Employee Benefits

State of Wisconsin Group Health Insurance

Program Features Prescription Benefit Manager

ATTENTION: Deadline to enroll an adult child up to age 27 on family coverage without restriction is Friday, January 29, 2010. If the application is received after January 29th, the child is considered a late enrollee.  In this situation, you will need to submit an application to add the child and to change coverage to the Standard Plan.  The adult child's coverage will be effective the first of the month following receipt of the application and will be subject to the 180-day waiting period for pre-existing conditions. 

Background

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.

See the ETF Group Health Insurance Program web page for detailed information about your health insurance options.

New for 2010

Effective January 1, 2010, employees of the University of Wisconsin System will be eligible to cover a same-sex or opposite-sex domestic partner and the domestic partner's children under a family health insurance policy. Please see UWSA's domestic partner benefit page for detailed information. Employees are also eligible to cover eligible adult children through the end of the month in which they turn 27. See ETF's Benefit Eligibility for Adult Children Up to Age 27 FAQ for more information.

ETF created two health insurance resources, a decision guide and a reference guide, to help you make informed decisions about health insurance coverage and enrollment.

To find a health care provider, see the 2010 Health Plan Provider Directory

2010 Health Insurance Premiums

Navitus created an online portal that allows access to benefit information on the Navitus website. Please see ETF's instructions about how to access the portal.

The 2009 It's Your Choice book for State Employees should be referenced for all 2009-related health insurance claims.

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

Eligibility

Who is eligible to enroll in health insurance?

  • Employees covered by the Wisconsin Retirement System (WRS) - includes eligible classified staff, faculty, academic staff and limited employees.
  • Employees in the Graduate Assistants/Short-Term Academic Staff category.
    • Student Assistant and Employee-in Training employees who are appointed to work at least 33% for one semester (academic year basis) or six months (annual basis). Eligible job titles include Project/Program Assistant, Fellow, Teaching Assistant, Research Assistant/Associate, Research Intern, Grad Intern/Trainee, Post Doc Fellow/Trainee, Post Grad Trainee/Intern (Non-Physician).
    • Short-term academic employees who are employed in positions not covered under the Wisconsin Retirement System (WRS) and hold a fixed-term terminal appointment of at least 28% for one semester (academic basis) or 21% for six months (annual basis). The appointment must be less than 12 months (two semesters for academic year appointments).
    • Visiting Faculty must meet the same minimum time and duration standards as short-term academic employees and they have the same benefits.  If on leave from another educational institution, state law excludes visiting faculty from WRS coverage for the first twelve months of UW employment.  Health insurance premiums are the same as for WRS-covered employees if the appointment is for at least one year (365 days).

What family members are eligible for coverage if I select family coverage?

  • Your spouse or domestic partner. Effective January 1, 2010, a domestic partner and a domestic partner's children are eligible for coverage under a family policy. Before adding a domestic partner to coverage, an employee must first establish a domestic partnership by submitting a notarized Affidavit of Domestic Partnership (ET-2371) to ETF.
  • Your child. The child must not be married and must not be eligible for group health insurance through his/her own employer for which his/her premium contribution is less than the additional premium amount you are required to pay to insure your adult child on your policy. For example, if you need family coverage regardless of whether you choose to cover your adult child, you do not have to pay an additional premium amount to insure your adult child. If your child’s premium cost is more than $0, your child IS eligible. If you would otherwise have single coverage if you did not insure your adult child, the additional premium amount to insure your adult child is the premium difference between single and family coverage. If your child’s premium cost is more than the additional amount you are required to pay for family coverage, your child IS eligible. Children include:
    • Your natural children
    • Stepchildren or children of your domestic partner
    • 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 in the custody of the subscriber, whichever occurs first. These dates are defined by Wis. Stat.§632.896. If the adoption of a child is not finalized, the insurer may terminate coverage of the child when the adoptive placement ends.
    • Legal wards that become your permanent ward before age 19. Coverage will be effective on the date that a court awards permanent guardianship to you (the subscriber).
  • Your grandchildren born to your 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.

A child may be covered until the end of the month in which he or she turns 27. Coverage may continue beyond that when a child:

  • Has a disability of long standing duration, are dependent on you, or the other parent, for at least 50% of support and maintenance, and are incapable of self-support
  • Was a full‐time student who was previously called to federal active duty when the child was under the age of 27 and while the child was attending, on a full‐time basis, an institution of higher education. The child must apply to an institution of higher education as a full‐time student within 12 months from the date the child fulfills his/her active duty obligation.

IMPORTANT TAX IMPLICATIONS: There are tax consequences to you when you provide coverage for dependents that do not meet the support test for federal income tax purposes, for example, domestic partners and adult children that are not dependent on you, or the other parent, for at least 50% of their support and maintenance. If you cover dependents who are not considered “tax dependents” under federal law, the fair market value of the health insurance benefits provided to those dependents will be included in your gross income. This amount is considered "imputed income." This will increase both your taxable income and your tax liability. Under federal law, a domestic partner cannot qualify as your spouse for purposes of excluding employer-provided health benefits from your taxable income. Unless your domestic partner qualifies as a dependent under the Internal Revenue Code (IRC) §152, you will be taxed on the fair market value of the cost of coverage provided to your domestic partner.

The health insurance imputed tax/fair market value tables are available on ETF's website. If you are covered under the WRS, see the "State - Active Employees" table. If you are not covered under the WRS and have health insurance through the Graduate Assistant/Short-Term Academic Staff health insurance program, see the "State - Graduate Assistants" table. If you have one non-tax dependent on your family health insurance policy (ex. your domestic partner), the fair market value is listed in the "1 non-tax Dependent" column. If you have two or more non-tax dependents on your family health insurance policy (ex. your domestic partner and your domestic partner's child), the fair market value is listed in the "2 or more non-tax Dependents" column. The amount listed in the column will be the amount added to your taxable income to determine your tax liability for the pay period in which you have a health insurance deduction. This amount will also be reflected on your year-end tax statement as "imputed income."

Imputed income calculators are available on the UW Service Center website. These calculators can help you estimate your additional tax liability. Please see the Tax Dependent Status Worksheet to help you determine if provide 50% of your adult child's or domestic partner's support.

Who is Considered a Tax Dependent for Employer-Provided Health Insurance Purposes?

A legal spouse and a dependent child under age 19 as of the end of the calendar year are automatically considered tax dependents.  In order for an adult child or a domestic partner to be considered a tax dependent for health insurance purposes, they must be considered either a “qualified child” or a “qualified relative” under Section 152 of Internal Revenue Code (IRC) and meet all the criteria, except for the income requirements, of a of either a "qualifying child" or a “qualifying relative" as outlined in IRS Publication 501. The Working Families Tax Relief Act of 2004 amended the requirements of a "qualifying child" and "qualifying relative" as they apply to employer-provided health insurance only.  These amendments are outlined in Internal Revenue Service Notice 2004-79.  These amendments relative to employer-provided health insurance are not specifically addressed in IRS Publication 501 so it may cause confusion when an employee is determining the tax dependent status of an adult child or domestic partner.

In general, the IRS requires that a “qualifying child” meet five tests:

  • The child must be your son, daughter or stepchild
  • The child must be
    • under age 19 at the end of the year,
    • under age 24 at the end of the year and a full-time student, or
    • any age if permanently and totally disabled.
  • The child must have lived with you for more than half of the year
  • The child must not have provided more than half of his/her own support for the year
  • If the child meets the rules to be a qualifying child of more than one person, you must be the person entitled to claim the child as a qualifying child.

In general, the IRS requires that a "qualifying relative" meet four tests:

  • The person does not meet the "qualifying child" tests (see above);
  • The person either (a) must be related to you in one of the ways listed under “Relatives who do not have to live with you (see below)”,or (b) must live with you all year as a member of your household (and your relationship must not violate local law).
  • The person’s gross income must be less than $3,650 for the year. (This requirement is not applicable when determining tax dependency for employer-provided health insurance.  For health insurance purposes, the domestic partner or adult child only needs to meet the remaining three tests to be a qualifying relative).
  • You must provide more than half of the person’s support for the year.

Note: If an adult dependent child does not qualify as a tax dependent as a "qualifying child", the child may qualify as a "qualifying relative."

Relatives who do not have to live with you – A person related to you in any of the following ways does not have to live with you all year as a member of your household to meet this test (relates to #2 under the “qualifying relative” test).  Any of the relationships listed below that are established by marriage must not have ended by death or divorce.

  • Your child, stepchild, foster child, or a descendant of any of them (for example, your grandchild). (A legally adopted child is considered your child.)
  • Your brother, sister, half brother, half sister, stepbrother, or stepsister.
  • Your father, mother, grandparent, or other direct ancestor, but not foster parent.
  • Your stepfather or stepmother.
  • A son or daughter of your brother or sister.
  • A brother or sister of your father or mother.
  • Your son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, or sister-in-law.

IMPORTANT: The information above should not be used as the sole source of information for determining the tax status of your adult child or domestic partner. UW System staff cannot provide you with tax advice. You should review all related IRS information and/or consult with a tax advisor if you have questions regarding how the federal rules apply to your situation.

When does health coverage end for my dependents covered on my family policy?

Coverage for dependents terminates on the earliest of the following dates:

  • The date eligibility for coverage ends for the subscriber.
  • The end of the month your child turns 27 or marries.
  • The end of the month your child ceases to be a full-time student and is age 27 or older. If your child was a full-time student and was called to federal active duty before age 27, the child may remain covered will attending, on a full-time basis, an institution of higher education, as long as the child applies to an institution of higher education as a full-time student within 12 months from the date the child fulfills the active duty obligation.
  • Your spouse and stepchildren's coverage will end at the end of the month a divorce is entered.
  • Your domestic partner and domestic partner's children's coverage will end at the end of the month you file an Affidavit of Termination of Domestic Partnership with ETF.
  • The end of the month in which a covered grandchild's parent (your child) ceases to be an eligible dependent or becomes age 18, whichever occurs first.

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.

Enrollment

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

In order to enroll in coverage, you must submit a completed Health Insurance Application/Change Form (ET-2301) directly to your institution's benefits office within 30 calendar days from the contractual begin date of your appointment. Coverage is effective the first of the month on or following the receipt of the application by your institution's benefits office. You are immediately eligible for the employer contribution towards your premium.

Classified Employees

There are two enrollment opportunities. The University does not pay the employer contribution towards the premium during the first two months of WRS covered employment (six months for LTEs). After two months (six months for LTEs), you are eligible for the employer contribution towards your premium.

  1. If you have no prior WRS-covered state/UW service and you want health coverage as soon as possible, you must submit an application to your benefits office no later than 30 calendar days from the begin date of your appointment. You will pay the total premium for the first two months of coverage (six months for LTEs).
  1. If you want health coverage when the University 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 two months (six months for an LTE) of WRS-covered service as a state/UW employee.

If you are transferring from another University System institution or state agency or if you are a new employee with at least two 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 initial enrollment period?

Employees are eligible to apply for coverage at any time under the Standard Plan with a 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 as of October 1 of any year, you can change to a different health plan, including a lower cost HMO, effective January 1 of the following year by submitting an application during the It's Your Choice period that occurs every October.

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.

What if neither I nor my dependent(s) have a Social Security number?

A new federal law became effective January 1, 2009, requiring that group health insurance plans report the Social Security numbers (SSN) of members who are or who may be eligible for Medicare to the Center for Medicare & Medicaid Services (CMS) . This reporting is to assist CMS and other health insurance plans to properly coordinate payment of benefits among plans so that claims are paid promptly and correctly. If you or your dependent are unable to provide a Social Security number due to being a non-citizen, you must instead complete an Affidavit for Insurance Purposes, form UWS 93. Return the completed Affidavit to your benefits office along with your completed applications for state group health insurance and/or Epic Supplemental coverage. If you or your dependent later obtains a Social Security number contact your benefits office.

Coverage

When does coverage begin?

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

Information about all available health plans is available in the It's Your Choice: Decision Guide. The health plan contacts are listed on the final page of the Decision Guide.

When can I change plans?

Employees may select any plan initially and may change plans during the It's Your Choice period for coverage effective January 1 of the next calendar year. You may also change plans within 30 days of moving out of your plan's service area or when you add a dependent to your policy due to marriage, beginning of a domestic partnership, birth, adoption or placement for adoption. These are generally the only times that employees can select a different plan. Employees changing plans during the It's Your Choice period 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.

2010 Uniform Benefits are outlined beginning on page 67 for the 2010 It's Your Choice: Reference Guide.

2009 Uniform Benefits are outlined in Part D of the 2009 It's Your Choice booklet.

If you have specific questions about the coverage and services of a particular plan, you should contact the health plan directly.

What are Uniform Benefits?

All participating HMOs and SMP are required to provide the same level of benefits. All of the plans are allowed to offer additional benefits beyond Uniform Benefits such as partial reimbursement for alternative medicine treatments, health risk assessments, wellness incentives... 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 Metro Choice is a preferred provider plan that provides 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.

When may I change from single to family coverage?

You may change from single to family coverage during the annual It's Your Choice enrollment period. Family coverage will become effective on the following January 1st. You also have 30 or 60 days from one of the following life events to change from single to family coverage.

You have 30 days after one of the following events to submit a health insurance application to your payroll and benefits coordinator to change from single to family coverage. Coverage will be effective on the date of the event.

  • Marriage
  • Establishment of a domestic partnership with ETF
  • You or any eligible dependents involuntarily lose other medical coverage or lose the employer contribution for the other coverage.
  • Legal guardianship is granted.
  • An unmarried parent whose only eligible child resumes full-time student status or becomes disabled and thus is again an eligible dependent. Coverage will be effective the date eligibility was regained.

You have 60 days after one of the following events to submit a health insurance application to your payroll and benefits coordinator to change from single to family coverage. Coverage will be effective on the date of the event.

  • Birth, adoption of a child or placement for adoption
  • 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. The effective date of coverage will be the date of birth if a statement of paternity is filed within 60 days of the birth. If filed more than 60 days after the birth, coverage will be effective on the first of the month following receipt of application.
  •  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, domestic partner 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 It's Your Choice 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, domestic partner 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 or domestic partner is also a state or university employee?

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

If you and your spouse or domestic partner 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 or domestic partner 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 or domestic partner) should not cancel your single coverage before the family contract is effective.

If, at the time of marriage or the effective date of a domestic partnership, 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 or the effective date of a domestic partnership. Failure to comply with this requirement may result in denial of claims for eligible dependents.

If you and your spouse or domestic partner 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 or domestic partner.

Premiums

2010 Health Insurance Premiums

2009 Health Insurance Premiums

How are employee premium contributions determined?

  • Represented employees: collective bargaining
  • Non-represented classified employees: non-represented compensation plan
  • Unclassified faculty,academic staff and limited: faculty and academic staff compensation plan approved by the Board of Regents
  • Non-represented graduate assistants: unclassified compensation plan.

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

The employee contributions towards health insurance are established by the Office of Employment Relations (OSER) and approved by Joint Committee on Employment Relations (JCOER ) in the  compensation plans and the bargaining agreements. 

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: Reference Guide. 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 are listed on the final page of the It's Your Choice: Decision Guide.

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?

Pharmacy and prescription benefits are administered by Navitus Health Solutions, a third-party pharmacy benefit manager (PBM). No matter which health plan is selected, all employees have prescription coverage through Navitus, not the individual health plan.

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. For employees covered by an HMO or the State Maintenance Plan, the 2009 out-of-pocket maximum is $385 per individual or $770 per family and the 2010 out-of-pocket maximum is $410 per individual and $820 per family. If enrolled in the Standard Plan, the out-of-pocket maximum is $1,000 per individual and $2,000 per family. After the out-of-pocket maximum is reached, Level 1 and 2 drugs are covered in full for the remainder of the year.

Important Note: Level 3 prescription co-payments do no apply to the out-of-pocket maximum and must continue to be paid after the annual out-of-pocket maximum has been met.

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. Navitus also has a secure section of their website called "Navi-Gate® for Members." Covered members can access formularies, Prior Authorization Forms and prescription drug history. Please see ETF's instructions about how to access the portal.

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 you are involuntarily terminated (for reasons other than gross misconduct) between September 1, 2008 and December 31, 2009, you may be eligible for an employer subsidy towards your health insurance premiums for up to nine months. For more information, visit COBRA Health Insurance Continuation Premium Subsidy

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 0.8% 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.

For more information about sick leave while employed and its benefit after retirement, see Sick Leave - A Valuable Benefit for All Employees.

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This document was last revised on February 1, 2010

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