This booklet has been developed to assist you in evaluating your health care options and to help guide you through the complexities of the benefits program. We have attempted to give you as much information as possible in the limited space available, but we could not include every detail of every plan. Actual benefits are determined by each of the plan contracts and those documents will prevail in any misinterpretation. This guide does not express all of the terms or conditions of those contracts. Therefore, if you have any questions concerning your benefits, please consult your contract, the Health Plan directly or call the Benefits Division at (608) 663-1746.
YOUR CHOICES
The Madison Metropolitan School District (MMSD) offers a choice of health insurance plans to you.
You may choose from Dean Health Plan HMO, Group Health Cooperative of South Central Wisconsin HMO (GHC-SCW HMO) or Unity HMO.
SELECTION PROCESS
To assist you in your selection process, the Benefit ComparisonGuide (pages 6-14) was developed. Refer to this section to compare the plans for which you are eligible and choose the plan that best fits your needs. Remember that each plan is different from the others, so you should determine whether the available physicians, premium level, benefit coverage, and type of health care delivery system are appropriate for you. All plans have some restrictions, exclusions, or limitations, so you should investigate all possibilities before making your choice. Feel free to call the Member Services Department of any plan should you have specific questions:
Dean:800-279-1301 GHC: 608-828-4853Unity: 1-800-362-3310
OUT-OF-AREA EMERGENCY CARE AND COVERAGE
Out of area urgent and emergency care is covered. Services with non-plan providers are subject to reasonable and customary charges. Members need to contact Member Services for their provider within 48 hours of the care. Any follow-up care would need prior authorization and will be covered at 50% of eligible charges. Non-Emergency care is not covered unless prior authorization has been approved. There is a $50.00 emergency room co-pay for all services unless you are admitted to the hospital.
All plans requires that you use approved facilities and physicians for urgent care, and whenever possible, for emergency (life threatening) care when in the service area. When temporarily more than 50 miles away, from your approved clinic, you may receive urgent care at any health care facility. It is necessary to notify GHC-SCW at 800-605-4327 Ext. 4514 within 48 hours when out-of-area care is received. Dean Health Plan at 800-279-1301and Unity at 800-362-3310.
WHO IS ELIGIBLE?
Any employee hired to work more than one-half time (19 or more hours per week or a 50% or more contract) is eligible to participate in the benefit plans and to receive Board of Education contribution to those plans.
WHEN DO YOU BECOME ELIGIBLE?
Most new employees become eligible forhealth, life, dental and long term care coverage on the first of the month following one month of employment. Example: If hired on September 17th, coverage begins November 1st. Employees who have their hours increased to more than half time become eligible the first of the month following one month of employment at the increased level
HOW TO ENROLL
Eligible employees (see above) must submit their applications within one month of their date of hireor date of increased hours to participate in the insurance plans in Initial Eligibility. You and your eligible dependents will be accepted into the plans without limitation or restriction if your application is received within that one-month time frame. Late applications will result in delayed enrollment between 3 months and one year, depending on the plan and may have to be approved through medical underwriting for some benefits.
Application forms are included in new employee orientation materials and some are also available on the “Staff Only” area of the District website https:hrweb.madison.k12.wi.us/empbenefits or through the Benefits Division at(608)663-1746.
ENROLLING DEPENDENTS
In order to be accepted eligible dependents must be enrolled under the same time-line as a new employee. These dependents will be enrolled through the same application as the employee.
New dependents acquired through marriage or partnership must be added to your plan within 30 days of the marriage or formation of partnership in order to avoid longer waiting periods and/or other coverage limitations/restrictions. If applications are received in a timely manner, coverage will be effective as of the date of the event.
New dependents acquired through birth or adoption must be added to your plan within 60 days of the date of birth or legal adoption placement date in order to avoid longer waiting periods and/or other coverage limitations/restrictions. If applications are received in a timely manner, coverage will be effective as of the date of the event.
SPECIAL RULES FOR MARRIED EMPLOYEES WHO BOTH WORK FOR THE DISTRICT
If two employees are married to each other, they are eligible for one family policy and one single policy underdental insurance. They are not eligible for two family policies under health or dental.
DESIGNATED FAMILY PARTNERS
Currently, all employee groups have insurance coverage options available for designated family partners. If you are interested in this coverage, call the Benefits Division at (608) 663-1746 for more information.
WHAT IF YOU DON'T ENROLL DURING INITIAL ELIGIBILITY?
If you, or your dependents, do not enroll in the benefits plans during Initial Eligibility and decide to enroll later, you and each of your dependents may have to submit health questionnaires, and/or may be subjected to longer waiting periods. In some situations, you may be considered ineligible for coverage.
There are three exceptions to this rule: 1. If you qualify for future OPEN ENROLLMENT (see OPEN ENROLLMENT section). 2. If you and/or your dependents are covered under another health/dental plan and that coverage is lost, you may enroll yourself and your eligible dependents into the MMSD plans without restrictions within 30 days of the loss of coverage. 3. If you are covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you may be accepted into the medical plan without a longer waiting period. Please contact the Benefits Division for further information.
ANNUAL OPEN ENROLLMENT - HEALTH INSURANCE ONLY
All eligible employees may participate in Open Enrollment for health insurance each year. (There is no annual open enrollment for any other benefit including dental insurance). The OpenEnrollment application period is October 15 through November 15 of each year with the insurance effective date being the following January 1. During this period, eligible employees without health insurance have the opportunity to enroll in the District group health plans just as if they were a new employee. Employees who currently have coverage may add any eligible, uncovered dependents during this time period. Details of the Annual Open Enrollment program are available to employees each year.
MAY I CHANGE MY HEALTH INSURANCE CARRIER?
Yes. Once each year, between mid October and early November, we have our Annual Choice period. During this timeeligible employees and their families, who are currently receiving health insurance through a participating District plan, may elect to switch to another available option for which they are eligible. New coverage becomes effective on January 1. Details of the Annual Choice program are available to employees each year. Should extenuating circumstances exist, the District has the right to extend the Annual Choice deadline. Employees will be notified of this extension should it occur.
HOW TO CANCEL COVERAGE
If, for some reason, you want to cancel your insurance coverage, you simply need to notify the Benefits Division, in writing, indicating that you wish to cancel coverage. This should only be done after careful consideration of your alternatives. Coverage will end the end of the month in which written request is received.
CANCELING DEPENDENTS
Should you desire to cancel dependent coverage on one or more dependents, you must complete new applications eliminating coverage on the affected dependents.
You must notify the benefits department within 30 days of an event such as Divorce or loss of
dependent status. You must complete a new application as required by the insurance company.
DENTAL COVERAGE
The District offers dental care coverage to eligible employees. Initial Eligibility follows the same enrollment criteria as medical insurance, see “WHO IS ELIGIBLE?”, “WHEN DO YOU BECOME ELIGIBLE?” and “HOW TO ENROLL.”. A summary of the plan is located on page 16 of this booklet.
There is noOpen Enrollment or Annual Choice with the Dental Plan. Those who apply for coverage after the Initial Eligibility period will be subject to a three-month delay in their coverage effective date, and may apply at anytime. Example:Initial Eligibility of September 10th. Application is received October 25, 15 days beyond the one-month enrollment period. Coverage would be effective as of January 1st (3 month delay).
One exception is if you and/or your dependents are covered under another dental plan and that coverage is lost, with proof of coverage loss, you may enroll yourself and your eligible dependents into the MMSD plan without restrictions within 30 days of the loss of coverage.
LIFE INSURANCE
Life insurance is available through the District. Separate Life brochures and related rate schedules are available within your new employee orientation materials or through the Benefits Division at 663-1697.Enrollment deadline for employees to receive guaranteed issue is within one month of the first day of work or date of eligibility. Enrollment for employees past this initial enrollment period is administered through medical underwriting.
LONG TERM CARE INSURANCE
The District offers long term care insurance to eligible employees, spouses, partners and other eligible family members. Enrollment deadline for employees to receive guaranteed issue is within one month of the first day of work or date of eligibility. Enrollment for employees past this initial enrollment period and for all eligible family members is administered through medical underwriting.
LONG TERM DISABILITY
The District also covers all eligible employees with LTD coverage. A separate plan description is available concerning this coverage. Coverage for the LTD plan is automatic on the first day of employment for all benefit eligible employees and is fully paid by the District.
TERMINATION OF COVERAGE
Health and Dental Insurance: Coverage extends through the month following termination of employment. Teachers who terminate at the end of a school year will have coverage through August of that year. All other employees terminating at the end of a school year have coverage through July of that year.
Life Insurance: Coverage extends through the month of termination of employment.
SUMMER RESIGNATIONS – Any school-year employee who resigns, retires or otherwise terminates during the summer will have their termination date backdated to the last day of work. All coverage extensions will be based on the last day worked.
COBRA AND WISCONSIN EXTENSION RIGHTS
Under most cases of termination or resignation, you and your dependents are eligible for insurance continuation coverage under COBRA and/or the Wisconsin Insurance Extension law. Should you or your family experience a qualifying event you must notify the Benefits Division (663-1746) to protect your COBRA and Wisconsin Insurance Extension rights. Insurance continuation information will be sent explaining your rights and benefits by the Benefits Division upon timely notification.
2013-2014 BENEFIT PLAN COSTS
July 1, 2013-June 30, 2014
EmployeePlan
Option /
SINGLE
MonthlyTotal / MMSD
Contribution / Employee
Deductible* / Employee
Payroll Deduction**
(See Below)
Dean Health Plan / $623.32 / $623.32 / See specific plan parameters for co-pays and deductibles / $0.00
Administrators $62.33
GHC-SCW / $474.21 / $474.21 / See specific plan parameters for co-pays and deductibles / $0.00
Administrators $47.42
Unity / $630.92 / $630.92 / See specific plan parameters for co-pays and deductibles / $0.00
Administrators $63.09
Delta Dental / $31.52 / $28.37 / $0.00 / $3.15
Employee
Plan
Option / FAMILY
Monthly
Total / MMSD
Contribution / Employee
Deductible* / Employee
Payroll Deduction**
(See Below)
Dean Health Plan / $1,639.33 / $1,639.33 / See specific plan parameters for co-pays and deductibles / $0.00
Administrators $163.93
GHC-SCW / $1,266.15 / $1,266.15 / See specific plan parameters for co-pays and deductibles / $0.00
Administrators $126.61
Unity / $1,659.32 / $1,659.32 / See specific plan parameters for co-pays and deductibles / $0.00
Administrators $165.93
Delta Dental / $81.72 / $73.55 / $0.00 / $8.17
**Administrators pay 10% of all eligible plans
Note: Rates for all medical plans are effective with June payroll deductions and rates for the dental plan are effective with July payroll deductions.
07-01-13
This benefit summary is intended only to highlight your benefits and should not be relied upon to fully determine your coverage. Please review your Member Certificate of Coverage for an exact description of the services and supplies that are covered, those that are excluded or limited, and other items and conditions of coverage.
Dean Member Certificate of Coverage can be found through DeanConnect at or to get a printed copy, call the Customer Care Center at 800-279-1301.”
GHC-SCW Member Certificate of Coverage and Benefit Summary can be found at or through MyChart. To receive a printed copy, call the GHC-SCW Member services at 828-4853.
Unity’s Member Certificate of Coverage can be found through MyUnity at . To receive a printed copy, call Unity Customer Service at 800-362-3310 Monday through Friday from 7am to 5pm.
BENEFIT COMPARISON GUIDE
Benefit
/ Group Health Cooperative-SCW / Dean Heath Plan / UnityHMO
/HMO
/HMO
Medical Reimbursement / Covered in full, except co-payments and limits in days or dollars where noted.No claim forms.
Out-of-area medically necessary urgent & emergency room care is covered. Member needs to contact GHC-SCW at 800-605-4327 within 48 hours or ASAP. Non-Urgent and Follow-up care while out of the service area is at 50% of eligible charges. Out-of area care must receive prior authorization.
Must call 800-605-4327 for Prior Authorization.
Policy Lifetime Maximum: No Limit / Covered in full, except co-payments and limits in days or dollars where noted. No referral is needed to any plan provider.Services with non-plan providers would need an approved referral prior to services being obtained.
Out of area urgent and emergency care is covered. Services with non-plan providers are subject to reasonable and customary charges. Member needs to contact Customer Service at 800-279-1301. Any follow-up care would need prior authorization.Will be covered at 50% of the maximum allowable fee.
Policy Lifetime Maximum: No Limit / Covered in full, except co-payments and limits in days or dollars where noted. No referral is needed to any plan provider.
If you obtain elective (non-emergency) services from a non-par provider, they must be prior authorized. Benefits will be limited to the usual, customary and reasonable charge.
If You receive Urgent or Emergency Services from a non-par provider, you must notify Unity at 800-362-3310 within 48 hours or as soon as is medically feasible. Benefits will be limited to the usual, customary and reasonable charge. Follow-up care provided by non-par providers requires prior authorization.
Policy Lifetime Maximum: No Limit
Hospitalization / Covered in full. Prior authorization is required .
Call GHC-SCW at 800-605-4327
Ext. 4514, within 48 hours of any out-of-area emergency hospital admit.
Any follow-up care must be preauthorized to be covered and will be covered at 50% of reasonable and customary / Covered in full. Prior authorization is required.
Call DEAN at 800-279-1301 within 48 hours of any out-of-area emergency hospital admission.
Any follow-up care must be preauthorized to be covered and will be covered at 50% of reasonable and customary / Covered in full. Prior authorization is required.
Call Unity at 800-362-3310 within 48 hours or as soon as is medically feasible for any out-of-area care. Benefits will be limited to the usual, customary and reasonable charge.
Any follow-up care at non-par providers must be preauthorized to be covered and will be covered at 100% of the usual, customary and reasonable charge.
Radiation Therapy/
Chemotherapy / Covered in full. / Covered in full / Covered in full.
Emergency Care / Subject to a $50 co pay. $50 co- pay waived if admitted to the hospital from the emergency room.
Contact GHC at 800-605-4327 within 48 hours of any out of area care. Follow up out-of -area care is covered at 50% of usual and customary with prior authorization / Subject to a $50 co-pay. $50 co-pay waived if admitted to the hospital from the emergency room
Call DEAN at 800-279-1301 within 48 hours of any out-of-area care.
Follow up care out-of-area is covered at 50% of usual and customary with pre-authorization / Subject to a $50 co-pay. $50 co-pay waived if admitted to the hospital from the emergency room
Call Unity at 800-362-3310 within 48 hours or as soon as is medically feasible for any out-of-area care. Follow-up care must be obtained at a participating provider.
Dependent Definition / Legally married spouse. Designated family partner meeting the definition outlined in District policy. Unmarried or married natural child, stepchild, or adopted child; or eligible partner’s natural child, stepchild, or adopted child to the end of the calendar year in which age 26 is attained. Grandchild eligible if dependent child is under the age of 18 years. Dependent child over limiting age is eligible if unable to provide own support due to physical or mental handicap, subject to GHC-SCW approval. / Legally married spouse. Designated family partner meeting the definition outlined in District policy. Unmarried or married natural child, stepchild, or adopted child; or eligible partner’s natural child, stepchild, or adopted child to the end of the calendar year in which age 26 is attained. Grandchild eligible if dependent child is under the age of 18 years. Dependent child over limiting age is eligible if unable to provide own support due to physical or mental handicap, subject to Dean approval. / Legally married spouse. Designated family partner meeting the definition outlined in District policy Unmarried or married natural child, stepchild, or adopted child; or eligible partner’s natural child, stepchild, or adopted child to the end of the calendar year in which age 26 is attained. Grandchild eligible if dependent child is under the age of 18 years. Dependent child over limiting age is eligible if unable to provide own support due to physical or mental handicap, subject to Unity approval.