Self-Insured Model for 2018 State Group Health Insurance

Page last updated: February 24, 2017 — 12:07 PM

In an effort to provide up to date information regarding the Self-Insured program model for State Group Health Insurance questions, UW–Madison Office of Human Resources will be posting questions received here and adding answers as they become available. Please review often for updates.

In future months, we will be holding educational sessions to provide information about our 2018 benefits programs. Please feel free to access the following resources for more information:

The University of Wisconsin’s benefit plans are administered by Employee Trust Funds (ETF) and governed by the State of Wisconsin. The Legislature’s Joint Finance Committee has oversight over any self-insurance contract for state workers as required by Wisconsin State Statute 40.03(6)(L). The Department of Employee Trust Funds (ETF) has stated that the committee needs to approve self-insurance contracts by May 1, 2017 in order to implement the change by January, 2018 as planned.


Frequently Asked Questions

Group Insurance Board (GIB) considerations

What does changing the group health insurance program from fully-insured to self-insured mean?

Per ETF’s FAQ:

This means that instead of paying health plans a monthly premium for coverage, the State will pay medical claims directly through third-party administrators. The State of Wisconsin already administers three self-insured benefit programs: pharmacy, uniform dental and the state-wide It’s Your Choice Access Health Plan.

Why the change?

Per ETF’s FAQ:

The Board made the decision to change from the current fully-insured program structure after a year of review, analysis and consideration of different options to achieve the following goals:
  • Quality care
  • Maintain benefit levels
  • Ensure provider access
  • Contain program costs
Analysis from the Board’s consulting actuary, Segal, shows that 98% of all current providers will be available in the new structure. The changes are estimated to save taxpayers $60 million over the 2017–2019 biennium. Similar savings is anticipated future years.

Please provide a breakdown of the projected $60 million savings over the next two years. Where will the savings come from?

Employee Trust Funds and Segal Consulting provided projections to GIB. Public information that was provided to the board can be located by reviewing the GIB meeting agendas and materials by date of meeting.

Educational Opportunities / Forums

Will UW–Madison be offering employee informational sessions and/or discussions?

In future months, once more information is known, we will be holding educational sessions to provide information about our 2018 benefits programs.

Will Employee Trust Funds (ETF) being offering any community forums? (Unanswered)

This question will be updated when we receive more information.

Funding

What is reinsurance?

A reimbursement system that protects insurers from very high claims. It usually involves a third party paying part of an insurance company’s claims once they pass a certain amount. Reinsurance is a way to stabilize an insurance market and make coverage more available and affordable.

What is the state’s plan for reinsurance? 100k? 1 million? 100 million? (Unanswered)

This question will be updated when we receive more information.

Will the self-insurance funds be mixed with Wisconsin Retirement System (WRS) retirement fund? (Unanswered)

This question will be updated when we receive more information.

What will happen the first year insurance costs outstrip the funds? (Unanswered)

This question will be updated when we receive more information.

What is a single-payer healthcare system?

Single payer health care is a universal health care system where a “single payer” fund, rather than private insurers, pays for health care costs. The “single payer” part refers to funding, not delivery. A single payer fund can have a private healthcare delivery system, a public delivery system, or a mix of the two. A fund can be controlled by any agency, but is typically organized and overseen by the government.

Benefits Coverage Changes & Claims

Are my medical benefits changing?

Per ETF’s FAQ:

The Board will finalize 2018 benefits it’s May board meeting, but has indicated that they would like to minimize benefit changes for next year. The benefits covered by the statewide It’s Your Choice Access Plan will mirror Uniform Benefits starting January 1, 2018. The differences are outlined in the table, below:

Benefit IYC Access Health Plan Uniform Benefits
Bariatric Surgery Covered Excluded
Adult hearing aids and adult cochlear implants Excluded Covered
Transplants Covers bone marrow, musculoskeletal, corneal, and kidney Covers bone marrow, musculoskeletal, corneal, kidney, parathyroid, heart, liver, kidney with pancreas, heart with lung, and lung
Oral Surgery Covers 23 procedures Covers 11 procedures
In/Out-of-Network In- and Out-of-Network coverage available In-Network coverage only

Are my dental benefits changing?

Per ETF’s FAQ:

No.

What will happen if there is a billing discrepancy for claims? (Unanswered)

This question will be updated when we receive more information.

Who will determine if claim(s) should be paid? (Unanswered)

This question will be updated when we receive more information.

Will my health insurance premiums increase?

At this time, we do not have any information on how this change will affect insurance premiums. Employee premium contribution amounts will provided during the It’s Your Choice open enrollment period this fall.

Providers/Network

Will Group Health Cooperative–South Central (GHC) be available in 2018?

The only provider network information currently available can be found on ETF’s website.

Further information regarding provider access was included in the Group Insurance Board’s letter to the Joint Committee on Finance (February 9, 2017). It states the following regarding GHC access:

Improved provider access – Participants will have access to more Wisconsin providers primarily because the statewide vendor has broader networks than are currently available to most participants. Most Group Health Cooperative–South Central providers will be included via other third party administrators (TPA’s) even though GHC did not participate in the RFP. It should also be noted that Physician’s Plus, which participated in the RFP but was not selected as a vendor, is publicly exploring a partnership with Quartz organizations. In addition, the statewide vendor will be available at premium rates competitive with regional plans. Today, the statewide network is only available through the IYC Access Health Plan (formerly Standard Plan), which is a Tier 3 plan and therefore not price competitive with the other regional plans.

Which Health Plans will be offered in 2018?

The following provider information is available on ETF’s website:

The Board will Issue Intent to Award Letters to six vendors, for three-year contracts. Compcare Health Services Insurance Corporation (Anthem Blue Cross Blue Shield) will administer statewide/nationwide services in partnership with five regional vendors. The vendors for regional services are:
  • Anthem Blue Cross Blue Shield
  • Dean Health Plan, Inc.
  • HealthPartners Administrators, Inc.
  • Network Health Administrative Services, LLC
  • Security Administrative Services, LLC
  • SPWI TPA, Inc. (Quartz*)
*Quartz is affiliated with Unity Health Insurance and Gunderson Health Plan.

Why did the Board choose these health plan vendors?

Per ETF’s FAQ:

The board chose vendors that scored well in the areas of quality measures, strong health management programs and cost effectiveness.

What will I need to do if my health plan will not be available in 2018?

Per ETF’s FAQ:

You will need to choose a different plan during the It’s Your Choice open enrollment period this fall. ETF will provide information in plenty of time for you to make a decision about which plan to choose for 2018.

How will I know which plans cover my primary care doctor and the rest of my health care team?

Per ETF’s FAQ:

ETF will provide information in plenty of time for you to make a decision about which plan to choose for 2018. Educational eLearning modules will be provided throughout the year to guide you through this transition process. While it might seem as though these are big changes, you will not see a difference in how your healthcare is delivered. The biggest change for you may just be the insurance card in your wallet.

Regionalization

What is regionalization, and why did the Board decide to regionalize the program?

Per ETF’s FAQ:

The Board approved dividing the state into four regions, with one statewide health plan and additional health plans offering coverage in each region. This change was recommended by the Board’s actuary, Segal. For more information, read the discussion that starts here in the Segal report.

The Board wanted to increase access to providers in all parts of the state, streamline program administration, simplify program information for participants, and control costs. Only the health plans offering the highest-quality providers at the best value will participate in a region. Many of the health plans' provider networks overlap. This means that many members can continue to see the providers (physicians, hospitals, clinics) they see today, even if they have to choose a different health plan.

How will regionalization affect my choice of doctors?

Per ETF’s FAQ:

98% of current providers will be available under the new program structure. During the It’s Your Choice open enrollment period, use the provider directories for the health plans in your region to determine which health plan offers your current providers.

When will I see provider directories from the health plans?

Per ETF’s FAQ:

Provider directories will be available during the It’s Your Choice open enrollment period this fall.

Is it possible that my current doctor won’t be offered by any health plan?

Per ETF’s FAQ:

Yes, but it is unlikely. 98% of current providers will be available under the new program structure. During the It’s Your Choice open enrollment period, use the provider directories for the health plans in your region to determine which health plan offers your current providers.

I live outside of Wisconsin and am enrolled in the IYC Access Plan (formerly Standard). How does this change affect me?

Per ETF’s FAQ:

You will still have access to providers statewide and nationwide, but your in-network benefits will now be the same as participants in the Uniform Benefit programs. More information regarding out-of-network benefits will be available prior to the It’s Your Choice open enrollment period this fall.

Anthem will replace WPS as the administrator of this plan option.

Domestic Partnerships

Will there be any change to insurance coverage for Domestic Partners?

Currently the only information available regarding the future of Domestic Partnerships benefits can be found in the State of WI 2017-2019 Budget proposal. See page 60, second bullet point.

Update 2/23/2017 – ETF has provided an Initial Review of the 2017-2019 State Budget which provides additional Domestic Partnership Program information.

Medicare

What implications, if any, does self-insured have for retirees on Medicare, plus the pension-funded WPS medi-gap policies? (Unanswered)

This question will be updated when we receive more information.