Human Resources
By Sally Loy
Changes Coming to State Group Health Insurance
Uniform Benefits
Section 9115 of WI Act 10 requires that the Group Insurance Board (GIB) design health care coverage plans for the 2012 calendar year that, after adjusting for inflation, reduces the average premium cost of tier 1 plans by at least 5% from the cost of the plan during the 2011 calendar year.
The GIB considered various options of achieving the cost reduction, such as the implementation of office visit and inpatient copayments, deductibles, coinsurance, adjusting the prescription drug benefit and eliminating the optional dental benefits offered by most plans.
After due deliberation, the GIB approved the following changes to Uniform Benefits, effective January 1, 2012, resulting from WI Act 10 implementation:
- Apply coinsurance to medical services. Benefits will be payable at 90% up to an annual out-of-pocket maximum of $500 for an individual/$1,000 for a family.
- Coinsurance is based on a set percentage of the cost. For example, if the discounted medical charges are $200, the member will be responsible for $20, which is 10% of the charge.
- Once a member has paid $500 in coinsurance for an individual, or $1000 for family coverage, in a calendar year, the 10% coinsurance will not be applied for the remainder of the year. The $1000 out-of-pocket maximum for families is cumulative, so once any combination of family members has paid $1000 in coinsurance, the coinsurance ends for the rest of that calendar year. It is not required that two family members each incur $500 in coinsurance in order to satisfy the $1000 coinsurance requirement.
- Preventive care, such as physicals and well-baby care, is not subject to coinsurance. Examples of preventive care will be provided by the Department of Employee Trust Funds this fall.
- Coinsurance will be applied to the discounted fee negotiated by the plan and the provider (as opposed the actual amount charged).
- Members will typically be billed for the coinsurance. Payment may not be due at the time of service.
- Increase the emergency room copayment from $60 per occurrence to $75 (waived if admitted). This does not get applied to the out-of-pocket maximum.
- If eligible to participate in the Employee Reimbursement Account (ERA) program, out-of-pocket costs for coinsurance and copays are eligible for reimbursement under the ERA Medical Expense Reimbursement Account.
Prescription Drug Benefits
There will be no changes to the prescription drug program for 2012. The annual out-of-pocket maximum of $410 for an individual or $820 for a family will remain and is separate from the out-of-pocket maximum for medical services.
Employee Eligibility
Most employees hired on or after July 1, 2011 will need to work 2/3 of full-time to be eligible for health insurance. Any service with a WRS-employer prior to July 1, 2011 will be sufficient for the employee to be eligible under the old eligibility rules, which required that the employee work 1/3 of full-time. This applies even if the prior position was not eligible for participation in the WRS.
- WRS-eligible classified employees will need to work 2/3 of full-time to be eligible to enroll. This is equivalent to working 1200 hours per year, which is 58% of full-time.
- Faculty, academic staff and limited employees who work 9 months per year, will need to work at least 880 hours in a year, which is 56% of full-time.
- Faculty, academic staff and limited employees who work 12 months per year, will need to work at least 880 hours in a year, which is 42% of full-time.
- Eligibility for graduate assistants, post-docs and limited employees is not changing.
