Plan Design Summary

The Access Plan design provides freedom of choice for doctors or hospitals across the country (nationwide coverage). There are lower costs when you use in-network providers, which are available nationwide. In exchange for increased flexibility in medical providers, you pay a higher monthly premium cost.

  • Uniform Dental benefits may be added for a minimal cost.
  • You can compare the Access Plan design to the other plan designs to determine if it will meet your medical needs.

Eligibility

You are eligible for the Access Plan design if you are eligible for the State Group Health Insurance plan.

Provider Network

WEA Trust administers the Access Plan. You may see any doctor or provider of your choice. However, you will receive a higher level of benefits (and pay less out-of-pocket) if you use a preferred or in-network provider.

To see if your doctor or hospital is a preferred or in-network provider, go to: https://www.weatruststatehealthplan.com/service-areas/access-medicare-plus-smp and look at the information under “IYC Access Plan”.

Coverage

In-Network Coverage

Uniform Benefits

Uniform Benefits refers to the schedule of benefits that are provided by WEA Trust for the Access Plan’s in-network benefits. The purpose of Uniform Benefits is to help contain the rising cost of health insurance and simplify your selection of a health plan. Because all health plans (insurance carriers) administer the same schedule of benefits, you can decide which plan to select on the basis of:

  • Cost
  • Quality and member satisfaction
  • Access to specific physicians or other health care providers
  • Referral policies

Uniform Benefits 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 providers involved and the managed care policies and procedures of each health plan.

Preventive Care

In general, routine preventive and wellness medical services received in-network will be covered at 100%, even if you have not met the deductible. Here is a list of preventive care services, as identified by the Patient Protection and Affordable Care Act.

Non-preventive Care

Non-preventive office visits received in-network are not subject to the deductible. See the Guide to Office Visit Copays for more information.

For non-preventive care received in-network, you will pay:

  • $15 copay for office visits
  • $25 copay for specialty office visits (includes specialty providers, urgent care, vision exam)

Other non-preventive care (e.g., lab tests, x-rays, inpatient care) will require you to meet your deductible before the plan will provide Uniform Benefits coverage. Once you meet the deductible, Uniform Benefits will take effect and you will pay either an office visit copay or coinsurance on other medically necessary care until you reach the annual out-of-pocket limit.

In-Network Deductible: $250 Individual/ $500 Family

The Access Plan design has an embedded deductible. This means that there is an individual and a family deductible. If an individual within a family plan meets the annual individual $250 deductible, the Uniform Benefits will take effect for that individual. This deductible applies to medical services only; there is no deductible for prescription drug coverage under the Access Plan design.

Once the deductible has been met, you will pay:

  • $15 copay for office visits (copay is not subject to deductible)
  • $25 copay for specialty office visits (includes specialty providers, urgent care, vision exam– copay is not subject to deductible)
  • $75 copay for emergency room visits (waived, if admitted). Deductible and coinsurance applies to services beyond the copay.
  • 10% coinsurance on most services except for office visits
In-Network Out-of-Pocket Limit: $1,250 Individual/ $2,500 Family

This annual out-of-pocket limit applies to medical services only. There is a separate annual out-of-pocket limit for prescription drug coverage under the Access Plan design. Once you reach your out-of-pocket limit, the plan pays 100% of most covered benefits for the rest of the year.

For a detailed list of covered benefits, see the Certificate of Coverage pdf .

Out-of-Network Coverage

The table below outlines the schedule of benefits that is administered by WEA Trust for services received out-of-network.

Access Plan Out-of-Network (Your Costs)
Deductible $500 Individual/$1,000 Family
Office Visit Copay After deductible: 30% coinsurance
Specialty Office Visit Copay After deductible: 30% coinsurance
Coinsurance 30% coinsurance
Out-of-pocket Limit $2,000 Individual/$4,000 Family
Preventive Care Subject to the deductible, copays and/or coinsurance

To see a detailed list of covered benefits, see the Certificate of Coverage pdf .

Pharmacy Benefits

Prescription drug coverage is included in the Access Plan design at no additional cost and is provided by Navitus Health Solutions. There is no deductible for prescription drug coverage under the Access Plan.

You will be required to pay either a copay or coinsurance when you buy prescription drugs which is determined by the level of the drug. All covered prescription drugs (Rx) fall into one of four cost-sharing levels, including Level 1 for most generic drugs and Levels 2, 3 and 4 for most brand-name drugs.

To determine what you would pay for prescription drugs, see the Comparison of Pharmacy Benefits.

Uniform Dental Benefits

Uniform Dental provides coverage for diagnostic, preventive and restorative services (such as fillings). It does not include coverage for major dental services such as crowns, root canals or implants. Uniform Dental benefits are administered by Delta Dental of Wisconsin and may be added on to your health insurance coverage for a minimal cost.

Click here to learn more about Uniform Dental benefits.

Premiums

For State Group Health premiums, see the Premiums page.

Forms & Resources

For all State Group Health Insurance forms and resources, click here.


last updated: 12/01/2017

Every effort has been made to ensure this information is current and correct. This page does not guarantee enrollment or the ability to make changes to your benefits.