Plan Design Summary
The High Deductible Health Plan (HDHP) plan design allows you to choose from a variety of local health plans (insurance carriers) that offer the same Uniform Benefits that include medical and prescription drug coverage (at no additional cost).
- Uniform Dental benefits may be added for a minimal cost.
- Compare the HDHP to the other plan designs to determine if it will meet your medical needs.
- This plan design only covers out-of-network benefits for emergency and urgent care services.
The HDHP has a higher deductible and out-of-pocket limits but the lowest monthly premium. In exchange for the increased cost sharing, this plan design is paired with a required Health Savings Account (HSA) to help you prepare for your out-of-pocket costs. If you enroll in the HDHP, you must also enroll in the HSA administered by TASC. Not everyone is eligible for this plan design. Review the Eligibility section below for more information.
Important: The HDHP does not pay any health care costs, including prescriptions, until the annual deductible has been met (with the exception of preventive services and prescriptions mandated by the Patient Protection and Affordable Care Act). After the annual deductible has been met, you will be responsible for office visit copays and applicable coinsurance on non-office visit services, up to the annual out-of-pocket limit.
For detailed information regarding this plan, review the Certificate of Coverage.
You are eligible for the HDHP if you meet the following requirements:
- You are eligible for the Wisconsin Retirement System (WRS) benefit package, and
- You are eligible for the Health Savings Account (HSA).
If you enroll in the HDHP, you must also enroll in the HSA. Therefore, you must be eligible for both the HDHP and the HSA (note: the HSA is a component of the HDHP).
Employees who are eligible for the Graduate Assistant benefit package are NOT eligible for the HDHP plan design.
Since this plan only covers out-of-network benefits for emergency and urgent care services, it is important to use the Health Plan Map to help you select a plan that includes the providers and hospitals in the preferred county that you would like to receive services in.
In Network Coverage
Uniform Benefits refers to the schedule of benefits that are provided by each health plan (insurance carrier). 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:
- 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.
In general, routine preventive and wellness medical services 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.
For non-preventive care, you must meet the annual deductible before the plan will provide Uniform Benefits coverage. This means that you will be responsible for paying the total costs of all medically necessary services until you meet the deductible, including prescriptions. 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.
Deductible: $1,500 Single/ $3,000 Family
The HDHP plan design has a non-embedded deductible. This means that if you have Family coverage, the full family deductible must be met before services are covered for any individual. This deductible includes both medical services and prescription drug benefits and applies to the annual out-of-pocket limit.
Once your deductible has been met, you will pay:
- $15 copay for office visits
- $25 copay for specialty office visits (includes specialty providers, urgent care, vision exam)
- $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
See the Guide to Office Visit Copays for more information on office visit charges.
Out-of-Pocket Limit: $2,500 Single/ $5,000 Family
The annual out-of-pocket limit for the HDHP plan design includes both medical and prescription drug expenses. Once you reach your annual out-of-pocket limit, the plan pays 100% of most covered benefits for the rest of the year.
This plan design only covers out-of-network coverage benefits for emergency and urgent care services. Contact your health plan immediately if you seek out-of-network emergency and/or urgent care services.
Prescription drug coverage is included in all health plan designs at no additional cost and is provided by Navitus Health Solutions. Under the HDHP design, you will be responsible for paying the total costs of prescriptions until you meet the deductible.
After you meet the deductible, you will be required to pay either a copay or coinsurance depending on the level of the drug. All covered prescription drugs 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.
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.
For State Group Health Insurance premiums, see the Premiums page.
Forms & Resources
For all State Group Health Insurance forms and resources, click here.
last updated: 12/06/2018
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.