Milwaukee County 2013 Health Benefits At-A-Glance
Selecting the right provider network not only serves you well, but also helps Milwaukee County address the challenge of dramatically-increasing health care costs so that we can continue to offer quality benefits for generations to come. For 2013, only the Milwaukee County Choice Plan is available to employees and retirees.
Milwaukee County Choice Plus Plan (PPO Comparable)
This plan features comprehensive benefits with deductibles and coinsurance at both in- and out-of-network providers. Highlights of the plan include:
$800 Individual, $1,050 Employee + Child(ren), $1,600 Employee + Spouse, $1,850 Family deductible
In-network physician office visit $30 copay
Fixed dollar co-pays for prescription drugs ($10 for generic, $30 for preferred brand drugs, $50 for non-preferred brand name drugs)
Mandatory mail order for maintenance medications ($25 for generic, $75 for preferred brand drugs, $125 for non-preferred brand name drugs)
Paid-in-full well-baby care
In-network and out-of-network benefits
Health Care Plan Summaries
2013 Summary Plan Description - Active Employees
2013 Summary Plan Descriptions - Retired Employees
Eligibility and Enrollment
All Milwaukee County employees appointed to a position with an authorized work week of twenty hours or more and are not excluded by job code or Ordinance are eligible to enroll in any health plan that is offered by Milwaukee County. The employee must enroll within 30 days of the date on which they became eligible to join the health plans. Such dates would include date of hire, return to work from leave of absence, or return to work after a layoff.
If you wish to enroll contact your payroll clerk for instructions on how to use the online enrollment system, www.benefitenroll.com . Benefits become effective the first of the month following 30 days after your hire date, or the date you return from a leave. If you do not enroll during your 30 day window, you must wait until the following Open Enrollment period to enroll for benefits for the next year.
Premiums are deducted twice per month from the paychecks you receive during the covered month. Your payroll clerk can advise you when coverage will begin. Coverage is never retroactive; that is, you cannot have coverage back dated to a period of time before you were eligible for coverage.
Dependents are generally defined as a lawful spouse, the eligible employee's unmarried children who reside with the employee at the same legal residence, meet various age requirements, and for whom the employee provides over 50% of financial support. If an eligible employee has the legal responsibility for a dependent's health expenses by virtue of a valid court order and the dependent does not reside with the employee, the dependent may still be enrolled. In addition to the eligible employee's own natural and/or lawfully adopted and/or legal guardianship children, the term 'children' shall include any stepchildren for whose medical expenses the eligible employee's lawful spouse has responsibility by virtue of a valid court order and they meet all eligibility requirements, or a natural child of a dependent child until the dependent parent is 18 years of age.
The eligible employee's children shall be covered until the last day of the month in which they attain age 27, provided they meet the above qualifications. A dependent child's eligibility will cease at the last day of the calendar month in which the dependent child marries. If you have any questions or unusual situations, please contact your payroll clerk or department HR staff for further clarification. Milwaukee County or the health care provider will periodically require proof that the requirements are met. It is your obligation to notify Milwaukee County through your payroll clerk of any covered eligible dependents who no longer qualify for coverage under the existing eligibility rules due to such things as divorce, or a child who no longer meets age requirements. If you do not, a non-eligible dependent's claims may be your responsibility when the non-eligibility is discovered.
The County offers single plans and family plans through all of its health care plans. A County employee and his/her dependents can only be enrolled in one plan. If two County employees marry, they must be covered under one plan. They may choose to enroll in either employee's plan by virtue of their marriage, as each is an eligible spouse of the other. However, they cannot choose to enroll in a health care plan other then the ones they were enrolled in prior to their marriage. (This is because our contracts only permit movement between health care providers during the open enrollment period.) If the County employees who marry fail to make a plan selection, the Benefits Division will enroll the less senior employee in the plan of the most senior employee.
If an active employee retires with less than fifteen years of County pension service credits, the retiree may participate in the health plan he/she is currently enrolled in on the same basis as the coverage provided to the active employee group as long as the retiree pays the full premium due for such coverage. Employees hired on and after January 1, 1994 may pay the premium in cash or by using sick leave credits accumulated at the time of retirement.
If an active employee retires with fifteen years or more of County pension service credit, the retiree may participate in the health plan in which he/she is currently enrolled on the same basis as coverage provided to the active employee group. The County will make the full premium contribution on behalf of this retiree if he/she was hired, generally on or before January 1, 1994. Union represented employees should check their labor agreement for the specific date in their contract. Employees hired on or after January 1, 1994 must pay the full premium in cash, or by using sick leave credits accumulated at the time of retirement.
Milwaukee County integrates its health plans with the Federal government's Medicare Part A and B programs. Since the scope of this law is so inclusive, any questions about this program and how it relates to your County health benefits should be directed to the Benefits Division at 414-278-4198.
Life Status Events (Enrollment outside of annual or new hire open enrollment)
All eligible employees and their eligible dependents have a period of thirty (30) days from the d ate of hire or a change in family status outlined by Section 125 of the IRS codes to enroll in the health plan of their choice. Once the thirty (30) day grace period has expired, an employee would have to wait until the next Open Enrollment period to make changes to coverage/plans.
You will be notified of the Open Enrollment period 45 days prior to the beginning of the period. An informational kit covering the County's benefit plans will be mailed to your home address of record before open enrollment. The kit contains a brochure which describes in great detail the various benefit plans which will be offered for the upcoming calendar year. Please watch for this mailing and read it carefully. Even if you do not intend to change your health care plans at that time, there is often other important material in the kit. The County has met its information requirements by mailing this kit to you. It is your responsibility to keep your enrollments up to date and to read all of the material so that you can make an informed decision about your future health care benefits.
Health Enrollment Cards
These ID cards, which are proof of your enrollment, are sent to you about three to four weeks after the effective date of your coverage, if you are newly enrolled. Your health plan creates the cards after receiving your enrollment information from the Benefits office. If you need additional cards, they can be requested directly from the health care plan you have selected. Please present this ID card whenever you request services from a doctor or hospital, as it will speed up your claim processing. You can obtain additional or replacement card by calling UnitedHealthcare directly or through their website.
If you enrolled in the Milwaukee County Choice Plus Plan, generally your doctor or hospital will submit their claim directly to the claims administrator if you show the office your health enrollment card which has billing Information on it. If you must submit a claim, please provide all the information requested on the claim form. It will speed up the processing of your claim.
All claims should be submitted as soon as possible after you have incurred the expense. All covered charges (except copays) will be applied to your individual and/or family deductibles. Once you have met the deductible, the claims administrator will make the appropriate payment directly to the provider unless you indicate on the claim form to pay you directly. You will receive an Explanation of Benefits (EOB) from the claims administrator in the mail. It is always a good practice to compare this EOB with any statements you have received. This helps you to determine what portion of the bill remains to be paid by you directly to the doctor or hospital. EOBs are also proof of medical expenses for tax purposes.
By law there is a certain provision in the oral surgery benefit levels that are covered and provided under your health insurance, not your dental insurance. It is always the patient's responsibility to fully understand their insurance coverage to maximize benefits under their plan.
Coordination of Benefits (Other than Medicare)
If you or your dependents are covered by other plans, such as additional group insurance, student coverage at a university, or no-fault auto coverage, total payments from all plans may be more than needed to cover the total expenses. Milwaukee County's Plan, like most other group medical plans, includes a Coordination of Benefits (COB) provision which enables you to recover as much of your medical care expenses as the coverage permits up to a maximum of 100% of expenses.
When a claim arises, submit the claim to the primary carrier. If you have a question about who the primary carrier is consult the claims administrator. If the claims administrator determines that another carrier is the primary carrier for your claim, the claim will be rejected for you to submit it to a different carrier. At least once a year the claims administrator will contact you by mail to determine if any other family members have health insurance in order to help minimize the County's medical costs and hence property taxes.
To help you determine who are the primary and secondary payers when both husband and wife have separate health plans, the following rules apply:
1. The employer's coverage is always primary on its employee.
2. Dependent Children. Payment order is based on birthdays rather than the gender of parents. T he plan of a parent with a birthday (month and day, not year) which occurs first in the calendar year will be the primary plan, i.e., pay its benefits first. Exceptions to the birthday rule determination will occur if t here is another plan covering the children (for example, a contract issued in another state) which does not contain the birthday rule. In this situation, the plan of the male covering the children will pay its benefits before the plan of the female.
3. Parents are divorced or separated. In this situation, the plan of the mother or stepfather with custody, or the plan of a parent with court ordered financial responsibility, will pay its benefits before the plan of the other parent.
If you sustain a claim due to an illness or injury caused by another party, or as a result of a work related illness or injury, your health plan will attempt to collect their paid claim expenses from the insurance carrier of the other party. It is required that you will cooperate with WPS in providing the necessary information in order for the plan to complete its investigation.
$500 Medical Insurance Waiver Award
Eligible employees can choose to waive their Milwaukee County medical coverage entirely if they have group coverage through a spouse or other employment. The $500 'Opt-Out' award is paid in April, July, September, or December. You must indicate your other coverage on the benefit enrollment system on the waiver page in order to receive the opt-out award.
An employee may re-enroll in any Milwaukee County medical plan during the year after proof and date of involuntary loss of the other medical coverage is provided and the $500 is paid back.