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ET-4814

Form Active Employee / Retiree / Local Employer

Local Employer Verification of Health Insurance Coverage

Local employers, complete to submit verification for an employee's or local-paid retiree's health insurance coverage.

25ET-2100cc

Brochure Retiree

2025 Medicare Advantage Evidence of Coverage - Non-deductible

This Evidence of Coverage provides details about Medicare health care coverage for the 2025 plan year.

25ET-2100ccd

Brochure Retiree

2025 Medicare Advantage Evidence of Coverage - Deductible

Medicare Advantage, with deductible, Evidence of Coverage for the 2025 plan year.

ET-2301

Form Active Employee / Local Employer / State Employer

Health Insurance Application/Change Form

Enroll in health insurance or change your coverage.

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-2314

Form Local Employer / State Employer

Request for Treatment as an Assistance Eligible Individual

The American Rescue Plan Act of 2021 (ARP) subsidizes the full COBRA premium for “Assistance Eligible Individuals” for periods of coverage from April 1, 2021 through September 30, 2021.

Brochure Active Employee / Local Employer / State Employer

Well Wisconsin Program Brochure

See information on the Well Wisconsin Program with WebMD.

24ET-2100cc

Brochure Retiree

2024 Medicare Advantage Evidence of Coverage - Non-deductible

This Evidences of Coverage provides details about Medicare health care coverage from January 1, 2024 - December 31, 2024.

24ET-2100ccd

Brochure Retiree

2024 Medicare Advantage Evidence of Coverage - Deductible

Medicare Advantage, with deductible, Evidence of Coverage for the 2024 plan year.

Medicare 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