Health Insurance - Eligibility

• Must seasonal employees be offered health insurance coverage? Many of our seasonal employees are students; how is health insurance handled when they return to school?

  Once an employee, including a seasonal employee, is WRS eligible, they must be offered all ETF administered insurances the employer participates in. The amount of the employer share of the health insurance premium can be as little as 25% if the seasonal employee works less than half-time, which is defined as 1,044 hours. The seasonal employee's employment status upon return to school dictates the options regarding health insurance. If considered on leave or layoff they can continue coverage by pre-paying the premiums to the employer and the employer will remit them to ETF along with the employer's share. If considered terminated they should be offered COBRA. If terminated, upon return to work they have a new health insurance enrollment option.

• A part-time employee declined our health insurance coverage when originally eligible due to being covered under their spouse's plan. The employee's spouse has now cancelled their health insurance with their employer. Can our employee now apply for coverage due to losing coverage under the spouse's plan?

  No, voluntary cancellation of other health insurance coverage does not create an enrollment opportunity for the dependent of that plan. However, if some other qualifying event occurs, such as a part-time employee whose hours increase so as to make them eligible for a greater employer share toward the premium.

• When a spouse who is the subscriber dies, is that considered loss of coverage?

  Yes, the widow(er) would have an enrollment opportunity.

• How many hours is considered less than half-time for determining employer share of health premiums?

  Half-time for local employers is defined as 1,044 hours, so less than half time would be anything less than 1,044 hours.

• A part-time employee with health insurance coverage cancelled their coverage and became coverered under their spouse's health insurance. The part-time employee's hours subsequently increased and they asked about re-enrolling. Does the increase in hours allow for a new enrollment opportunity?

  In this case, even though there was a previous cancellation of coverage, there is a new enrollment opportunity but only if the hours increase from less than half-time to half-time or greater. Half-time is defined as 1,044 hours.

• An employee previously declined health insurance coverage because they were covered under their spouse's plan. The spouse's employer subsequently stopped contributing to the premium. Does that create a health insurance enrollment opportunity for our employee?

  Yes. When the employer share toward the health insurance premium ends (not decreases) under the spouse's health insurance, your employee may take advantage of a 30 day enrollment period without waiting periods for pre-existing conditions.

• An employee elected single coverage because their spouse and dependents were covered under the spouse's health insurance plan. Ther spouse has now terminated their employment and gone to a new employer. Does that constitute a loss of coverage permitting our employee to switch to family coverage?

  Yes, employees enrolled in single coverage (though eligible for family coverage) may change to family coverage if any eligible dependents covered under another health plan lose eligibility for that coverage. So, even if the spouse goes to another employer who provides health insurance, this would be considered a loss of coverage event.

• An eligible employee declined ETF administered health insurance coverage because they had other comparable coverage. Due to that coveage being lost, they now want to apply for the group health insurance administered by ETF. Is something needed to substantiate the loss of coverage?

  Yes, when application is being made due to loss of other comparable coverage, the Health Insurance Application/Change Form (ET-2301) must be accompanied by documentation from the previous health plan that includes the reason for and date of the coverage loss.

• Can the employer pay varing premium percentages for different employee groups?

  Yes, as long as the employer pays at least the required minimum percentage of the premium for every covered employee.

• We have certain groups of employees who are under WRS but due to the limited number of hours we haven't offered them health insurance coverage. Can we offer them coverage now?

  First, all WRS eligible employees must be offered health insurance coverage and any other insurance administered by ETF. Coverage cannot be limited to a particular department, a classification of employee, special interest group, part-time versus full-time, or union contract group. If an employer failed to offer health insurance coverage to an otherwise eligible employee, the employee is limited to the Standard Plan with a 180 day waiting period for pre-existing conditions and hospitalization, unless some enrollment event occurs. There's no employer error provision for health insurance.

• When an employee is covered under their spouse's plan and the spouse's employer contribution to the premium decreases or the plan deductible increases, is that considered a loss of coverage that would allow the employee to enroll under the Wisconsin Public Employers Health Insurance program administered by ETF?

  No, the employer share would have to cease altogether otherwise it would be a voluntary cancel.

• If covered under the spouse's health insurance and the spouse switches jobs where the new employer's health insurance isn't available until after working 6 months, is that considered loss of coverage?

  Yes, that would constitute an event qualifying your employee for a health insurance enrollment opportunity.

• An insured employee is adopting and the adoption agency told the employee that health insurance typically won't cover the adopted child for several months following adoption; is that true?

  No, the Wisconsin Public Employers Group Health Insurance program covers an adopted child immediately upon adoption or placement for adoption.

• When an event occurs allowing a switch from family coverage to single coverage can a change in plans also be made?

  No. Plan changes can only occur during the annual Dual Choice period or if a move to a different county occurs.