Patient Rights and Responsibilities

As a participant in this health insurance program, you have certain rights and responsibilities. By becoming familiar with them, you will be able to make the most of your health care.

Program Option
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
  • State Employee and Retiree Health Plan & Supplemental Benefits

Internet Site Privacy Policy

The Wisconsin Department of Employee Trust Funds (ETF) maintains this Internet site to provide benefits information and service to Wisconsin state and local government employees and employers. To operate this site, we collect information about how the Internet site is used. The purpose of this privacy notice is to demonstrate our commitment to protecting your privacy when you access our website and let you know what types of information we collect, why it is collected, and how it is used.

ET-6301
Form Other Benefit Recipient

Notice of Death

Notify the third party administrator of the group life insurance program of a member death.

ET-2314a
Form Local Employer / State Employer

Model COBRA Subsidy Notice

This is the Model Notice for COBRA Continuation Subsidy under the American Rescue Plan [ARP] Act of 2021. Employers please note that information for qualified beneficiaries must be completed. 

ET-8945
Form Other Benefit Recipient

Vendor Privacy Incident Report

Use this form to report any possible or confirmed breaches of protected health information (PHI) or personally identifiable information (PII).

COBRA: Continuation of Coverage Rights for the Group Health Insurance Program

Program Option
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
  • State Employee and Retiree Health Plan & Supplemental Benefits
ET-2311
Form Active Employee / Local Employer / State Employer

COBRA Continuation - Conversion Notice

Under federal law, known as COBRA, you and your qualified beneficiaries may continue group health insurance coverage, if eligible.

Women’s Health and Cancer Rights Act of 1998

Program Option
  • Local Annuitant Health Program (LAHP)
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
  • State Employee and Retiree Health Plan & Supplemental Benefits

​​​​​​​Public Records Notices

Recognizing the people’s right to information about the government’s decision making process, the Department of Employee Trust Funds will, consistent with the state’s Public Records Law (Wis. Stat. §§ 19.31 to 19.39), provide information regarding ETF’s affairs, except for individual personal information restricted by statute.

ET-8106
Brochure Active Employee / Retiree / Local Employer / State Employer

Department of Employee Trust Funds Public Records Notice

ETF will, consistent with the state’s Public Records Law, provide information regarding ETF’s affairs, except for individual personal information restricted by statute.