Employee Benefits

State of Wisconsin Group Health Insurance

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 a self-insured preferred provider 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.

HMOs 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.

At the ETF Group Health Insurance Program web page (includes 2008 premiums and It's Your Choice books), you can link to the 2008 It's Your Choice book for State Employees, which is in pdf format for easy searching. The sections of the It's Your Choice book are shown along the left side of the web page. Simply click on the section you would like to see. The sections are:

  • Important Considerations when selecting a health plan
  • Section A:Premium Rate Information
  • Section B:State and Federal Notifications/Patients' Rights and Responsibilities
  • Section C:  Common Questinos and Answers
  • Section D:Uniform Benefits, which apply to all participating health plans except the Standard Plan
  • Section E:  Health Plan Report Cards
  • Section F: Where to Get More Information
  • Section G:  Plan Descriptions.  Include plan-specific information such as dental benefits, service area and major provider information
  • Notable Plan and Program Changes Effective January 1, 2008

Other information that is available at the ETF Group Health Insurance Program website includes:

Eligibility

Who's eligible?

  • Employees who participate in the Wisconsin Retirement System (WRS) - including classified employees and faculty and academic staff.
  • Employees in the Graduate Assistants/Short-Term Academic Staff category including eligible graduate and post-graduate employees, eligible short-term academic employees, and eligible visiting faculty.

    Eligible graduate and post-graduate employees are those who are appointed to work for at least one semester (6 months for year-round positions), and for at least 33% of full-time. Eligible job titles include Graduate, Project/Program, and Teaching Assistant, Research Associate, Research Intern, Postgraduate Trainee 1-7, and Intern (Non-Physician).

Eligible short-term academic employees are those who are employed in positions not covered under the Wisconsin Retirement System (WRS) and are holding a fixed-term terminal appointment of at least 28% (academic basis) or 21% (annual basis) with an expected duration of at least six months (one semester for academic basis appointees) but less than 12 months (two semesters for academic basis appointments).

Visiting Faculty must meet the same minimum time and duration standards as short-term academic employees and they have the same benefits.  If you are on leave from another educational institution, state law excludes you from WRS coverage for the first twelve months of UW employment.  However, your health insurance premiums are the same as for WRS-covered employees if your appointment is for at least one year (365 days).

Enrollment

Faculty, Visiting Faculty, Academic Staff, Graduate Assistants/Short-term Employees

If you are faculty, visiting faculty, academic staff (unclassified positions) or if you fall into the graduate assistants/short-term employee category you must submit an application to your staff benefits specialist no later than 30 calendar days from the contractual begin date of your appointment. The University pays most of your health insurance premium.

Classified Employees

If you are a classified employee, you generally have two opportunities for enrollment in the State Group Health Insurance Program. The University does not pay for the first six months of your health insurance. After six months, the University pays most of your health insurance premium.

  1. If you want health coverage as soon as possible, you must submit an application to your staff benefits specialist no later than 30 calendar days from the begin date of your appointment. You will pay the total premium for the first six months of your employment.
  1. If you want health coverage when the University first 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 six months as a state employee in the Wisconsin Retirement System (WRS).

If you are transferring from another University System institution or state agency or if you are a new employee with at least six 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.

What happens if I did not sign up during my enrollment opportunity?

Employees not currently participating in the State Group Health Insurance program are eligible to apply for coverage at any time with the Standard Plan (a preferred provider plan), but are required to serve a six-month (180-day) waiting period for pre-existing conditions. Standard Plan premiums and the required employee contributions are substantially higher than premiums for HMOs.

If you are covered under the State Group Health Insurance program in effect by October 1 of any year, you will be allowed to change to a different health plan effective January 1 of the following year by submitting an application during the Dual-Choice enrollment period in the fall.

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 lose 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 in the State Group Health Insurance Program without waiting periods for pre-existing conditions, 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). If you are currently enrolled and need to change from single to family coverage, all eligible family members must have lost the other coverage in order to qualify.

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. This special enrollment also allows you to change health plans within 30 days of the event.

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.

If you do not enroll during these special enrollment opportunities, your coverage will be limited to the Standard Plan with a 180-day waiting period for pre-existing conditions.

Coverage

When does coverage begin?

Coverage begins the first of the month on or following your eligiblity 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?

The health insurance program provides a variety of plans including health maintenance organizations and the self-insured Standard Plan, which offers a preferred-provider network. The It's Your Choice book, which is an annual listing of health plan choices and State health insurance coverage, is distributed to all employees upon hire and again during the Dual-Choice enrollment period in the fall. In addition, the health plan contacts, on the last page of the It's Your Choice book, gives you names, contact information, and website links (if available) for all the plans in the program.

When can I change plans?

Employees may select any plan initially and may change plans during the Dual-Choice enrollment period for coverage effective January 1 of the next calendar year. This is generally the only time employees can select a different plan. Employees changing plans due to a Dual-Choice election will have continuous coverage with no exclusions for pre-existing health conditions.

What is the Standard Plan?

The Standard Plan is a self-insured plan that offers a nationwide network of preferred providers. As of January 1, 2006 Wisconsin Physicians Service (WPS) administers 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.

Please note that Uniform Benefits do not apply to the Standard Plan.

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. As of January 1, 2006 SMP is 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.

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. Some plans also include limited coverage for dental services.

If you have specific questions about the coverage and services of a particular plan, you should contact the health plan directly. The health plan contacts, found on the back page of the It's Your Choice book, contains the contact information for all of the plans.

What are Uniform Benefits?

All participating HMOs and SMP provide the same benefit plan. 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. WPS Patient Choice 1 and 2 are 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.

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.

Who can be covered?

You can have single or family coverage. Single coverage covers you only. If you select family coverage, your eligible dependents are your spouse and unmarried children. Unmarried children are eligible for coverage to the end of the year in which they turn age 19 or age 25 if they are full-time students and are dependent upon you and/or the other parent for at least 50% of their support, meet the support tests as a dependent for federal income tax purposes (whether or not the dependent is claimed) and are:

  • Your natural children
  • 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 for adoption with the subscriber, whichever occurs first. These dates are defined by Wis. Stat. § 632.896.
  • Your stepchildren
  • Legal wards that became wards of the subscriber before age 19. Coverage will be effective on the date that a court awards permanent guardianship to the subscriber.
  • Grandchildren born to 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.

In addition, if your child has a physical or mental disability that is expected to be of long-continued or indefinite duration, and is incapable of self-support, the age limits and student status requirements do not apply. You will be required to verify your dependents' eligibility annually.

When does coverage for dependent children terminate?

Coverage for dependent children who are not physically or mentally disabled terminates on the earliest of the following dates:

  •  The end of the month in which the child marries.
  • The end of the calendar year in which the child:
    1. Turns 19 while not a full-time student.
    2. Ceases to be a full-time student and is age 19 or older.
    3. Turns 25 while still a full-time student.
    4. Ceases to be dependent for support and maintenance.
    5. For a stepchild, the end of the month in which your divorce from the child's parent is entered.

The date eligibility for coverage ends either for the dependent or the subscriber. For information about your dependents' right to continue coverage, you may want to view this PowerPoint presentation.

Under no circumstances may other relatives (e.g., parents, grandparents) be covered under a family contract.

When may I change from single to family coverage?

You may change from single to family coverage without restriction if an application is received by your staff benefits specialist within 30 days of first being eligible for family coverage (within 60 days of the birth or adoption of a child). This usually occurs upon marriage, but other examples are:

  • A single woman giving birth or a single person adopting his or her first child.
  • 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.
  • An unmarried parent whose only child over the age of 19, but not over age 25, becomes a full-time student (and thus an eligible dependent).
  • Any eligible dependent loses other group medical coverage.
  •  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:

  • If you are currently enrolled in the Standard Plan, family coverage is effective the first day of the month on or following receipt of the application, with a 180-day waiting period for pre-existing conditions for the added spouse and/or dependent children.
  • If you are currently enrolled in any plan other than the Standard Plan, 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 Dual-Choice enrollment period. At other times, coverage may be switched to the Standard Plan effective the first day of the month on or following receipt of the application with a 180-day waiting period for pre-existing conditions for the added spouse and/or dependents. There is no waiting period for any children born after the effective date of the Standard Plan coverage.

What if my spouse is also a state or university employee?

If your spouse 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 and any eligible dependents. You may not have one single contract and one family contract, or two family contracts.

If you and your spouse are each enrolled for single health coverage, you may change one of the single contracts to a family contract at any time without restriction. The other single contract will be canceled. Also, the named subscriber for family coverage can be changed to the other spouse at any time or the family coverage may be split into two single plans with the same carrier. 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. You (or your spouse) should not cancel your single coverage before the family contract is effective.

If, at the time of marriage, 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. Failure to comply with this requirement may result in denial of claims for eligible dependents.

If you and your spouse 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.

Premiums

How are employee premium contributions determined?

For represented employees, the employee premium contribution is subject to collective bargaining.

For nonrepresented classified employees, premium contributions are established by the nonrepresented compensation plan.

Premium contributions for faculty/academic staff are established by the faculty and academic staff compensation plan and approved by the Board of Regents.

Premium contributions for nonrepresented graduate assistants are established by unclassified compensation plan.

All compensation plans are approved by the Joint Committee on Employment Relations.

Effective with the January 2004 coverage month, health plans are placed into tiers based on the health plan’s efficiency and other factors. The employee contribution is determined by the tier in which the health plan is placed.

The employee contributions towards health insurance are established by the Office of Employment Relations and approved by Joint Committee on Employment Relations (JCOER ) in the  compensation plans and the bargaining agreements.  No action has yet been taken on this issue for 2008; as such, the 2007 employee contributions remain in force until further notice. The monthly cost for full-time nonrepresented classified employees, for represented classified employees whose bargaining unit has settled, and for faculty/academic staff, and university senior executives is:
Tier 1 single coverage
$27.00
Tier 2 single coverage
$60.00
Tier 3 single coverage
$143.00
   
Tier 1 family coverage
$68.00
Tier 2 family coverage
$150.00
Tier 3 family coverage

$358.00

The premium contribution for non-represented graduate assistants is one-half of the above rates.

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.

The premiums are paid two months in advance. For example, the premium deduction from your September earnings is for November 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 Dual-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.

Program Features

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.

If you have coverage under the Standard Plan, 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. Some 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 book. 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. The health plan contacts, found on the back page of the It's Your Choice book, contains the contact information for all of the plans.

How do I choose a health insurance plan?

Considering the following issues may help you decide on which plan to select:

  1. Cost of the plan to you
  2. Quality of services provided
  3. Plan referral policies
  4. Access to specific physicians or other health care providers

How does the prescription drug benefit work?

Beginning January 1, 2004, all participants will receive their pharmacy benefits from the pharmacy benefit manager (PBM), Navitus Health Solutions (Navitus). Your health plan is no longer involved with coverage for or approval of prescription drugs.

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 three-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

There is an annual Out-of-Pocket Maximum that applies to Level 1 and Level 2 Prescription Drugs and Insulin. In 2008, under an HMO or SMP, after $350 in copayments are paid in the calendar year for an individual or $700 in copayments for a family, Level 1 and 2 drugs are covered in full for the remainder of the year. The annual out-of-pocket maximum for participants in the Standard Plan is $1,000 per individual or $2,000 per family.

Important Note: Copayment for Level 3 drugs are not applied to the annual out-of-pocket maximum.

Navitus offers mail-order prescriptions at a reduced cost (3-month supply for 2 copayments) and also has other cost-saving features available such as pill-splitting and generic sampling.

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.

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 for 36 months 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 booklet or ask your staff benefits office.

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. For more information on continuation rights, you may want to view this PowerPoint presentation.

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 31 days after termination of group coverage. If you have questions regarding conversion, write or call the plan in which you are enrolled.

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.

Examples:

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.

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This document was last revised on October 25, 2007

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