ET-2545
Form Active Employee

Additional Contributions Remittance

If you choose to make voluntary additional employee paid contributions, complete and return this form with your payment.

Some Out-Of-State Coverage

Medical Associates Health Plan

Major Health Systems
  • Medical Associates Clinic
  • Mercy Medical Center - Dubuque
  • Crossing Rivers Health
  • Grant Regional Health Center
  • Southwest Health Center
Full Service Areas
  • Crawford County
  • Grant County
  • Iowa County
  • Lafayette County
Limited Service Areas
  • Iowa
  • Illinois

HSA Eligible Expenses

An eligible expense is a health care service, treatment, or item the IRS states can be paid for without taxes. Eligible expenses can be incurred by you, your spouse, or qualified dependents. The Health Savings Account (HSA) can only be used to pay for eligible medical expenses incurred after your HSA was established.

Program Option
  • State Employee and Retiree Health Plan & Supplemental Benefits
Plan Year
  • 2025

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.