Plan Design Summary
The Health Plan design allows you to choose from a variety of local health plans (insurance carriers) that offer the same Uniform Benefits package that includes medical and prescription drug coverage (at no additional cost).
- Uniform Dental benefits may be added for a minimal cost.
- Compare the Health Plan design 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.
For detailed information regarding this plan, review the Certificate of Coverage.
You are eligible for the Health Plan design if you are eligible for the State Group Health Insurance plan.
Since this plan design only covers out-of-network benefits for emergency and urgent care services, it is important that you use the Health Plan Map to help you select the plan that includes the providers and hospitals in the preferred county that you would like to receive services in.
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.
Under the Health Plan design, non-preventive office visits are not subject to the deductible. See the Guide to Office Visit Copays for more information.
For non-preventive care, 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.
Deductible: $250 Individual/ $500 Family
The Health 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 Health 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
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 Health Plan design. Once you reach your 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. There is no deductible for prescription drug coverage under the Health Plan design.
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.
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.