Health Insurance - Coverage

• Each year we receive a letter regarding the status of our dependent, who is a student. Where does this student status letter come from, the health plan or ETF?

  The individual health plans send out a student status letter annually to all subscribers with dependents who are dependent based on full-time student status.

• If hired prior to the first of the month and the health insurance application is completed by the first of the month, but the first day of work is actually after the first, for example the third of the month, can health insurance begin on the first of that month?

  No, coverage would begin the first of the following month. The WRS coverage effective date would be the employee's first day on the job for compensation, not the date the job was offered and accepted. You cannot have health insurance coverage prior to being WRS eligible, therefore, health insurance coverage would be effective the first of the month following the WRS coverage effective date.

• What is the effective date of family coverage when marriage occurs resulting in a switch from single to family health insurance coverage? When do family premiums begin?

  Family coverage is effective the date of the marriage. When the marriage occurs before the 16th of the month, family premiums are due for the month of the marriage. When the marriage occurs after the 15th of the month, family premiums are due for the following month. No preexisting condition clauses apply.

• What happens if a full-time student drops out of school mid-year, are they still covered until the end of the year?

  That depends upon the circumstances. Coverage for dependent children under 25 who drop out of school during the second semester (January - May) and who have all or most of their tuition refunded, are not eligible for coverage for that year until they are enrolled and attending school again.

• How and when can a health program option change be made, for example, if an employer wants to switch from a Traditional HMO option to a Deductible HMO option?

  The governing body of the employer would need to file a resolution, which must be received by ETF no later than October 1, for a January 1 effective date.

• When a marriage occurs after the 15th of the month, resulting in the employee switching from single to family coverage, when do family premiums begin?

  Regardless of what day in the month the marriage occurs, family coverage begins on the date of the marriage if an application switching from single to family is filed. Regarding premiums, when the marriage occurs after the 15th of the month, family premiums begin the 1st of the month following the marriage. When the marriage occurs prior to the 16th of the month, family premiums are due for the month of the marriage.

• Employee with single health insurance coverage is getting married on the 13th of the month. The husband has health coverage with another employer. Due to the marriage occurring prior to the 16th of the month, family premiums will be due for the month of the marriage. Can the family coverage begin the 1st of the next month to avoid double coverage and payment?

  No, if family coverage is elected it must begin on the qualifying event, i.e., the date of marriage. Another option to consider would be to keep the two single coverages until a child enters the picture. Otherwise, the family premium is required for the month of the marriage when the marriage occurs prior to the 16th of the month marriage, and single coverage payment would still be due on the other plan. Another option would be to cancel one single coverage prior to October 1st, buth that would involve the risk of no coverage for 13 days for the person who cancelled their single coverage.

• When an employee terminates toward the end of the month, and premiums for the next month have already been paid, do they have coverage for that next month or should the employer request a premium refund?

  An employee has health insurance coverage through the end of the month for which premiums have been paid.

• A newly hired employee is eligible for WRS and Health insurance coverage on their first day of work. The employee then terminates before being employed for 30 calendar days. What happens with their health insurance coverage? What if there were claims during that period?

  Employment of less than 30 calendar days makes that period ineligible for WRS coverage and their WRS account should be terminated accordingly (refer to WRS Administration Manual (ET-1127)) However, per Wis. Stat. 40.22 (6), an employee's employment that terminates after a period of service less than 30 calendar days can not affect their eligibility for health insurance coveage. Therefore, health insurance coverage is valid for that time period.

• When two members of a family have coverage under different health plans, how do the plans coordinate the benfit payment to the provider? Which is the primary plan? Do they use the birthdate rule?

  That's something worked out with the plans, not ETF.