ALEX

It is important to understand what these terms mean so you can understand your potential out-of-pocket costs. Use the Glossary of Health Coverage and Medical Terms, provided by the U.S. Department of Labor.

For information about the major health systems for each insurance carrier and links to each insurance carrier’s provider directory, review the 2022 Health Plan Search.

Each health insurance carrier offers two plan designs: the Health Plan and High Deductible Health Plan (HDHP). Both plan designs provide the same benefits. You need to decide if you want the Health Plan or HDHP and then select the health insurance carrier that best meets your needs (based on which hospitals, doctors, and clinics you want to use). To help you determine which plan design may be best for you, view the Plan Design Options eLearning video, provided by the Department of Employee Trust Funds.

When enrolled in an HDHP, you are financially responsible for all non-preventive medical expenses incurred, including most pharmacy benefits costs, until you meet the annual deductible. A deductible is the amount you pay for medical costs before your health insurance starts to pay a portion of the costs. For instance, for a family HDHP with a $3,000 deductible, you’ll have to cover $3,000 in medical costs out of your own pocket before your insurance starts to pay benefits.

If you enroll in an HDHP, you are required to enroll in a Health Savings Account (HSA). An HSA is an individually-owned, triple tax-advantaged savings account you may use to pay for eligible medical, dental, vision, and prescription expenses for you, your spouse and qualifying dependents. To enroll in an HDHP and an HSA, you must be eligible for both.

To learn more about whether an HDHP is right for you, view the following Plan Design Options eLearning video, provided by the Department of Employee Trust Funds.

The HDHPs and Health Plans both have deductibles before benefits are payable. The difference is the amount of the deductible and what it applies to. Both plan designs cover an annual preventive exam at no cost to you (unless there are services provided during the exam that are not considered preventive).

If you have family coverage with an HDHP:

You will pay for non-preventive medical services until you meet your annual $3,000 family deductible ($1,500 for single coverage). This includes visits to medical providers, including chiropractor, physical therapy, tests, procedures, facility charges, and pharmacy benefits. Benefits are payable once the deductible is met.

Prescription drugs are subject to the deductible.

If you have family coverage with a Health Plan:

You will pay for non-preventive medical services until you meet your annual $500 family deductible ($250 for single coverage). If an individual within a family plan meets the annual individual $250 deductible, benefits are then payable by the plan for this individual. This includes tests, procedures, and facility charges.

Visits to medical providers, including chiropractor, and physical therapy, are subject to the office visit copay (even if the deductible has not been met).

Prescription drugs are not subject to the deductible; however, copayments and coinsurance will apply.

The Access Plans are more costly because they offer a national provider network and out-of-network coverage. These are the plans people tend to select when they want to have access to out-of-network providers. They are also the plans retirees who live outside of Wisconsin may select. These two groups tend to have higher than average claims costs, which has directly led to higher premiums. There is also little ability for the health plan to negotiate for reduced pricing with out-of-network providers.

The Access Plans are not usually considered unless one of the situations described above apply or if there are dependents who reside or attend school outside of the Health Plans’ service area that need regular care and their expected medical costs exceed the additional premium costs for the Access Plan. Note: Dependents who reside or attend school outside of the Health Plans’ service areas may seek urgent care or emergency room services out-of-network.