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

Glossary
ETF: The Department of Employee Trust
Funds, a state of Wisconsin agency that
manages health insurance, retirement
and other benefit programs for WRS
participants and employers. Programs
cover state and participating local
employees and retirees.
Excluded Services: Health care services
that your health insurance or plan
doesn’t pay for or cover.
Formulary: A list of covered prescription
drugs. The Wisconsin Public Employers
Group Health Insurance Program’s
formulary is available on Navitus Health
Solutions’ website at https://navitus.com/
Pages/default.aspx.
Grievance: A written complaint filed with
the health plan, PBM or ETF following a
decision made by the health plan or PBM
that was not favorable to the member.
Group Insurance Board: The governing
body that sets policy and oversees
the administration of the Group Health
Insurance Programs for the State of
Wisconsin and participating Wisconsin
Public Employers.
Habilitation Services: Excluded health
care services that help a person keep,
learn or improve skills and functioning
for daily living. Examples include therapy
for a child who isn’t walking or talking
at the expected age. These services
may include physical and occupational
therapy, speech-language pathology
and other services for people with
disabilities in a variety of inpatient and/
or outpatient settings. Also referred to as
custodial care.
Health Insurance: A contract that
requires your health insurer to pay
some or all of your health care costs in
exchange for a premium.
HEDIS ® (Healthcare Effectiveness Data
& Information Set): Compares the
performance of health plans with regard
to the delivery of care and service.
HMO (Health Maintenance Organization):
A health plan that uses a specific
network of doctors, clinics, hospitals and
other medical providers located in a
specific geographic area. Members of
HMOs are expected to receive services
within that network.
Home Health Care: Health care services
a person receives at home.
Hospice Services: Services to provide
comfort and support for persons in the
last stages of a terminal illness and their
families.
Hospitalization: Care in a hospital that
requires admission as an inpatient and
usually requires an overnight stay. An
overnight stay for observation could be
outpatient care.
Hospital Outpatient Care: Care in a
hospital that usually doesn’t require an
overnight stay.
In-network Coinsurance: The percent (for
example, 10%) you pay of the allowed
amount for covered health care services
to providers who contract with your
health insurance or plan. In-network
coinsurance usually costs you less than
out-of-network coinsurance under a PPO.
Decision Guide Page 90