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

Standard Plan
Administered by WPS Health Insurance
(800) 634-6448 wpsic.com/state
Not Available
Overall Quality Rating
See Report Card section
What’s New for 2013
In the past, members have asked for a
Preferred Provider Organization (PPO) to be
offered as the Standard Plan. This modern
PPO will be easier to understand. It will
continue to provide you with freedom of
choice among providers in Wisconsin and
nationwide.
In-network covered services will be subject
to a deductible of $100 per individual/$200
per family with 100% coverage thereafter.
Services from out-of-network providers will
be subject to a $500 individual/$1,000 family
deductible. Thereafter, services are payable
at 80% to an out-of-pocket maximum of
$2,000 individual/$4,000 family.
Last year WPS offered a basic health risk
assessment (HRA) to allow members to
better understand the health risks associated
with responses given to the health and
wellness questions. To continue assisting
members with health and wellness goals,
this year WPS will offer a more complete
HRA that will include biometric screenings,
which determine the risk level of an
individual for certain diseases and other
medical conditions. By knowing risk levels, an
individual can better make decisions related
to their health and wellness. To request an
HRA, see the contact information below.
General Information
This Standard Plan is a comprehensive
health plan that provides you with freedom
of choice among hospitals and physicians
in Wisconsin and across the nation. See
the Comparison of Benefit Options section
starting on Page 22 for more information or
for greater detail on modernized benefits,
contact WPS.
Provider Directory
Go to wpsic.com/state/pdf/dir2013_
statewide_eastern.pdf or wpsic.com/state/
pdf/dir2013_statewide_western.pdf to
search for a provider within Wisconsin and
bordering areas. You can also visit wpsic.
com/state/fad2013-state-national.shtml to
search for providers within Wisconsin, as
well as nationwide. You may also contact
member services to request a copy.
Pre-Certification
To avoid a $100 inpatient benefit reduction,
you, a family member or a provider must
notify WPS of any inpatient hospitalization to
request pre-certification.
Referrals and Prior Authorizations
• Referrals are not necessary.
• Members or providers may request prior
authorization for services when concerned
if WPS will pay and at what rate. Without
an approved prior authorization, WPS
may deny payment. Prior Authorization is
newly required for lower back surgery and
high-tech radiology services. Please visit
wpsic.com/state and follow the Member
Materials link to obtain a copy of a
Medical Preauthorization Request Form or
call member services.
Mental and Behavioral Health Services
Medically necessary services are available
when performed by licensed mental health
professionals practicing within the scope of
their license. Inpatient services will be limited
to 365 days.
Dental Benefits
No dental coverage provided.
Health Risk Assessment Information for Enrolled Members:
Contact Mark Mitchell at (800) 333-5003
Decision Guide Page 49