State of Wisconsin Group Health Insurance
|Program Features||Prescription Benefit Manager|
Health insurance is a major part of the fringe benefit package available to you as a university/state employee. The University pays a substantial portion of the premium cost.
The State Group Health Insurance Program offers comprehensive hospital, surgical, and major medical benefits and services through several health maintenance organizations (HMOs) and preferred provider plans (PPOs) as well as a self-insured preferred provider plan (the Standard Plan). The State Group Health Insurance Program is authorized under Wisconsin statute (§ 40.51 and 40.52) and administered by the Department of Employee Trust Funds under the direction of the State Group Insurance Board.
Participating health plans are approved annually for inclusion in the Program based on Group Insurance Board criteria. They are required to offer a set of uniform benefits that is substantially equivalent to the preferred provider "Standard" plan. The Standard plan does not offer the uniform benefits.
2012 & 2013 Health Insurance Resources
See the ETF Group Health Insurance Program web page for detailed information about your 2012 or 2013 health insurance options.
- 2013 It's Your Choice: Decision Guide (provides an overview of available plans including provider networks, quality ratings and benefit comparisons)
2013 It's Your Choice: Reference Guide (contains all state and federal required notifications, a FAQ section and information about uniform benefits, including a schedule of benefits)
- 2012 It's Your Choice: Decision Guide
2012 It's Your Choice Reference Guide
- Overview of the 3-Tier Managed Health Care Model
For information on the impacts of 2011 WI Act 10 (2011 Budget Repair Bill) and WI Act 32 (2011 Biennial Budget), please see Changes Coming to State Group Health Insurance.
Who is eligible to enroll in health insurance?
- Employees covered by the Wisconsin Retirement System (WRS) - includes eligible classified staff, faculty, academic staff and limited employees.
Employees in the Graduate Assistants/Short-Term Academic Staff category.
- Student Assistant and Employee-in Training employees who are appointed to work at least 33% for one semester (academic year basis) or six months (annual basis). Eligible job titles include Project/Program Assistant, Fellow, Teaching Assistant, Research Assistant/Associate, Research Intern, Grad Intern/Trainee, Post Doc Fellow/Trainee, Post Grad Trainee/Intern (Non-Physician).
- Short-term academic employees who are employed in positions not covered under the Wisconsin Retirement System (WRS) and hold a fixed-term terminal appointment of at least 28% for one semester (academic basis) or 21% for six months (annual basis). The appointment must be less than 12 months (two semesters for academic year appointments).
- Visiting Faculty must meet the same minimum time and duration standards as short-term academic employees and they have the same benefits. If on leave from another educational institution, state law excludes visiting faculty from WRS coverage for the first twelve months of UW employment. Health insurance premiums are the same as for WRS-covered employees if the appointment is for at least one year (365 days).
What family members are eligible for coverage if I select family coverage?
Your spouse or domestic partner. Effective January 1, 2010, a domestic partner and a domestic partner's children are eligible for coverage under a family policy. Before adding a domestic partner to coverage, an employee must first establish a domestic partnership by submitting a notarized Affidavit of Domestic Partnership (ET-2371) to ETF. See ETF's Domestic Partner Benefits Brochure and UWSA's domestic partner benefit page for detailed information.
Your child. Children
- Your natural children.
- Stepchildren or children of your domestic partner.
- Adopted children and pre-adoption placements. Coverage will be effective on the date that a court makes a final order granting adoption by the subscriber or on the date the child is placed in the custody of the subscriber, whichever occurs first. These dates are defined by Wis. Stat.§632.896. If the adoption of a child is not finalized, the insurer may terminate coverage of the child when the adoptive placement ends.
- Unmarried and married children are eligible until the end of the month in which they turn age 26 (does not include the child's spouse or children).
Legal wards that become your permanent ward before
age 19. Coverage will be effective on the date that
a court awards permanent guardianship to you (the
Your grandchildren born to your insured dependent
children may be covered until the end of the month in which
your insured dependent (your grandchild’s parent) turns age
18. Your child’s eligibility as a dependent is unaffected by the
birth of the grandchild.
An unmarried child may be covered until the end of the month in which he or she turns 26. Coverage may continue beyond that when a child:
- Has a disability of long standing duration, are dependent on you, or the other parent, for at least 50% of support and maintenance, and are incapable of self-support
Was a full‐time student who was previously called to federal active duty when the child was under
the age of 26 and while the child was attending, on a full‐time basis, an institution of
higher education. The child must apply to an institution of higher education as a full‐time student within 12 months from the date the child fulfills his/her active duty obligation.
IMPORTANT TAX IMPLICATIONS - Domestic Partner Coverage
Coverage for a Domestic partner and Domestic Partner's Children: There are tax consequences to you when you provide coverage for dependents who are considered "non-tax dependents" for health insurance purposes under federal and state tax codes. Family members who are eligible for coverage under State Group Health Insurance but who are not typically considered your tax dependents include your domestic partner and your domestic partner's children. For example, if you have a domestic partner who is not dependent on you for at least 50% of his or her support and maintenance, your domestic partner is considered a non-tax dependent for health insurance purposes. If you cover dependents who are considered non-tax dependents for health insurance purposes under federal law, the fair market value of the health insurance benefits provided to those dependents will be included in both your state and federal gross income. This amount is considered "imputed income." This will increase both your taxable income and your tax liability. Unless your domestic partner or your partner's children qualify as a dependent under the "qualifying relative" test under Internal Revenue Code (IRC) §152, you will be taxed on the fair market value of the cost of coverage provided.
The health insurance imputed tax/fair market value tables are available online. If you are covered under the WRS, see the "State - Active Employees" table. If you are not covered under the WRS and have health insurance through the Graduate Assistant/Short-Term Academic Staff health insurance program, see the "State - Graduate Assistants" table. If you have one non-tax dependent on your family health insurance policy (ex. your domestic partner), the fair market value is listed in the "1 non-tax Dependent" column. If you have two or more non-tax dependents on your family health insurance policy (ex. your domestic partner and your domestic partner's child), the fair market value is listed in the "2 or more non-tax Dependents" column. The amount listed in the column will be the amount added to your taxable income to determine your tax liability for the pay period in which you have a health insurance deduction. This amount will also be reflected on your year-end tax statement as "imputed income."
Imputed income calculators are available on the UW Service Center web site. These calculators can help you estimate your additional tax liability. Please see the Tax Dependent Status Worksheet to help you determine if provide 50% of your adult child's or domestic partner's support.
Note About Adult Children: Prior to a recent state law change, if an employee carried an adult child on family health insurance who was not a tax dependent for health insurance purposes, the fair market value of coverage for that child(ren) was included in the employee's taxable state income and state taxes were owed on this additional income. This taxable benefit is considered "imputed income." 2011 Wisconsin Act 49, signed into law on November 4, 2011, eliminated this requirement. Prior to a recent state law change, if an employee carried an adult child on family health insurance who was not a tax dependent for health insurance purposes, the fair market value of coverage for that child(ren) was included in the employee's taxable state income and state taxes were owed on this additional income. This taxable benefit is considered "imputed income." 2011 Wisconsin Act 49, signed into law on November 4, 2011, eliminated this requirement.
Who is Considered a Tax Dependent for Employer-Provided Health Insurance Purposes?
A legal spouse, dependent child under age 19 and adult children until the end of the calendar year in which they turn 26 are automatically considered tax dependents under both federal and state tax law. In order for a domestic partner or a domestic partner's children to be considered a tax dependent for health insurance purposes, he or she must be considered a “qualified relative” under Section 152 of Internal Revenue Code (IRC) and meet all the criteria, except for the income requirements, of a “qualifying relative" as outlined in IRS Publication 501. The Working Families Tax Relief Act of 2004 amended the requirements of a "qualifying relative" as they apply to employer-provided health insurance only. These amendments are outlined in Internal Revenue Service Notice 2004-79. These amendments relative to employer-provided health insurance are not specifically addressed in IRS Publication 501 so it may cause confusion when an employee is determining the tax dependent status of a domestic partner or a domestic partner's child.
In general, the IRS requires that a “qualifying child” meet five tests:
- The child must be your son, daughter or stepchild
- The child must be
- under age 19 at the end of the year,
- under age 24 at the end of the year and a full-time student, or
- any age if permanently and totally disabled.
- The child must have lived with you for more than half of the year
- The child must not have provided more than half of his/her own support for the year
- If the child meets the rules to be a qualifying child of more than one person, you must be the person entitled to claim the child as a qualifying child.
In general, the IRS requires that a "qualifying relative" meet four tests:
- The person does not meet the "qualifying child" tests (see above) and is not the qualified child of you or any other taxpayer (including your domestic partner);
- The person either (a) must be related to you in one of the ways listed under “Relatives who do not have to live with you (see below)”,or (b) must live with you all year as a member of your household (and your relationship must not violate local law).
- The person’s gross income must be less than $3,650 for the year. (This requirement is not applicable when determining tax dependency for employer-provided health insurance. For health insurance purposes, the domestic partner or domestic partner's child needs to meet the remaining three tests to be a qualifying relative).
- You must provide more than half of the person’s support for the year.
Relatives who do not have to live with you – A person related to you in any of the following ways does not have to live with you all year as a member of your household to meet this test (relates to #2 under the “qualifying relative” test). Any of the relationships listed below that are established by marriage must not have ended by death or divorce.
- Your child, stepchild, foster child, or a descendant of any of them (for example, your grandchild). (A legally adopted child is considered your child.)
- Your brother, sister, half brother, half sister, stepbrother, or stepsister.
- Your father, mother, grandparent, or other direct ancestor, but not foster parent.
- Your stepfather or stepmother.
- A son or daughter of your brother or sister.
- A brother or sister of your father or mother.
- Your son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, or sister-in-law.
How do I change the tax status of a dependent on my health insurance coverage?
If you need to change the tax status of one of your dependents, you need to complete the Dependent Tax Status Change Form (UW1541) and submit it to your institution's benefits office for processing.
IMPORTANT: The information above should not be used as the sole source of information for determining the tax status of your domestic partner or domestic partner's child. UW System staff cannot provide you with tax advice. You should review all related IRS information and/or consult with a tax advisor if you have questions regarding how the federal rules apply to your situation.
When does health coverage end for my dependents covered on my family policy?
Coverage for dependents terminates on the earliest of the following dates:
- The date eligibility for coverage ends for the subscriber.
- The end of the month your unmarried child turns 26.
- The end of the month your married child turns 26.
- Your spouse and stepchildren's coverage will end at the end of the month a divorce is entered.
- Your domestic partner and domestic partner's children's coverage will end at the end of the month you file an Affidavit of Termination of Domestic Partnership with ETF.
The end of the month in which a covered grandchild's parent (your child) ceases to be an eligible
dependent or becomes age 18, whichever occurs
It is important to notify your payroll/benefits office when any of these events occur as there are strict time limitations for electing continuation of coverage. For information about your dependents' right to continue coverage, please contact your payroll/benefits office.
Under no circumstances may other relatives (e.g., parents, grandparents) be covered under a family contract.
Faculty, Visiting Faculty, Academic Staff, Graduate Assistants/Short-term Employees
In order to enroll in coverage, you must submit a completed Health Insurance Application/Change Form (ET-2301) directly to your institution's benefits office within 30 calendar days from the contractual begin date of your appointment. Coverage is effective the first of the month on or following the receipt of the application by your institution's benefits office. You are immediately eligible for the employer contribution towards your premium.
There are two enrollment opportunities. The University does not pay the employer contribution towards the premium during the first two months of WRS covered employment (six months for LTEs). After two months (six months for LTEs), you are eligible for the employer contribution towards your premium.
- If you have no prior WRS-covered state/UW service and you want health coverage as soon as possible, you must submit an application to your benefits office no later than 30 calendar days from the begin date of your appointment. You will pay the total premium for the first two months of coverage (six months for LTEs).
- If you want health coverage when the University contributes towards the premium, you must submit your application on or before the first of the month following the month in which you complete your first two months (six months for an LTE) of WRS-covered service as a state/UW employee.
If you are transferring from another University System institution or state agency or if you are a new employee with at least two months of prior Wisconsin Retirement System service with a state agency, you must submit an application to your staff benefits specialist no later than 30 calendar days from the contractual begin date of your initial appointment with the University or your coverage may lapse.
Regardless of when you want your health coverage to be effective, you are strongly encouraged to submit a completed application as soon as possible to avoid missing your initial enrollment period.
If you are covered under the State Group Health Insurance program as of October 1 of any year, you can change to a different health plan, including a lower cost HMO, effective January 1 of the following year by submitting an application during the It's Your Choice period that occurs every October.
What happens if I did not sign up during my initial enrollment period?
In 2011, employees are eligible to apply for coverage at any time under the Standard Plan with a 180-day waiting period for pre-existing conditions. Standard Plan premiums and the required employee contributions are substantially higher than premiums for HMOs.
Effective January 1, 2012, the option to enroll at any time during the year will not be available. If there is not a qualifying event (e.g., marriage, birth of a child), you may only enroll for single or family coverage during the annual It's Your Choice enrollment period, with coverage becoming effective the following January 1.
Also effective January 1, 2012, if you are not insured under the state health insurance program at the time of retirement, you may enroll in the Standard Plan in anticipation of retirement for the purpose of preserving unused sick leave for escrow. Escrowed sick leave is converted to credits to pay for your State Group Health Insurance as an annuitant. If you are terminating employment (not retiring), you have 20 years of WRS service and you have unused sick leave, you may also enroll in the Standard Plan prior to termination in order to escrow unused sick leave for use when you become an annuitant. Coverage must be in effect for a full coverage month prior to the date of retirement or termination.
What happens if I had other health insurance, but lost it?
If you and/or your dependent(s) are not insured under the State Group Health Insurance program because of being insured under a comparable group health insurance plan elsewhere, and you or your dependent loses eligibility for that coverage or the employer terminates its premium contributions, you may take advantage of a special 30-day enrollment period to become insured or enroll your dependent in the State Group Health Insurance Program without restrictions, if you are otherwise eligible.
This enrollment opportunity is also available to employees and/or dependents who lose medical coverage under medical assistance (Medicaid), as a dependent of a member of the U.S. Armed Forces, or as a citizen of a country with national health care coverage comparable to the Standard Plan.
The enrollment period begins on the date the other group health insurance coverage terminates because of loss of eligibility (e.g., termination of employment, divorce, loss of employer contribution, etc., but not voluntary cancellation of coverage).
To enroll, submit a health insurance application form and other information documenting the loss of coverage to your staff benefits office within 30 days of the date the other coverage ended. The effective date of coverage will be the day after the termination date of the other coverage.
Are there any other special enrollment opportunities?
HIPAA (Health Insurance Portability and Accountability Act) allows a special enrollment when an employee or dependent is eligible but not enrolled and there is a marriage, birth, adoption, or placement for adoption, if coverage is elected within 30 days of the event. Coverage is effective on the date of birth, adoption or placement for adoption, or marriage.
If you are covered when a qualifying event occurs, you can also elect to change health plans within 30 days of the event. Should you or a covered dependent ever reach the health plan's lifetime maximum benefit, you may also elect to change plan within the required time frame.
In 2012, if you do not enroll during these special enrollment opportunities, you will need to wait until the next open enrollment period to enroll yourself and/or eligible dependents in the health insurance program. In 2011, if you do not enroll during these special enrollment opportunities, you may apply at any time but your coverage will be limited to the Standard Plan (anyone newly added and over age 19 will also have a 180-day waiting period for pre-existing conditions).
What if neither I nor my dependent(s) have a Social Security number?
A new federal law became effective January 1, 2009, requiring that group health insurance plans report the Social Security numbers (SSN) of members who are or who may be eligible for Medicare to the Center for Medicare & Medicaid Services (CMS) . This reporting is to assist CMS and other health insurance plans to properly coordinate payment of benefits among plans so that claims are paid promptly and correctly. If you or your dependent are unable to provide a Social Security number due to being a non-citizen, you must instead complete an Affidavit for Insurance Purposes, form UWS 93. Return the completed Affidavit to your benefits office along with your completed applications for state group health insurance and/or Epic Supplemental coverage. If you or your dependent later obtains a Social Security number contact your benefits office.
When does coverage begin?
Coverage begins the first of the month on or following your eligibility for coverage and your employer's receipt of the application. For example, if you're eligible as of September 1 and you do not submit your health insurance application until September 2, your health coverage will not be effective until October 1. If, on the other hand, you submit your application on September 1 (or before), your coverage would be effective on September 1. Health insurance coverage can only be effective on the first of a month, except in the case of a special enrollment period as described above.
What insurance plans are provided?
Information about all available health plans for 2013 is available in the 2013 It's Your Choice: Decision Guide.
Information about all available health plans for 2012 is available in the 2012 It's Your Choice: Decision Guide.
When can I change plans?
Employees may select any plan initially and may change plans during the It's Your Choice period for coverage effective January 1 of the next calendar year. You may also change plans within 30 days of moving out of your plan's service area for a period of at least 90 days or when you add a dependent to your policy due to marriage, beginning of a domestic partnership, birth, adoption or placement for adoption. These are generally the only times that employees can select a different plan. Employees changing plans during the It's Your Choice period will have continuous coverage.
What is the Standard Plan?
The Standard Plan is a self-insured plan that offers a nationwide network of preferred providers. Since January 1, 2006 Wisconsin Physicians Service (WPS) has administered the Standard Plan. You and your eligible dependents may receive care from any qualified health care provider anywhere in the world for treatment covered by the plan. You may be responsible for filing claims and for finding the providers that can best meet your needs. Your costs for seeing a provider within the network are generally lower than for out-of-network providers.
Members pay 10% coinsurance on routine non-preventive covered medical services received from a preferred provider up to an annual out-of-pocket maximum of $800 per individual or $1,600 per family. Services are also subject to a deductible of $200 per individual or $400 per family. Deductibles and coinsurance increase for covered medical services received from a non-preferred provider.
Please note that Uniform Benefits do not apply to the Standard Plan. This plan does not provide any preventive or diagnostic dental coverage.
What is the State Maintenance Plan (SMP)?
The State Maintenance Plan (SMP) is a self-insured plan that is available in those counties that lack a qualified Tier-1 Health Maintenance Organization. Since January 1, 2006 SMP has been administered by WPS and provides uniform benefits coverage. It has a provider network that must be used. A referral is required for all services outside the care of your primary care physician or clinic. This plan does not provide any preventive or diagnostic dental coverage.
What is a qualified plan?
In order to be qualified in a county, a plan must meet Group Insurance Board requirements for hospital services and the number and type of specialists and other providers available in that county. The concept helps ensure that plans have adequate providers in a county. A plan that is not qualified in a particular county can still be offered there, but you should review the provider directory to be sure that your medical needs can be met. Plans cannot be qualified in the first year they participate in the program. A plan may be qualified in a county one year but not be qualified in that county the following year, or vice versa.
What is an HMO?
A health maintenance organization (HMO) is an association of hospitals, physicians, and other health professionals who contract or collectively agree to provide all medically-necessary covered services to the HMO participants in return for a pre-paid fee. Each HMO offers service only in specific areas of the state. All insured members of an HMO are expected to receive their health care only through physicians, health professionals, and hospitals affiliated with that HMO.
HMOs generally refer outside their networks only if they are unable to provide needed care within the HMO. If you go to a non-HMO provider without being referred, you will not be reimbursed by the HMO. If you have questions regarding the availability of physicians, hospitals, or other medical professionals, contact your HMO directly.
All HMOs offer the same Uniform Benefits. The purpose of Uniform Benefits is to help contain the rising cost of health insurance and simplify the selection of a health plan for employees. This does not mean that all plans will treat all illnesses in an identical manner. Treatment will vary depending on the needs of the patient, the physicians involved, and the managed care policies and procedures of each insurance plan. Most plans also include limited coverage for dental services.
2013 Uniform Benefits are outlined beginning on page 65 for the 2013 It's Your Choice: Reference Guide.
If you have specific questions about the coverage and services of a particular plan, you should contact the health plan directly.
What are Uniform Benefits?
Except for the Standard Plan, all participating health plans, including SMP, are required to provide the same level of benefits. All of the plans are allowed to offer additional benefits beyond Uniform Benefits such as partial reimbursement for alternative medicine treatments, health risk assessments, wellness incentives. You select your plan by its provider network and employee cost. You do not have to compare the medical benefits of each plan, although the HMO plans also provide some preventive dental coverage at no additional cost. WEA Trust and WPS Metro Choice are both preferred provider plans that provide uniform benefits when a preferred provider is used. Benefits are paid at a lower level if you use a non-preferred provider.
Members pay 10% coinsurance on routine non-preventive covered medical services, up to an annual out-of-pocket maximum of $500 per individual or $1,000 per family.
What are routine or preventive services and why are they treated differently than treatment of an illness?
Routine, preventive care is care that is designed to help prevent disease, or to diagnose it in the early stages. Federal health care reform requires first dollar coverage of preventive care services upon the annual contract renewal when grandfathering of the health plan is lost as a result of significant benefit and/or premium changes (this occurred when employee premium contributions increased in or around August 2011). The list of federally required preventive services is available at HealthCare.gov. Your provider uses standardized codes to bill your insurer for services.
May I choose any plan offered by the Group Health Insurance Program?
Yes, but if you choose an HMO distant from your home or work you must still receive non-emergency care from the providers that the HMO offers. You do not have to live or work in a county in which the State Maintenance Plan (SMP) is offered in order to elect SMP, but you must receive services in a county where SMP is offered.
When may I change from single to family coverage?
You may change from single to family coverage during the annual It's Your Choice enrollment period. Family coverage will become effective on the following January 1st. You also have 30 or 60 days from one of the following life events to change from single to family coverage.
You have 30 days after one of the following events to submit a health insurance application to your staff benefits office to change from single to family coverage. Coverage will be effective on the date of the following event:
- Establishment of a domestic partnership with ETF
- You or any eligible dependents involuntarily lose other medical coverage or lose the employer contribution for the other coverage.
- Legal guardianship is granted.
- An unmarried parent whose only eligible child resumes full-time student status or becomes disabled and thus is again an eligible dependent. Coverage will be effective the date eligibility was regained.
You have 60 days after one of the following events to submit a health insurance application to your staff benefits office to change from single to family coverage. Coverage will be effective on the date of the following event:
- Birth, adoption of a child or placement for adoption
- A single father declaring paternity. Children born outside of marriage become dependents of the father on the date of the court order declaring paternity or on the date the statement of paternity is filed with the Department of Health and Family Services or equivalent if the birth was outside of the State of Wisconsin. The effective date of coverage will be the date of birth if a statement of paternity is filed within 60 days of the birth. If filed more than 60 days after the birth, coverage will be effective on the first of the month following receipt of application.
- A married person enrolled for single coverage who desires family coverage upon the birth or adoption of a child. All eligible dependents will be covered.
The right to change from single to family coverage without restriction does not include a divorced parent to whom the custody of the children has been transferred. Even if you are a non-custodial parent, you are expected to maintain family coverage while your children are eligible for the Program.
Applications submitted within the 30-day enrollment period (60 days for birth or adoption) will provide coverage effective on the date of the change (e.g., marriage). You may also change health plans due to one of these qualifying events by submitting an application to your campus benefits office within 30 days of the event.
A National Medical Support Notice requiring coverage of a non-covered dependent child will be honored with no restrictions.
What if I miss the deadline for changing from single to family coverage?
Applications submitted after the 30-day period (60 days for birth or adoption) have the following restrictions:
- Except in very limited circumstances (e.g., special 30-day enrollment period explained above), switching from single to family coverage is only possible during the annual It's Your Choice period.
What if my spouse or domestic partner is also a state or university employee?
If your spouse or domestic partner is also a university or state employee or an annuitant of the State of Wisconsin and eligible for State Group Health insurance, you may each have a single coverage or one of you may elect to have family coverage, which will cover your spouse or domestic partner and any eligible dependents. You may not have one single contract and one family contract, or two family contracts.
If you and your spouse or domestic partner are each enrolled for single health coverage and your premium contributions are paid on a post-tax basis, you may change one of the single contracts to a family contract at any time without restriction. The other single contract will be canceled. If you pay your premium contributions on a pre-tax basis, you can combine two single plans into one family plan annually at the It's Your Choice enrollment period or within 30 days of the date a new dependent is obtained. You (or your spouse or domestic partner) should not cancel your single coverage before the family contract is effective. You (or your spouse or domestic partner) should not cancel your single coverage before the family contract is effective.
Family coverage may be split into two single plans with the same carrier at any time if your premium contributions are paid on a post-tax basis. If you each have a different plan, you must decide which plan to continue. Your new family coverage will be effective on the first of the month after your staff benefits office receives the application. If you pay your premium contributions on a pre-tax basis, you may split family coverage into two single plans at the It's Your Choice enrollment period or within 30 days of the date the last dependent child loses eligibility for coverage. You (or your spouse or domestic partner) should not cancel your family coverage before the single contracts are effective.
If, at the time of marriage or the effective date of a domestic partnership, the employees and/or annuitants each have family coverage or one has family coverage and the other has single coverage, coverage must be changed to one of the options listed above within 30 days of marriage or the effective date of a domestic partnership. Failure to comply with this requirement may result in denial of claims for eligible dependents. Tthere is an exception if covering the domestic partner would result in imputed income. In that case, the couple may have a family plan to cover one employee and dependent children and a single plan to cover the other employee.
The named subscriber for family coverage can be changed to the other spouse or domestic partner within 30 days of the date the named subscriber:
- Terminates employment; or
- Goes on an approved leave of absence
IMPORTANT: If you and your spouse or domestic partner each have single coverage, no dependents are covered and if one of you should die, that individual's sick leave credits would not be available for use by the surviving spouse or domestic partner to pay for health insurance premiums.
How are employee premium contributions determined?
- Represented employees: collective bargaining (prior to enactment of 2011 Act 10, Budget Repair Bill)
- Non-represented classified employees: non-represented compensation plan
- Unclassified faculty,academic staff and limited: faculty and academic staff compensation plan approved by the Board of Regents
- Non-represented graduate assistants: unclassified compensation plan.
All compensation plans are approved by the Joint Committee on Employment Relations.
The employee contributions towards health insurance are established by the Office of Employment Relations (OSER) and approved by Joint Committee on Employment Relations (JCOER ) in the compensation plans and the bargaining agreements.
How are premiums paid?
Your share of monthly health premiums is automatically deducted from your payroll check on a pre-tax basis (unless you are an LTE or request otherwise). Your earnings statement will indicate the health plan under which you have coverage and the amount deducted.
Premiums are paid one month in advance of coverage. For example, the premium deduction from your September earnings is for October coverage. Because of this, you may have multiple deductions taken from your first paychecks when you initially enroll.
Premium amounts are subject to change annually. The premium amounts for the following calendar year are announced during the It's Your Choice enrollment period, which is held each fall in October.
- If you are a classified employee paid on a bi-weekly basis, your premiums will be deducted only from the first bi-weekly pay period of each month.
- If you are faculty or academic staff paid on an annual basis (12 monthly payroll checks), your premiums will be deducted each month of the year.
- If you are faculty or academic staff paid on an academic year basis (9 monthly payroll checks), you will have four health premium deductions taken from your last payroll check of the second semester (paid June 1) if you are expected to hold an appointment in the Fall semester. These multiple deductions will provide you with continuous health coverage during the summer months. You will not have health premium deductions taken from any summer payroll checks.
Will the Program cover all of my medical expenses?
No. Although the State Group Health Insurance Program offers comprehensive coverage, not every medical expense is included. For example, all of the plans require you to pay a portion of the cost for prescription drugs. The Standard Plan has deductibles that you must pay. All non-preventive medical services are paid at 90%. Members are responsible for 10% coinsurance, up to annual out-of-pocket maximums of $500 per individual or $1000 per family (Standard Plan's annual out-of-pocket maximums are $800 per individual or $1600 per family).
If you have coverage under the Standard Plan (or receive emergency services outside of your health plan's provider network), all or some coverage for a specific medical service may be denied if the provider charges more than the usual, reasonable, and customary rate, as determined by the Plan. If you have coverage under an HMO, the Plan may refuse to pay for services you obtained without a referral from the HMO. Services that are not medically necessary or are experimental/investigational, as determined by the Plan, may not be covered. The Standard Plan and SMP do not include coverage for routine dental or optometry services. Most HMOs offer coverage for some dental services at no additional premium cost.
All HMOs in the State Group Health Insurance program must offer Uniform Benefits. Covered services and exclusions are outlined in detail in the It's Your Choice:.Reference Guide for the year in which the services are received. Coverage under the Standard Plan differs somewhat from Uniform Benefits.
If you have specific questions about the coverage and services of a particular plan, you should contact the health plan directly.
How do I choose a health insurance plan?
Considering the following issues may help you decide on which plan to select:
- Cost of the plan to you
- Quality of services provided
- Plan referral policies
- Access to specific physicians or other health care providers
Pharmacy and prescription benefits are administered by Navitus Health Solutions, a third-party pharmacy benefit manager (PBM). No matter which health plan is selected, all employees have prescription coverage through Navitus, not the individual health plan.
Navitus created an online portal that allows access to benefit information on the Navitus web site. Please see ETF's instructions about how to access the portal.
A link to Navitus Health Solutions, the Prescription Benefit Manager
Participants will receive a separate identification (ID) card from Navitus, in addition to the ID card they receive from their health plan. The Navitus card must be shown at the time prescription drugs are purchased.
The following shows the member's cost under the four-level copayment structure for pharmacy benefits:
- Level 1 Copayment for each formulary prescription drug = $5.00 (for preferred generic and certain low cost brand name drugs).
- Level 2 Copayment for each formulary prescription drug = $15.00 (for preferred brand name and certain higher cost generic drugs).
- Level 3 Copayment for each non-formulary prescription drug = $35.00
- Level 4 Copayment for certain specialty drugs = $50.00. If the Diplomat Specialty Mail Order Pharmacy is used, the copayment may be reduced to $15.
There is an annual out-of-pocket maximum that applies to Level 1 and Level 2 prescription drugs and insulin. For employees covered by an HMO or the State Maintenance Plan, the out-of-pocket maximum is $410 per individual and $820 per family each year. If enrolled in the Standard Plan, the out-of-pocket maximum is $1,000 per individual and $2,000 per family each year. After the out-of-pocket maximum is reached, Level 1 and 2 drugs are covered in full for the remainder of the year.
There is a separate annual out-of-pocket maximum for Level 4 drugs of $1,000 per individual and $2,000 per family.
Important Note: Level 3 prescription co-payments do no apply to the out-of-pocket maximum and must continue to be paid after the annual out-of-pocket maximum has been met.
Navitus offers Level 1 and Level 2 mail-order prescriptions at a reduced cost (3-month supply for 2 copayments) through WellDyneRx and also has other cost-saving features available such as pill-splitting and generic sampling. You can also obtain a 90-day supply from your pharmacy for three copayments.
For more information, such as what a formulary is, how it is established, and which level of copayment applies to specific prescriptions, visit www.navitushealth.com or call Navitus toll-free at 1-866-333-2757. Navitus also has a secure section of their web site called "Navi-Gate® for Members." Covered members can access formularies, Prior Authorization Forms and prescription drug history. Please see ETF's instructions about how to access the portal.
Will I get an insurance card?
Insurance cards arrive approximately four to six weeks after your forms have been completed and processed. Employees should contact the health insurance provider directly to inquire about missing insurance cards.
You will also receive a separate prescription drug card from Navitus Health Solutions. You must show the ID card each time you purchase prescription drugs to ensure that you receive the maximum benefit.
What happens if I terminate employment?
If you lose coverage due to a reduction in hours of employment or due to termination of employment (for reasons other than gross misconduct), you and/or your dependents may continue health insurance coverage through COBRA - the Consolidated Omnibus Budget Reconciliation Act of 1985. Continued coverage is available for dependents when their eligibility ends or in the event of employee death, layoff, or retirement. For detailed information regarding continuation/conversion of your health insurance refer to the It's Your Choice: Reference Guide or ask your staff benefits office.
If employment terminates or the employee's eligibility for coverage is lost on or after January 1, 2012, the employee and dependents may continue coverage for up to 18 months. If a dependent loses eligibility but the employee maintains eligibility, the dependent may continue coverage for up to 36 months. If employment terminates or the employee's eligibility for coverage is lost prior to January 1, 2012, coverage may be continued for up to 36 months.
If an employee with family health coverage terminates employment and does not elect to continue coverage, the spouse and/or dependents each have a right to continue coverage on their own, as long as they elect coverage within the election period.
You have the responsibility to inform your staff benefits office of a spouse or dependent losing eligibility for coverage under the State Group Health Insurance program. If you have changed marital status, or you or your spouse have changed addresses, complete a new application as notification of this change. Under Federal Law, if your staff benefits office is not notified within 60 days of the later of (1) the event that caused the loss of coverage, or (2) the end of the period of coverage, the right to continuation coverage is lost. A voluntary change in coverage from a family plan to a single plan does not create a continuation opportunity.
After you notify the University, the University then has the responsibility to notify you or your dependent of the right to choose continuation coverage. Under the law, you must inform the Department of Employee Trust Funds that you want to continue coverage within 60 days from the termination of your current coverage or within 60 days of the date you were notified by the University, whichever is later. If you do not choose continuation coverage, your group health insurance coverage will end.
The conversion privilege is also available to dependents when they cease to be eligible under the subscriber’s family contract. Request for conversion must be received by the plan within 30 days after termination of group coverage. If you have questions regarding conversion, write or call the plan in which you are enrolled. Conversion coverage will be more expensive that continued coverage and may not offer similar benefits.
As of January 1, 2012, if you are not insured under the state health insurance program at the time of termination and you have 20 years of WRS service and unused sick leave, you may enroll in the Standard Plan for the purpose of preserving unused sick leave for escrow. Escrowed sick leave is converted to credits to pay for your State Group Health Insurance as an annuitant. Coverage must be in effect for a full coverage month prior to the date of termination. You may then escrow the sick leave credits if you have coverage under a comparable health insurance plan.
What happens when I retire?
If you receive a WRS retirement, you may continue your State of Wisconsin Group Health Insurance program coverage for your entire lifetime. When you terminate with at least 20 years of creditable service (whether or not you choose to begin your annuity immediately) or when you retire and begin an immediate annuity (no matter how many years of service you have), your unused sick leave is converted to credits at your highest hourly State or University pay rate, and these credits are used to pay health insurance premiums until exhausted. The University does not contribute to health insurance premiums after employment ends.
Employees with 15 or more years of adjusted continuous State and/or UW service are eligible for supplemental sick leave credits. Supplemental sick leave credits in an amount equal to your own accumulation—subject to program maximums—are converted at your highest hourly rate of pay.
The University pre-funds the sick leave credits with an annual contribution of approximately 1.2% of salary.
An employee who retires after 5 years, has accumulated 480 hours of sick leave, and whose highest hourly salary was $30 would have non-taxable sick leave credits of $14,400 (480 x 30).
In addition to the regular sick leave credits, an employee who retires after at least 15 years of continuous service would be entitled to supplemental sick leave credits in an amount equal to his or her own accumulation, subject to program maximums.
As of January 1, 2012, if you are not insured under the state health insurance program at the time of retirement, you may enroll in the Standard Plan in anticipation of retirement for the purpose of preserving unused sick leave for escrow. Escrowed sick leave is converted to credits to pay for your State Group Health Insurance as an annuitant. Coverage must be in effect for the month in which you retire. You may then escrow the sick leave credits if you have coverage under a comparable health insurance plan.
For more information about sick leave while employed and its benefit after retirement, see Sick Leave - A Valuable Benefit for All Employees.
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This document was last revised on March 14, 2013