Navigate to a Topic

General Information

1. Why do changes to the health plans and benefits happen?

Each year the Wisconsin Department of Employee Trust Funds 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. For more information, see Enrolling for Coverage FAQs 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. What is the health insurance Marketplace and is it an option for me?

The Marketplace, established under the Affordable Care Act, 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. Visit healthcare.gov for more information.

Note: Premiums for Marketplace insurance cannot be paid out of sick leave credits or with any employer contribution. 

Insurance Complaint Process

3. 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 Group Health Insurance Program is required to have a complaint and grievance resolution procedure in place to help resolve a participant's problems. Contact your plan or PBM to get information on how to initiate this process. You must exhaust all of your appeal rights through the plan or the PBM first in order to pursue review through an External Review/Independent Review Organization (IRO) or through ETF and the Board. If the plan or PBM 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 by phone at 608-261-7947 or email. For more information visit ETF's Benefits Dispute webpage.

4. 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 the right 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 by phone at 608-261-7947 or email or visit ETF's Benefits Dispute webpage. 

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 rescission of coverage. Apart from this exception, you have no further rights to a review through ETF or the courts once the IRO decision is rendered.

5. 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 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 by phone at 608-261-7947 or email or visit ETF's Benefits Dispute webpage. To initiate an ETF review, write a letter to ETF and request an ETF Insurance Complaint Form (ET-2405). Complete the complaint form and attach your letter and 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.

Tax Implications

6. Are my health insurance premiums deducted from my paycheck on a pre-tax or post-tax basis?

State and Grad Only: The health insurance premiums for employees are automatically deducted from your paycheck on a pre-tax basis. This is often referred to as Automatic Premium Conversion. This means that you save on federal and state income tax and FICA taxes (Social Security and Medicare taxes). This is a permanent tax exclusion; no taxes will be owed at a later date.

Important Note: When premiums are deducted on a pre-tax basis, Internal Revenue Code regulations governing premium conversion restrict changes that can be made to your health insurance benefits during the plan year. You may not make changes or cancel your participation in the health plan during the plan year unless your decision to do so is a result of a qualifying change in status event and is allowed by the health plan rules. For more information, see Dependent Information FAQs Question: What are my coverage options if my spouse is also a state of Wisconsin or participating Wisconsin Public Employer (WPE) employee or state retiree? and the Life Events Guide.

If you wish to pay your premiums on a post-tax basis, you may fill out an Automatic Premium Conversion Waiver/Revocation of Waiver (ET-2340) and return it to your payroll/benefits office before the end of the year. Post-tax premium deductions will begin with the January deduction. Once you have filed a waiver it will remain in effect for future plan years unless you file another Automatic Premium Conversion Waiver/Revocation of Waiver (ET-2340) to revoke the waiver.

Retirees: Since your premiums are not taken from a paycheck they are considered post-tax.

7. Are there tax implications for covering my non-tax dependent who is an adult child?

No. The Affordable Care Act 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 COBRA/continuants, ETF).

8. Is the State of Wisconsin Group Health Insurance Program grandfathered under the Affordable Care Act?

No. Note that 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, local employers may choose to offer a similar program.