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Health Plan Information

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

Active employees: File an application through your benefits/payroll/personnel office to notify their health plan of changes. 

Retirees and continuants: To enroll, change plans, or increase coverage, submit a paper application to ETF:

Failure to report changes on time may result in loss of benefits or delay payment of claims. Changes that should be reported include:

  • Change in health plan (for example, from your current Health Plan to the 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 your primary care clinic (PCC), you may contact your health plan.

For more information see the Dependent Information FAQs Question: Which changes need to be reported?

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 Uniform Benefits Certificate of Coverage (ET-2180) and Schedule of Benefits that describe your benefits. ETF provides the  Health Plans, Access Plan, Medicare Plus, and the Uniform Pharmacy Benefits Certificates of Coverage and Schedule of Benefits 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 prior authorization for non-emergency hospitalizations and contact be made if there is an emergency admission. Prior authorizations may also be required for high-tech radiology (for example, MRI, PET, CT scans) and for low back surgeries. Check with your health plan and make sure you understand any requirements.

For the 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 health plan as soon as reasonably possible.

3. Will a health plan HMO cover dependent children who are living away from home?

Only if the 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. 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 as soon as reasonably possible.

If you are enrolled in IYC Medicare Advantage you must show your health plan's card  when you visit your provider. 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. 

For more information see the Coordination of Benefits Provision found in the health plans, 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 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 $10,150 individual/20,300 family, which is the maximum you will pay for essential health benefits. Please see your Schedule of Benefits and/or Certificate of Coverage for information on which services apply to the OOPL and MOOP.

Provider Information

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

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

For emergency or urgent care, health 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 health plan may not pay the entire bill and try to negotiate lower fees. However, the health plan must ultimately hold you harmless from collection efforts by the provider. For more information see the definition of Emergency in the Uniform Benefits Certificate of Coverage (ET-2180).

8. How do I choose a PCP, 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 online Health Plan Search page 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 or your employer maintains a current list of this information.

10. Can I change PCPs or PCCs?

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

11. If my PCP or other healthcare professional is listed with an IYC health plan, can I continue seeing him or her if I newly enroll in that health plan?

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

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

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

If you are enrolled in a health plan you will need to find an in-network provider for your care. If you are in your second or third trimester of pregnancy 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 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 health 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 health 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 health plan's network.

13. What if I need medical care that my PCP or PCC cannot provide?

A participant must designate a PCP or PCC. Your 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.

You should utilize only providers in your health plan for care related to an injury that may fall under workers' compensation in case workers' compensation denies your claim.

Premium Contribution 

14. How are health premium contributions determined? 

State and grad employees only: 

For eligible employees, the employer contribution is determined either through collective bargaining or through the applicable compensation plan.

The three-tier health insurance program was implemented as an innovative approach that holds costs down as it creates incentives for health plans to reduce their costs to the state and encourages employees in the state to choose the health plans that are most efficient in providing quality health care. Health plans are tiered based on providing the most cost-effective, quality care, within certain thresholds determined by ETF. Health plans providing the most cost-effective, quality care are assigned to Tier 1, moderately cost-effective plans to Tier 2, and the least cost-effective plans to Tier 3.

The Access Plan is a PPO that offers a nationwide provider network. Since this model is less cost-effective than an HMO, this plan is Tier 3, unless you are an employee who lives and is assigned to work outside of Wisconsin. For you, it is a Tier 2 plan, as your health plan choices are very limited outside of Wisconsin.

Local employees only:

Employers determine the amount they will contribute toward the premium under one of the two methods described here. For more information, see the Health Plan Tiers page.

  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 are tiered based on providing the most cost-effective, quality care, within certain thresholds determined by ETF. Health plans providing the most cost-effective, quality care are assigned to Tier 1, moderately cost-effective plans to Tier 2, and the least cost-effective plans to Tier 3.

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 local 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?

State, grad, and local employees who tier only: No, all plans are required to offer Uniform Medical Benefits. Premium rates and tier placement may vary because of many factors, including:

  • 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
  • How frequently individuals covered by the plan use the benefits

Members who enroll in the Uniform Dental Benefit plan will have a slightly higher premium than members who choose health insurance without dental.

16. If a plan is not in Tier 1, does that mean it provides lower-quality health care?

State, grad, and local employees who tier only: No. The Group Insurance Board requires that plans demonstrate high quality in order to be in the program. This is verified by our collection of data from the Consumer Assessment of Health Plans (CAHPS) survey, the Health Plan Employer Data and Information Set (HEDIS), and other quality measures.

17. How often will premium rates change? 

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

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

State, grad, and local employees: Premiums are deducted from your paycheck. If you have questions contact your employer.

Note: If eligible, your premiums will automatically be deducted from your payroll check on a pre-tax basis, unless you choose otherwise.

Retirees only: 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). However, the state does not pay any portion. Local employers may contribute. Your premiums are post-tax.

Your monthly premiums will be paid in one of the following ways:

State employees:

  • From your Accumulated Sick Leave Conversion Credits, until those credits are exhausted. If you are insured in the state program and have accumulated sick leave at the time of your retirement or death (and your applicable compensation plan or collective bargaining agreement provides for sick leave conversion), see the Accumulated Sick Leave Credit Program for more information.

Retirees: If  your annuity is large enough, your premiums will be deducted from your annuity. Premiums will be automatically deducted a month in advance of coverage . If there is no annuity or your annuity is not large enough to take premiums, then they will be paid as follows:

  • From direct billings to you. Your health plan will bill you directly for premiums on a monthly basis. Warning: Your coverage will be canceled if you fail to pay your premium in a timely manner. If you are eligible and choose to reenroll, coverage will be effective January 1, following enrollment during the annual open enrollment period. If you are a surviving dependent, you are not eligible for reenrollment.

  • From your converted life insurance. You may elect to convert your life insurance to pay health insurance premiums if you meet the following criteria: 

    • If you are retired and have life insurance coverage through the state of Wisconsin
    • If you are at least 66 years old
    • For state employees, you must have used up all your sick leave credits

    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 and an election form, contact ETF. See the brochure Converting Your Group Life Insurance to Pay Health or Long-Term Care Insurance Premiums (ET-2325) for additional information.

Benefits and Opt Out 

19. 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. If you are a state employee and want to learn more, visit the Opt Out FAQ. 

20. Are the Uniform Dental Benefits available to Wisconsin Public Employers Group Health Insurance Program?

Local only: 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.

Deductible/Copayment/Coinsurance/OOPL

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.

Example: Paying a copayment for an emergency room visit.

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 durable medical item 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 OOPL and 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 state and WPE (local government) programs have OOPLs in place that apply to certain medical and prescription drug out-of-pocket costs. For more information 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 enforces MOOP limits that are much higher than the OOPLs of the Group Health Insurance Programs. For any essential health benefit costs that do not stop at the program OOPL (e.g., adult hearing aids) the federal MOOP provides 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 $10,150 individual or $20,300 family as the program's MOOP.

Note: For the Group Health Insurance Program, the MOOP typically only applies to Level 3 and Non-Preferred Level 4 prescription drugs. For members in the HDHP, the OOPL is the most you will pay for claims. It acts as the MOOP. 

25. What are the IYC health plan medical deductible amounts?

For more information about your specific benefit design, please visit Benefits Available to Me and select your employer. For retirees, select your former employer.

26. Does the medical deductible apply to dental services?

No. There is no deductible associated with covered services under the Uniform Dental Benefit, including for the HDHP option.

27. Does the medical deductible have to be met before office visit/emergency room copayments are applied?

No, but any additional services you receive (e.g., lab work or testing) may be subject to the deductible and any applicable coinsurance.

Preventive Services

28. 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 here.

29. Does the deductible or office visit copayment apply to federally required preventive services?

No. These preventive services are covered at no cost to you, as long as the services are provided by an in-network provider. They do not apply to the deductible, including under the HDHP. You can find a list of these preventive services here.