare information.
Individuals may choose to enroll in another Medicare Part D prescription drug plan, however, it is not recommended or required for your continued coverage under the State of Wisconsin Group Health Insurance Program.
If you choose to enroll in a different Medicare Part D plan your health insurance premium for the state plan does not change, but your supplemental wrap-around pharmacy coverage will be secondary to the other Medicare Part D plan (See Questions below: Does Medicare Part D affect my prescription drug coverage? Should I enroll? and Will my health insurance premium go down if I enroll in a Medicare Part D prescription drug plan?).
3. What plan designs are offered to retirees and their dependents who are eligible for Medicare?
Three different plan designs are offered to retirees and their dependents who are eligible for Medicare. They are:
IYC Medicare Advantage
The benefits of this plan design match the Uniform Benefits offered by the other insurers under the IYC Health Plan – Medicare, with minor exceptions. This plan has a nationwide PPO network that allows members to use any healthcare provider in the country that accepts Medicare and is willing to work with the vendor, UnitedHealthcare (UHC). In this PPO, in-network or out-of-network services are allowed with the same member cost share.
Medicare Plus
This is a group Medicare Supplement or Medigap plan offered by UHC. This plan design supplements the portion of covered services not paid by Medicare (deductibles and coinsurance), with few exceptions. Members may receive care nationwide and worldwide from any qualified healthcare provider for treatment covered by the plan.
IYC Health Plan – Medicare
This plan design offers Uniform Benefits like those active employees receive, but for Medicare enrollees, the plan coordinates with Medicare coverage. This means Medicare pays first and IYC Health Plan - Medicare pays second. Often, enrollees on this plan were enrolled with the same health plan they had prior to becoming eligible for Medicare. The IYC Health Plan – Medicare plan is available through each of the 11 competing, contracted health plans.
For more information, see the Medicare Plan Designs Quick Comparison.
4. Can I change health plans, cancel my insurance or change coverage levels when my dependent or I have a Medicare coverage change?
Yes. Covered retirees may change plans, cancel coverage, or change coverage levels (from family to individual), when a covered individual has a change in their Medicare coverage (for example, when they turn age 65 and gain Medicare). This does not apply to non-retirees.
To change plans, you should submit your application prior to your Medicare effective date. This can be sent up to 3 months in advance. Coverage with your new plan will be effective on the same date as Medicare. You may also submit the application up to 30 days after your Medicare effective date, but then coverage will be effective on the first of the month after ETF receives your application.
If you cancel coverage, the change will be effective on the last day of the month following receipt of the application.
If you change from family to individual coverage, the change will be effective on the first the month following the receipt of the application.
Note: If you are eligible for Medicare, you must be enrolled in Part A (hospital) and Part B (medical) portions of Medicare at the time of your retirement. If you are insured under active employee coverage, these requirements to enroll for Medicare coverage are delayed for you and your dependents until the termination of employment. If you are not enrolled for all available portions of Medicare upon retirement you will be responsible for the portion of your claims that Medicare would have paid beginning on the date Medicare coverage would have become effective, except for under the IYC Medicare Advantage plan. If you are not enrolled in both Medicare Parts A and B, you are not eligible for IYC Medicare Advantage.
5. If Medicare coverage is in effect, how do I file Medical, Part B, and Pharmacy claims?
If Medicare is the primary insurance your provider must submit claims to Medicare first. Once Medicare processes the claim(s), Medicare will send you a quarterly Medicare Summary Notice (MSN). Exception: If you are enrolled in the IYC Medicare Advantage plan, your provider will submit claims to that plan and they will send you an Explanation of Benefits (EOB).
IYC Health Plan Medicare:
Many health plans have an automated procedure after Medicare processes the claim, through which the provider then submits it to the health plan for processing. However, some health plans require members to submit a copy of the MSN and, in certain circumstances, a copy of the provider's bill. You should discuss with your provider if they will bill Medicare and your health plan on your behalf. Contact your health plan for additional information.
IYC Medicare Advantage:
IYC Medicare Advantage, offered by UnitedHealthcare (UHC), allows members to seek care anywhere in the United States and its territories. The benefits are the same in or out of network. You can see any provider that accepts Medicare and is willing to treat you and bill UHC. When you visit your provider, you must show your health plan's card. Your provider will submit your claims directly to the health plan. To request reimbursement for a covered service charge that you paid, fill out a Direct Member Reimbursement form from UHC and send it, along with your receipt (note your name and your member ID), and a copy of your health plan ID card to the address on the back of that card. Contact UHC for more information.
You must be enrolled in Medicare Parts A and B to be eligible for the IYC Medicare Advantage plan. You should keep your Medicare card in a safe place, but you should not show it when you receive healthcare services, as the IYC Medicare Advantage plan will be primary for your service. See Question: If I have Medicare as my primary coverage, how are my benefits coordinated?
Medicare Plus:
Your responsibilities in the claims process will depend on the policies and practices of the medical facility from which you receive care. You may be required to submit the claims to Medicare and then submit the proper forms to UHC for supplemental payments. Refer to the Medicare Plus Certificate of Coverage (ET-4113) available online (also available on paper from ETF) for more information, and contact your healthcare provider or facility regarding their particular Medicare claims procedures.
Pharmacy Benefit Manager:
As long as you maintain the Navitus MedicareRx (PDP) as your Medicare Part D plan Navitus will process your claims for both Part D and the supplemental wrap coverage that is included.
However, if you choose to enroll in a Medicare Part D plan other than the Navitus MedicareRx (PDP), your supplemental wrap coverage, which is part of your State of Wisconsin Group Health Insurance Program pharmacy benefits, will be considered secondary. You should be prepared to file the secondary claims manually through Navitus. Contact Navitus or visit their website for more information on filing manual claims. Refer to the Medicare Part D Information section for more details.
Medicare Part B pharmacy claims are covered under the supplemental wrap benefit. For specific information on Medicare Part B pharmacy coverage and Part B claims processing, see the plan description page for Navitus Health Solutions.
6. What is the Medicare Cross-over Option?
Retirees only: Medicare Cross-over is designed to eliminate some of the paperwork involved in filing medical claims. Some plans have an agreement with Medicare to crossover claims for any services that Medicare processed as primary. Medicare will automatically forward your Medicare Summary Notice (MSN) to those plans for services you receive throughout the United States. Claim forwarding is automatic for each person covered under Medicare when a plan participates in Medicare Cross-over. You do not need to complete a form or contact a plan to take advantage of crossover. Please contact your health plan for further information.
7. If I have Medicare as my primary coverage, how are my benefits coordinated?
Retirees only: Since all state health plans have coverage options that are coordinated with Medicare, you will remain covered by the plan you selected after you are enrolled in Medicare, even though Medicare is the primary payor of your claims.
Exceptions:
- If you are enrolled in the IYC Medicare Advantage plan, UnitedHealthcare (UHC) will pay your claims.
- If you are enrolled in the Access Plan or State Maintenance Program (SMP) through Dean Health Plan, your coverage will be changed to the Medicare Plus plan through UHC. There are some differences in benefits between these plans. Medicare Plus is designed to supplement the benefits you receive under Medicare. For purposes of paying benefits, Medicare is the primary plan and Medicare Plus is the secondary plan. This means Medicare benefits apply first toward claim payments, and then Medicare Plus reviews the claim second to determine if their supplemental benefits cover any remaining payment due.
- If you are enrolled in one of the IYC Health Plans your health coverage will remain substantially the same as before Medicare coverage became effective. For purposes of paying benefits, Medicare is the primary plan and the State of Wisconsin Group Health Insurance Program is the secondary plan. This means Medicare benefits apply first toward claim payments, and then the IYC Health Plan reviews the claim second to determine if their benefits cover any remaining payment due. Because of this coordination with Medicare benefits, your monthly premiums for state health insurance will be less.
Note: For some benefits under the IYC Health Plan Medicare and IYC Medicare Advantage, such as durable medical equipment, Medicare Part B and the health plan both have a 20% coinsurance that you are responsible to pay.
8. What is the Social Security Income-Related Monthly Adjusted Amount (IRMAA) and does it affect me?
If you are enrolled in Medicare and your modified adjusted gross income (AGI) exceeds certain limits established by federal law, you may be required to pay an adjustment to your monthly Medicare Part B (medical) and Medicare Part D (prescription drug; i.e. Navitus MedicareRx (PDP)) coverage premiums. The additional premium amount you will pay for Medicare Part B and Medicare prescription drug coverage is called the IRMAA. Since Medicare beneficiaries enrolled in the State of Wisconsin Group Health Insurance Program are required to have Medicare Parts A, B, and D the IRMAA may impact you if you have higher income.
To determine if you will pay the additional premiums, Social Security uses the most recent federal tax return that the IRS provides and reviews your modified AGI. Your modified AGI is the total of your AGI and tax-exempt interest income.
Social Security notifies you in November about any additional premium amounts that will be due for coverage in the next year because of the IRMAA. You must pay the additional premium amount, which will be deducted from your Social Security check if it's large enough. Failure to pay may result in Medicare terminating your coverage. The IRMAA is paid to Social Security, not the State of Wisconsin Group Health Insurance Program. It is not included in your State of Wisconsin Group Health Insurance Program premium.
Additional information can be found in SSA Publication No. 05-10536 or by calling the SSA toll-free at 1-800-772-1213.
9. What happens if an individual retires before age 65 or is otherwise not eligible for Medicare?
A retiring individual who is not eligible for Medicare will stay on their current plan.
When the retiree turns age 65 or otherwise becomes eligible for Medicare they will move to the Medicare version of the plan they are currently enrolled in, or they may change plans by filing an application within 30 days of gaining eligibility for Medicare.
Medicare Part D Information
10. How are vaccines covered under Medicare?
Most vaccines are covered under Medicare Part D. Members can show their Navitus member card at any in-network pharmacy and receive vaccines covered by Medicare Part D at no cost.
Flu and Covid-19 vaccines and boosters are covered under Medicare Part B instead, and can be accessed in two different ways. At no cost to them, members can either go to an in-network medical provider and receive their flu and Covid-19 vaccines/boosters, or they can go to a pharmacy, show their red, white, and blue Medicare card, and receive their flu and Covid-19 vaccines/boosters.
11. Which Medicare Part D prescription drug coverage is provided under the State of Wisconsin Group Health Insurance Program?
Medicare related prescription drug coverage will be provided by Navitus Health Solutions (Navitus) through a self-funded, Medicare Part D Employer Group Waiver Plan (EGWP) called the Navitus MedicareRx (PDP). This plan is underwritten by Dean Health Insurance Inc., a federally-qualified Medicare contracting prescription drug plan. This affects Medicare-eligible participants covered under an annuitant contract enrolled in the State of Wisconsin Group Health Insurance Program. As required by Uniform Benefits and Medicare Plus, a supplemental wrap benefit is also included to mainly provide full coverage to State members when Medicare Part D coverage does not during the Medicare Part D Deductible Phase or Coverage Gap Phase.
Your group health insurance premium already includes the cost of this benefit. There is no separate premium that needs to be paid for this Medicare Part D coverage. It is important that you read and understand the information presented on the Navitus MedicareRx plan description page. It is available online under the Members page or on paper by calling ETF.
12. Does Medicare Part D affect my prescription drug coverage? Should I enroll?
A Medicare Part D Prescription Drug Plan (PDP) provides primary coverage of prescription benefits through Medicare. While enrollment in a PDP is voluntary, if you do not enroll when you are first eligible and do not have what Medicare considers creditable coverage, you may have to pay a penalty in the form of a higher PDP premium once you do enroll.
Under the State of Wisconsin Group Health Insurance Program, after you become eligible for Medicare Part D, the following will happen:
- You will be automatically enrolled in the Navitus MedicareRx (PDP). Medicare-eligible spouses and/or dependents will also be enrolled. This is Medicare Part D coverage. Your group health insurance premium already includes the cost of this Medicare Part D coverage.
- You will also be automatically enrolled for supplemental wrap coverage to ensure your prescription drugs are covered when you reach the Medicare Part D Deductible Phase or Coverage Gap Phase. Your group health insurance premium already includes the cost of this supplemental wrap coverage.
When you are enrolled in the Navitus MedicareRx (PDP), you will be issued a new ID card that you will be required to use.
If you would like to maintain coverage similar to your current level of prescription drug benefits under ETF's program it is not necessary to enroll in another Medicare Part D plan. Nevertheless, participation in a Medicare Part D prescription drug plan is voluntary and you should carefully consider all options before making any kind of decision to enroll in a different Medicare Part D plan.
Additionally, if you are enrolled in Medicare and your modified adjusted gross income exceeds certain limits established by federal law, you may be required to pay an additional amount for your Medicare Part D coverage under the Navitus MedicareRx (PDP). See Question above: What is the Social Security Income-Related Monthly Adjusted Amount (IRMAA) and does it affect me? Please note that the IRMAA is not unique to the Navitus MedicareRx (PDP). If you are required to pay the IRMAA, you would have to do so under any Medicare Part D plan.
13. Will my medications be covered at the same level under Medicare as they were when I was an active employee?
Some medications that are covered at a different level or require prior authorization under Medicare Part D coverage did not have these requirements under ETF's Commercial Pharmacy Benefit. Please check the IYC Medicare Plan Formulary to see if there are changes in coverage to your current medications.
14. Will my health insurance premium go down if I enroll in a different Medicare Part D prescription drug plan?
No. Your health insurance premium includes both medical and prescription drug coverage. If you choose to enroll in a different Medicare Part D plan, you will be dropped from the Navitus MedicareRx (PDP) and you will have to pay an additional premium to the other plan you enroll in. However, you will still have secondary coverage with the supplemental wrap benefits under the State of Wisconsin Group Health Insurance Program. There is no partial refund of the State of Wisconsin Group Health Insurance Program premium if you choose to enroll in a different PDP. Navitus will coordinate coverage with Medicare and pay secondary claims after Medicare processes your prescription claims from the other Medicare Part D plan, minus the applicable copayments and coinsurance that are your responsibility. If you enroll in another Medicare Part D plan, and you intend to stay in that program, notify ETF immediately. If ETF enrolls you in the Navitus MedicareRx (PDP), you may be automatically disenrolled from your other plan by the Centers for Medicare and Medicaid Services (CMS).