It's Your Choice 2013 - Decision Guide (ET-2128d-13) - ETF

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Choose Wisely the Navitus SpecialtyRx, specialty pharmacy program. Non-formulary specialty and certain other drugs are not eligible for the reduced copayment, and the copayments do not count toward the Level 4 OOPL. To enroll in the Navitus SpecialtyRx, specialty pharmacy program or to obtain additional information, call 1-877-651-4943 or visit diplomatpharmacy.com. THINGS TO CONSIDER DURING IT’S YOUR CHOICE OPEN ENROLLMENT 3. May I change from single to family coverage during the It’s Your Choice Open Enrollment period? Yes, you have the opportunity to change from single to family coverage without a waiting period or exclusions for preexisting medical conditions. Coverage will be effective January 1 of the following year for all eligible dependents. Note that if you are subject to tax liability for dependents, such as adult children, and/or a domestic partner and his/her child(ren), you can elect not to cover such individuals. For information about the tax impact of covering non-tax dependents, see Frequently Asked Question 4 and 5. For information on changing from family to single coverage, see the Frequently Asked Questions section of the It’s Your Choice: Reference Guide. 4. What are the tax implications for covering non-tax dependents? Domestic Partners: The fair market value for insurance coverage provided for a domestic partner and his or her children, if elected, must also be calculated and added to your income unless the domestic partner and his/her children qualify as the employee’s tax dependents. The fair market value of the health insurance benefits will be calculated and added to your earnings as imputed income (see Question 5 for definition). The monthly imputed income amounts vary by health plan and are provided for either one non-tax dependent, or two or more non-tax dependents. These dollar amounts will be adjusted annually and are available from your employer (affected annuitants may contact ETF). Employees who are unsure if a person can be claimed as a dependent should consult IRS Publication 501 or a tax advisor. Employees may change from single to family coverage to add a newly eligible domestic partner or other dependent who does not qualify as a tax dependent under Internal Revenue Code Section 152 during the plan year. The additional premium attributable to the non-qualified dependent will be taxable. Adult Children: The Patient Protection and Affordable Care Act (PPACA) and 2011 Wisconsin Act 49 eliminated tax liability for the fair market value of elected health coverage for these Decision Guide Page 8
Choose Wisely dependents through the month in which they turn 26 if eligible. If the tax dependent status of your dependent changes, please notify your employer or for annuitants and continuants, ETF. 5. What is imputed income? Imputed income is the non-cash benefit earned for items—for example, health insurance for certain dependents—that is reported as income to the government on forms such as the W-2. Employees and annuitants may be taxed on the fair market value of the health care coverage extended to their dependents who do not qualify as dependents for tax purposes. Note: See Question 4 to learn when imputed income applies. For more information, employees should contact their employer and annuitants should contact ETF. 6. If I do not change from single to family coverage during the It’s Your Choice Open Enrollment period, will I have other opportunities to do so? There are other opportunities for coverage to be changed from single to family without restrictions as described below: 1. If an electronic or paper application is received by your benefits/payroll/personnel office for active employees or ETF for annuitants/continuants within 30 days of the following events, coverage becomes effective on the date of the following event: • Marriage. • The date ETF receives the completed Affidavit of Domestic Partnership (ET-2371). • You or any of your eligible dependents involuntarily lose eligibility for other medical coverage or lose the employer contribution for the other coverage. • Legal guardianship is granted. • An unmarried parent whose only eligible child becomes disabled and thus is again an eligible dependent. Coverage will be effective the date eligibility was regained. 2. If an application is received by your benefits/payroll/personnel office for active employees or ETF for annuitants/continuants, within 60 days of the following events, coverage becomes effective on the date of the following event: • Birth, adoption of a child or placement for adoption (timely application prevents claim payment delays). • A single father declaring paternity. Children born outside of marriage become dependents of the father on the date of the court order declaring paternity, on the date the acknowledgement of paternity is filed with the Department of Health Services (or equivalent, if the birth was outside of the state of Wisconsin), or on the date of birth with a birth certificate listing the father’s name. The effective Decision Guide Page 9
Page 1 and 2: It’s Your Choice: 2013 Decision G
Page 3 and 4: Table of Contents Choose Wisely....
Page 5 and 6: Choose Wisely Sheboygan Fiesta Hisp
Page 7 and 8: Choose Wisely Standard Plan Benefit
Page 9: FREQUENTLY ASKED QUESTIONS IT’S Y
Page 13 and 14: Choose Wisely back of this Guide or
Page 15 and 16: Choose Wisely When you use in-netwo
Page 17 and 18: Choose Your Health Plan radiology (
Page 19 and 20: Local Government Employees and Annu
Page 21 and 22: LOCAL HEALTH PLAN TIERS Choose Your
Page 23 and 24: Choose Your Health Plan HEALTH PLAN
Page 25 and 26: Comparison of Benefit Options BENEF
Page 27 and 28: Comparison of Benefit Options BENEF
Page 29 and 30: Choose Your Health Plan coordinated
Page 31 and 32: Health Plan Features - At a Glance
Page 33 and 34: Anthem Blue Preferred - Northeast N
Page 35 and 36: Anthem Blue Preferred - Southeast N
Page 37 and 38: Dean Health Plan Inc. (800) 279-130
Page 39 and 40: Group Health Cooperative of South C
Page 41 and 42: Health Tradition Health Plan (877)
Page 43 and 44: Humana - Eastern (800) 4humana [(80
Page 45 and 46: Medical Associates Health Plans (80
Page 47 and 48: MercyCare Health Plans (800) 895-24
Page 49 and 50: Physicians Plus (608) 282-8900 or (
Page 51 and 52: Standard Plan Administered by WPS H
Page 53 and 54: UnitedHealthcare of Wisconsin North
Page 55 and 56: Unity Health Insurance - Community
Page 57 and 58: WEA Trust PPO - East (800) 279-4000
Page 59 and 60: WPS Metro Choice Northwest (800) 63
Page 61 and 62:
Choose Quality HEALTH PLAN REPORT C
Page 63 and 64:
Quality Composite Rating Chart Unde
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CAHPS ® Composite Rating Chart Und
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Choose Quality GRIEVANCE AND COMPLA
Page 69 and 70:
Choose Quality OTHER QUALITY INFORM
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NAVITUS HEALTH SOLUTIONS — Pharm
Page 73 and 74:
NAVITUS MedicareRX (PDP)— Pharmac
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For Medicare eligible, retired, dis
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myETF Benefits System Instructions
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Department of Employee Trust Funds
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ETF Use Only State of Wisconsin Dep
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Applicant Name Social Security Numb
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DUPLICATE APPLICATION FOR YOUR RECO
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DUPLICATE APPLICATION FOR YOUR RECO
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Glossary Coinsurance: Your share of
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Glossary In-network Copayment: A fi
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Glossary Preventive Services: Routi
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Health Plan Contact Information Ant
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