Form Active Employee / Local Employer / State Employer

Health Care Provider Form

Complete this form using results from your most recent health care provider visit to earn credit for the Well Wisconsin Program.

Out-Of-Network Health Services for Access Plans

Out-of-network services are only available with the Access Plan and Access HDHP. Learn how much it will cost to visit the doctor, have labs drawn, get an X-ray, and more.

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

No Surprises Act

The No Surprises Act (the Act) is a part of the Consolidated Appropriations Act of 2021 (CAA). The CAA was passed by the U.S. Congress in December of 2020. The Act portion of the legislation addresses surprise medical billing by healthcare providers and other member protections. Learn more about the No Surprises Act and its developing guidelines.

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

Group Health Insurance

The State of Wisconsin Group Health Insurance Program is an employer-sponsored program offering group health coverage to employees of state agencies, the UW System, UW Hospitals & Clinics Authority, participating local government employers, and annuitants (and their insured survivors).

General Information FAQs

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

In-Network Health Services

Learn how much it will cost to visit the doctor, have labs drawn, get an X-ray and more.

Program Option
  • State Employee and Retiree Health Plan & Supplemental Benefits
Plan Year
  • 2025
Doctor listening to child's heartbeat, with mother beside the child

2025 Insurance Changes

Learn about all insurance changes for the 2025 plan year. Changes this year include a health plan name change, expanded coverage of the State Maintenace Plan (SMP) for members in the local program, an increase to the deductible for the High Deductible Health Plan (HDHP), and more.

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
ET-2385
Form Active Employee / Local Employer / State Employer

Health Savings Account (HSA) Enrollment

For UWs use only, as a paper alternative for a member who cannot complete their HSA enrollment online.

Breakdown of Your Costs by Plan Design

Learn how much you can expect to pay when you visit the doctor, get an X-ray, and more.
Plan Year
    2025
Program Option
    Local High Deductible Health Plan (PO17) & Supplemental Benefits

Breakdown of Your Costs by Plan Design

Learn how much you can expect to pay when you visit the doctor, get an X-ray, and more.
Plan Year
    2025
Program Option
    Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits