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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 health 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 It's Your Choice (IYC) Health Plan to 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.

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 IYC Health Plans, 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 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 an IYC Health Plan HMO cover dependent children who are living away from home?

Only if the IYC 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 IYC 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 $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 an IYC Health Plan HMO cover care from physicians who are not affiliated with the health plan?

Most IYC 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, ultimately the health plan must hold you harmless from collection efforts by the provider (See the definition of Emergency Care in the Uniform Benefits Certificate of Coverage (ET-2180).).

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 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 an IYC health plan, can I continue seeing him or her if I newly enroll in that IYC 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 IYC Health Plan or HDHP HMO you are considering enrolling in. Confirm this with the IYC Health Plan or HDHP HMO's provider directory. Even though your current physician may join an IYC Health Plan or HDHP HMO, he or she may not be available as your PCP just because you join that IYC Health Plan or HDHP HMO.

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

If you are enrolled in an IYC Health Plan HMO or HDHP HMO, you will need to find an in-network provider for your care. If you are in your 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 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.

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

13. What if I need medical care that my primary care provider (PCP) or primary care clinic (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.

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? Why was a tiered premium contribution structure implemented?

State and Grad 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. Each health plan is rated and placed in a tier based on providing the most cost-effective, quality care (as determined by ETF). Health plans in the same tier have been determined to be within certain thresholds in their level of providing cost-effective, quality care.

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.

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

State and Grad only: No, all plans are required to offer Uniform Medical Benefits. 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 plan use the health plan.

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

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

State and Grad 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.

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

State and Grad only: 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. Your premiums are post-tax.

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

  • 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), the credits can be converted to a dollar amount to pay your health premiums for the State of Wisconsin Group Health Insurance Program (Sick leave credits can only be converted for payment of State of Wisconsin Group Health Insurance Program premiums; they cannot be used for other insurance; they have no cash value and accrue no interest.). If you choose to escrow (preserve) your sick leave, this can be done at the time of retirement or at a later date. Contact ETF for the escrow form. Note: If you qualify for a Wisconsin Retirement System disability benefit, you have the option of being paid your sick leave hours or having them converted to pay your health premiums while you are receiving your disability annuity.
  • If you have no sick leave credits available or your credits are exhausted, then monthly premiums will be paid from deductions from your monthly retirement, disability, or beneficiary annuity payment. 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:
  • 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 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. If you are retired and have life insurance coverage through the state of Wisconsin, are at least age 66, and have used up all your sick leave credits, you may elect to convert your life insurance to pay health insurance premiums. 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.

19. Do I have to use my sick leave credits to pay my health premiums?

Retirees only: You do not have to use your sick leave credits to pay your health premiums if:

  • You escrow your sick leave. If you are insured in the state program on your termination date, are eligible to use sick leave credits, and are covered under comparable health coverage, you may escrow your sick leave credits. You may also elect to escrow later if you become covered by a comparable health coverage when you are insured in the state program. You may escrow indefinitely as long as you have comparable health coverage continuously during the escrow period. You may elect coverage under any health plan in the state program without waiting periods or exclusions for preexisting conditions when timely reenrolled, or
  • You are covered under your spouse's State of Wisconsin Group Health Insurance Program plan. If you retire and are also a dependent on your spouse's State of Wisconsin Group Health Insurance Program plan, you will have your sick leave credits inactivated until your spouse retires and depletes his or her own sick leave credits.

Note: You can initiate use of your sick leave credits once a year during the annual open enrollment period. (See Sick Leave Conversion Credit Program (ET-4132) brochure for detailed information.)

20. Can I use my sick leave credits to pay for health insurance premiums outside of the State of Wisconsin Group Health Insurance Program, like for Medicare Part B?

No. First, state law doesn’t allow this option. The sick leave program was designed to help pay the cost of health insurance that is offered by the health plans under contract with the Group Insurance Board (Board). Because this program is defined in the statutes, ETF isn’t authorized to allow employees to use these credits to pay any other premiums.

A second reason is the potential negative tax consequences for participants. For tax purposes, the sick leave program is treated like an employer’s contribution to the health insurance of its active employees. Any change to the usage of these funds, that is, to permit their use to pay for health insurance outside of the Board's authority, could carry substantial tax liabilities for all participants. For example, if participants had the option to receive cash payments for other health insurance instead of the current contribution toward our employer-sponsored plan, the sick leave payments could become subject to income tax for all participants, even if only a few individuals chose to receive the payment directly.

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

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 of $15 for a primary care 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 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 state and WPE (local government) programs have 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 enforces MOOP limits that are much higher than the OOPLs of the State of Wisconsin and WPE 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 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 $9,450 individual or $18,900 family as the program's MOOP.

Note: For the State of Wisconsin 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?

The medical deductible is $250 per individual and $500 per family for the IYC Health Plan. Keep in mind that certain preventive services are covered at 100%. Office visit copayments and prescription drug costs are not subject to the deductible and do not apply toward meeting the deductible.

Note: You can find complete deductible and benefit information for your plan online.

26. When does the medical deductible apply?

All eligible medical charges are subject to the annual deductible. There are three exceptions:

  1. Office visits are subject to a per-visit copayment of $15 for primary care and therapy office visits, and $25 for specialty care and urgent care visits.
  2. Emergency room visits are subject to a $75 per-visit copayment.
  3. Preventive services from an in-network provider are covered at 100% per federal law.

These visits are not subject to the deductible, but any additional services you receive (e.g., lab work or testing) may be subject to the deductible and any applicable coinsurance.

27. 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 High Deductible Health Plan (HDHP) option.

28. 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.

29. How much are the office visit copayments?

 

Office Visit Type $15 Primary Care Visit $25 Specialty Visit
Family Practice •  
General Practice •  
Internal Medicine •  
Gynecology/OB •  
Midwives •  
Nurse Practitioners •  
Physician Assistant •  
Pediatrics •  
Urgent Care   •
Chiropractic •  
Home Health Visit Subject to deductible and coinsurance Subject to deductible and coinsurance
Palliative Care Visit • 
For primary care provider only		 • 
For specialist only
Vision Exam   •
Pre/Postnatal Visits •* 
For family practice with obstetrics or OB/GYN		 •* 
For maternal/fetal specialist
Mental Health Visits/Therapy •  
Physical Therapy •  
Occupational Therapy •  
Speech Therapy •  
Other Practitioner   •

* If all prenatal visits are billed as a package at the end of pregnancy, then deductible and 10% coinsurance apply. Check with your doctor’s office for more information.

30. Do office visit copayments count toward the annual out-of-pocket limit (OOPL)?

Yes, office visit copayments are applied to the annual OOPL.

31. Does coinsurance apply to various services that are subject to the deductible (e.g., lab tests, diagnostic X-rays)?

Yes. After the deductible is met, a 10% coinsurance will be charged for all non-copayment related services beyond the charge for the office visit.

Exception: A 20% coinsurance applies to covered durable and disposable medical equipment, certain hearing aids, and cochlear implants.

32. What are the High Deductible Health Plan (HDHP) deductible amounts?

The medical deductible is $1,600 per individual and $3,200 per family for the HDHP per federal law. The only services covered before your deductible is met are preventive services; these are covered by the plan at 100%.

Preventive Services

33. 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.

34. 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 High Deductible Health Plan (HDHP). You can find a list of these preventive services here.