1. Who is eligible for the High Deductible Health Plan (HDHP)?

To be eligible for an HDHP, you must be enrolled in the state-sponsored Health Savings Account (HSA).

You must also be one of the following:

  • A state employee who is enrolled in the Wisconsin Retirement System;
  • A Limited Term Employee (LTE) who is eligible for the State of Wisconsin Group Health Insurance Program; or
  • A retiree, including those with a family contract where all members are younger than age 65. If you or your spouse has Medicare Part A and Part B, you are ineligible for the HDHP. For more information, see Question: Who is not eligible for the HDHP?

Note: Graduate assistants and short-term academic staff are not eligible for the HDHP. 

2. What is an HDHP?

It is health insurance that has an annual deductible that must be paid by you before health care costs are covered (with the exception of preventive services required by the Affordable Care Act). The HDHP must be paired with the state-sponsored Health Savings Account (HSA). The plan is designed to offer a lower monthly premium in return for sharing more health care costs with the member.

3. Do I have to enroll in the state-sponsored Health Savings Account to be eligible for the HDHP?

Yes. Under Wisconsin state law, state employees must enroll in the state-sponsored HSA to be eligible for the HDHP.

4. Who is not eligible for the HDHP?

The following people are not eligible for the HDHP:

  • Short-term academic staff not in the Wisconsin Retirement System.
  • Graduate assistants.
  • Retirees older than age 65. These retirees must be enrolled in Medicare Part A and B, and that coverage disqualifies them from participating in the HSA/HDHP. If the Medicare enrolled retiree is on a family contract, no member on the family contract may have an HDHP plan. 
  • Retirees with family coverage who insure a dependent who is eligible for and has Medicare either by being age 65 or older, or is disabled.
  • Subscribers not eligible to enroll and participate in the state-sponsored HSA.
  • Subscribers with other disqualifying health coverage that pays out-of-pocket health care expenses before meeting the plan deductible, such as a spouse’s non-HDHP health plan, Medicare, or a Health Care Flexible Spending Account (FSA). For more information, see Health Savings Account (HSA) FAQs Question: What happens to my HSA if I change health plans, terminate employment, or retire?
  • Subscribers claimed as dependents on the tax return of someone other than the subscriber's spouse. 

5. What constitutes disqualifying other health coverage?

Disqualifying other health coverage is coverage under any other health plan in addition to the HDHP that provides health care coverage prior to meeting the HDHP deductible. Below are examples of other health coverage that pays for out-of-pocket health care expenses before you would meet your HDHP deductible:

  • Traditional Health Plan (non-HDHP) – Health insurance that has first dollar coverage or a lower deductible than HDHP minimums
  • All forms of Medicare (e.g. Part A, Part B, etc.)
  • BadgerCare (Medicaid)
  • All forms of TRICARE (e.g. TRICARE for Life, TRICARE Standard, CHAMPUS, etc.)
  • Accessed Veterans Administration (VA) benefits in the past 90 days (Exceptions may apply. See HSA Administrative Guide for more details)
  • A Health Care FSA owned by you or your spouse in the same year
  • Health Care Reimbursement Account (HRA)
  • Health Care FSA
  • Travel insurance that pays for medical expenses covered by your health plan

6. Are there exceptions to the rule disallowing other health coverage?

Yes. There are a number of exceptions to the rule requiring HDHP coverage for an HSA and disallowing other health coverage. Exceptions include:

  • Permitted insurances:
    • Accident insurance
    • Dental insurance
    • Vision insurance
    • Long-term care insurance
    • Workers' compensation insurance
    • Liability insurance related to property
    • Hospitalization insurance
  • Preventive care
  • Post-deductible care (that is, coverage for services that start after you meet the HDHP deductible)
  • Limited Purpose Flexible Spending Account

If you are unsure whether an insurance policy or other health coverage policy you have is allowed with the HDHP and HSA, contact your employer's benefits/payroll/personnel representative.

7. Does liability insurance coverage impact my eligibility for the HDHP?

No. Liability insurance for ownership, use of property, or workers' compensation will not disqualify an individual.

8. Does specified disease or illness coverage impact my eligibility for the HDHP?

No. Coverage for a specified disease or illness, such as cancer, diabetes, or asthma is allowed in addition to HDHP and HSA coverage without impacting eligibility.

Note: Some insurance products appear to satisfy the specified disease exception, but actual coverage is not for a disease. You should check with your disease or illness insurance provider to make sure your disease or illness coverage is compatible with both an HDHP and HSA.

9. Does supplemental insurance like accident coverage impact my eligibility for the HDHP?

No. Accident insurance that pays a fixed amount per day for hospitalization or injuries is allowed and does not disqualify you from the HDHP and HSA benefit option.

10. Does critical illness insurance coverage impact my eligibility for the HDHP?

Some critical illness insurance plans are designed to be compatible with HDHP and HSA eligibility and others are not. A critical illness insurance plan that pays the HDHP deductible is not allowed. You should check with your critical illness insurance provider to make sure your plan is compatible with both an HDHP and HSA.

11. Does my coverage under my spouse’s traditional health insurance plan impact eligibility for the HDHP?

Yes. Any health plan coverage that pays for services before the HDHP's deductible is met disqualifies you from the HDHP and HSA benefit option.

12. I am enrolled in family coverage in the HDHP and HSA benefit option. I do not have any other health coverage, but my spouse has a health plan that pays before the HDHP deductible is met. Does my spouse’s other health coverage impact my eligibility for family coverage for the HDHP and HSA?

No. To determine eligibility, only your coverage matters. The health coverage of your spouse does not impact your eligibility for family coverage as long as you are not covered by your spouse's plan.

13. I am enrolled in family coverage in the HDHP and HSA benefit option. I do not have any other health coverage, but my dependent child has a health plan that pays before the HDHP deductible is met. Does my dependent child’s other health coverage impact our eligibility for family coverage for the HDHP and HSA?

No. To determine eligibility, only your coverage matters. The health coverage of your dependent child does not impact your eligibility for family coverage in the HDHP and HSA benefit option.

14. Does participation in a Health Care Reimbursement Account (HRA) make me ineligible for the HDHP and HSA benefit option?

Yes, unless the HRA is one of the following types of HRA:

  • Limited Purpose HRA
  • Post-deductible HRA
  • Retirement HRA
  • Suspended HRA

Note: If you are unsure what type of HRA you have, contact the vendor or bank that provides your HRA to verify before you enroll in the HDHP and HSA.

15. Does my Health Care Flexible Spending Account (FSA) coverage disqualify me?

Yes. Your Health Care FSA coverage will make you ineligible for the HDHP and HSA benefit option. Your Health Care FSA is considered another health plan because you can use the money in your Health Care FSA for general health care expenses prior to meeting your HDHP deductible. 

16. Does my Medical Spending Account coverage disqualify me?

Yes. Your Medical Spending Account is the same type of benefit as a Health Care FSA. The industry uses a few different names to describe a Health Care FSA including: Flexible Spending Account, Medical Flex Plan, Flexible Spending Arrangement, Medical Reimbursement Plan, Medical Spending Account, etc. Any plan that provides coverage for health care expenses prior to meeting the HDHP deductible would disqualify you from the HDHP and HSA benefit option.

17. Does my spouse’s Health Care FSA coverage disqualify me from the HDHP and HSA benefit option?

Generally, yes. If your spouse’s Health Care FSA can be used to pay for your medical expenses prior to meeting the HDHP deductible, then this makes you ineligible.

18. If my spouse’s Health Care FSA plan document provides that only my spouse is covered, am I still disqualified?

No. The rule disqualifying you when your spouse is covered by a Health Care FSA assumes the Health Care FSA can also be used for you. Given the popularity of HSAs, some plan documents are drafted to allow individuals the choice of whether or not to cover their spouse. If your spouse’s Health Care FSA cannot be used for you, then your spouse's account will not disqualify you.

19. If my spouse’s Health Care FSA plan document does not allow my spouse to exclude me from Heath Care FSA coverage, can I agree not to use my spouse’s Health Care FSA to remain eligible?

No. In order to remain eligible, your spouse’s Health Care FSA plan document must provide an option to exclude you from your spouse’s Health Care FSA coverage.

20. If I carry over unused Health Care FSA funds, does that disqualify me from the HDHP and HSA benefit option for the entire next year?

Yes. If you are covered under a Health Care FSA, you are not eligible for the HDHP and HSA benefit option.  This answer remains the same if the only reason you have Health Care FSA coverage is because of a carryover of unused Health Care FSA funds. Leftover funds may, however, be rolled into a Limited Purpose FSA, which is HSA-compatible and not disqualifying. For more information, see Question: If I have Health Care FSA carryover funds, what options are available to allow HDHP and HSA benefit option eligibility as soon as possible?

21. If I have Health Care FSA carryover funds, what options are available to allow HDHP and HSA benefit option eligibility as soon as possible?

If you newly enroll in the HDHP and HSA benefit option, your eligible Health Care FSA funds will automatically carry over from your Health Care FSA to an LPFSA.

If your spouse has Health Care FSA carryover funds, your spouse should check with their employer to see if the funds can be waived or transferred to an LPFSA.

22. What is a deductible?

A deductible is the fixed amount that you must pay before your insurance begins to make payments for covered medical services. For example, if you have a $1,650 deductible, you must pay out-of-pocket for $1,650 in covered medical expenses before your insurance pays anything (with the exception of preventive services mandated by the Affordable Care Act). Medical expenses that are non-covered do not count toward your deductible.

23. How will I know when I’ve met my deductible?

Health plans will provide you with statements called Explanation of Benefits after you receive services that will provide this information. While it’s always a good idea to keep track of your out-of-pocket medical expenses on your own, you can check with your health plan to determine where you are in meeting your deductible. You might also be able to keep track of your deductible on your health plan's member portal. See your individual health plan's website for more information.

24. Are prescription benefits still offered under the HDHP?

Yes, the prescription benefits remain the same, with the exception of an added deductible that must be paid before your copays apply. However, prescription drugs that are considered preventive medications are provided with "first-dollar" coverage under the HDHP, meaning that your benefits pay for these drugs before you meet your deductible. You will still have to pay the copayment on preventive medications in most cases although there are also some drugs that are covered at 100% by federal law, meaning you will not have to pay the copayment on these specific drugs. You can find the lists of preventive prescription drugs that are paid with "first-dollar" coverage and those that require no copayment under federal law on the Navitus-ETF benefit website. Click on the HDHP plan to see the formulary, including the Standard Preventive Drug and ETF Discount Drug lists.

25. Why is the deductible so high?

An HDHP must meet certain requirements, including the minimum amount of the deductible and maximum out-of-pocket limit, as set by the IRS.

26. Are any services covered by the HDHP before I reach my deductible?

Yes, examples of covered services, before the deductible is met, include in-network preventive medical services and certain preventive prescription drugs. A list of preventive medical services covered at 100% is available at Healthcare.gov.

27. Is there a separate deductible for medical and prescription drug costs?

No, the amount you pay for medical claims submitted to your health plan and prescription drug claims submitted to the Pharmacy Benefit Manager (PBM), both count towards a single deductible.

28. How do my health plan and the Pharmacy Benefit Manager track my costs and apply them to my deductible?

Your health plan and the PBM share your claims data in order to account for all the costs you pay. The combined amount is applied to your deductible. However, be aware that claims processing for prescription drugs happens very soon after you receive your prescriptions, but medical claims processing takes more time. As such, there may be times when you have actually met your deductible but your health plan and the PBM are not aware of it. Retroactive adjustments and refunds for costs you paid after reaching your deductible will occur.

29. Will I receive an insurance ID card to present to my provider?

Yes, you will have an insurance ID card the same as you would under any of the other health plan options. Make sure you give your provider your health insurance information so your claims count against your deductible.

30. Can I use my sick leave credits to pay for my premium and deductible?

Retirees can use their sick leave credits to pay for health insurance premiums only. These credits cannot be transferred to your HSA.

31. If I am enrolled in the Uniform Dental Benefit plan and the HDHP, does my dental coverage also have the same deductible?

No, the Uniform Dental Benefit is separate from the medical and prescription drug benefits. There is no deductible associated with the Uniform Dental Benefit plan.

32. Are the deductible and out-of-pocket limits (OOPLs) changing for 2025?

Federal law requires that the deductibles increase to $1,650 for individual / $3,300 for family. The out-of-pocket amounts are not changing for 2025.

33. I am an employee and my spouse is currently covered under my HDHP and has decided to enroll in Medicare coverage. Will their new Medicare coverage impact my HDHP eligibility?

No, your spouse enrolling in Medicare will not impact your HDHP eligibility. You are still eligible for the HDHP as long as you do not have any other health coverage. For more information, see Question: I am enrolled in family coverage in the HDHP and HSA benefit option. I do not have any other health coverage, but my spouse has a health plan that pays before the HDHP deductible is met. Does my spouse’s other health coverage impact my eligibility for family coverage for the HDHP and HSA? 

Retirees: For more information, see Question: Who is eligible for the High Deductible Health Plan (HDHP)? 

34. If I experience a qualifying life event mid-year, can I switch from an HDHP to a non-HDHP plan design and enroll in the Health Care Flexible Spending Account?

Yes, you can switch your HDHP to a non-HDHP plan design and enroll in the Health Care FSA midyear if you experience a qualifying life event. However, if you are enrolled in a non-HDHP plan design with a Health Care FSA, you are not eligible to switch to an HDHP with an HSA. The Health Care FSA election is made for the full year and you may not opt-out after the start of the plan year. 

35. Can I use a Limited Purpose FSA (LPFSA) to pay for medical expenses? 

Yes, after you have met your health insurance deductible, your LPFSA can be used to pay for qualified medical expenses. Your LPFSA can pay for vision and dental expenses before you reach your deductible.

Once you meet your deductible, submit a Deductible Met Form to Optum Financial. This form will certify your deductible has been met and allow your LPFSA to be used for medical expenses.