Health Insurance

Your Choices

The Madison Metropolitan School District (MMSD) offers three different medical plans to its employees. However, not every plan is available to every employee, and the costs of plans vary.

If you are an MTI-represented employee, you may choose from either Group Health Cooperative HMO (GHC) or Wisconsin Physicians Service Statewise PPO (WPS).

If you are an Administrative, AFSCME, Building Trades, or other non-MTI employee, you may choose from either Group Health Cooperative HMO (GHC) or The Alliance PPO.

Selection Process

To assist you in your selection process, the Benefit Comparision Guide (below) 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:

WPS: 221-7058
The Alliance: 800-221-7038
GHC: 828-4853

Out-of-Area Emergency Care and Coverage

WPS & The Alliance cover emergency care without regard to the specific facility or doctor providing that care. However, if the care is not considered an acute emergency, deductibles and co-pays will be enforced under both plans.

Emergency care can be received from the closest facility regardless of your location. It is necessary to notify GHC at 800-605-4327 Ext. 4514 within 48 hours when out-of-area care is received. GHC 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.

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. In addition, Substitute Teachers working a minimum of 1 day per month are eligible for long-term care, medical and dental coverage and Substitute SEA's are eligible for medical coverage if they pay the entire premium cost.

When do you Become Eligible?

Most new employees become eligible for long-term care, medical, life and dental 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. New teachers and temporary contract teachers with a 50% or more contract hired for the fall semester become eligible on September 1 if they submit their plan applications by the end of New Teacher Orientation Day, usually in August. Applications received after New Teacher Orientation Day are effective 1st of the month following one month of employment. New substitute teachers become eligible on the first of the month following one month after their first assignment and must apply for coverage within one month of that first assignment.

2006-07 BENEFIT PLAN COSTS
July 1, 2006 - June 30, 2007

Employee Plan Option	SINGLE
Employee Plan Option	Monthly Total	MMSD Contribution	Employee Deductible* (see below)	Employee Payroll Deduction*** (see below)
The Alliance	$529.00	$502.55	In Network $0.00 Out of Network $250 Individual	$26.45**
GHC	$345.15	$345.15	$0.00	$0.00
WPS	$656.53	$590.88	In and Out of Network $300 Individual	$65.65
Delta Dental	$29.01	$26.11	$0.00	$2.90
Employee Plan Option	FAMILY
Employee Plan Option	Monthly Total	MMSD Contribution	Employee Deductible* (see below)	Employee Payroll Deduction*** (see below)
The Alliance	$1246.35	$1254.95	In Network $0.00 Out of Network $250 Individual/$500 Family	$66.05**
GHC	$921.55	$921.55	$0.00	$0.00
WPS	$1721.80	$1549.62	In and Out of Network $300 Individual/$600 Family	$172.18
Delta Dental	$75.22	$67.70	$0.00	$7.52

* All deductibles are payable as claims are incurred.
** Administrators pay premium as of 8/1/04.
*** Substitutes pay full monthly cost of all insurance.

Note: Rates for all medical plans are effective with June payroll deductions and rates for the dental plan are effective with July payroll deductions.

BENEFIT COMPARISON GUIDE

Benefit	The Alliance PPO		Group Health	WPS Statewide PPO
Benefit	In-Network	Out-of-Network	Group Health	In-Network	Out-of-Network
Medical Reimbursement	Co-payments and limits in days or dollars where noted.	All out-of-network covered expenses are subject to a $250 calendar year deductible per person (limit $500 per family) and are then payable at 80% of the first $5,000 then 100% in a calendar year. Maximum out-of-pocket expenses due to deductibles and co-insurance is $1,250 per person but no more than $2,500 per family.	As long as care is provided through GHC primary care provider or referral there are no deductibles or co-payments. No limits in days or dollars of coverage, except where noted. No claim forms. Put-of-area medically necessary urgent and emergency room care is covered. Member needs to contact GHC at 800-605-4327. Follow-up medical care will be covered at 50% of eligible charges. Out-of-area care must receive prior authorization.	Policy year deductible is $300 single, $600 family. Copayments and limitatrions on dollars and days where noted. Prescription drug and mental/nervous, alcohol/drug expenses due are not counted toward deductible or out of pocket maximum.	All out of network charges are subject to a 20% co-insurance after satisfying the $300 single or $600 family deductible. Maximum out of pocket expenses due to deductibles and co-insurance are $800 single and $1600 family. Prescription drug and mental/nervous, alcohol/drug expenses due are not counted toward deductible or out of pocket maximum.
Hospitalization	100% usual, customary and reasonable charges. Pre-admission certification is required.	Subject to deductible and co-insurance. Pre-admission certification is required.	Covered in full. Call GHC at 800-605-4327 Ext. 4514 within 48 hours of any out-of-area emergency hospital admission.	Subject to deductible. Semi-private room and miscellaneous hospital expenses for 365 days per confinement are covered. 3 business day prior pre-admission certification required.	Subject to deductible and coinsurance. Semi-private room and miscellaneous hospital expenses for 365 days per confinement are covered. 3 business day prior pre-admission certification required.
Surgical-Medical Care	100% usual, customary and reasonable charges.	Subject to deductible and co-insurance.	Covered in full.	Subject to deductible.	Subject to deductible and coinsurance.
Maternity	100% usual, customary and reasonable charges.	Subject to deductible and co-insurance.	Covered in full.	Subject to deductible.	Subject to deductible and coinsurance.
Physician Visits in Hospital	100% usual, customary and reasonable charges.	Subject to deductible and co-insurance.	Covered in full.	Subject to deductible.	Subject to deductible and coinsurance.
X-Ray and Lab Test	100% usual, customary and reasonable charges.	Subject to deductible and co-insurance.	Covered in full.	Subject to deductible.	Subject to deductible and coinsurance.
Radiation Therapy/ Chemotherapy	100% usual, customary and reasonable charges.	Subject to deductible and co-insurance.	Covered in full.	Subject to deductible.	Subject to deductible and coinsurance.
Emergency Care	100% usual, customary and reasonable charges.	Covered at 100% usual, customary and reasonable charges for emergency procedures for participant while he/she is not confined in a hospital.	Life threatening emergencies covered in full, contact GHC within 48 hours. Please refer to reference card in Provider Directory for examples.	Subject to deductible.	Subject to deductible and coinsurance.
Dependent Definition	Legally married spouse. Designated family partner meeting the definition outlined in District plan. Unmarried 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 25 is attained. Dependent child must be a full time student or supported more than 50% by parent(s). 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.	Legally married spouse. Designated family partner meeting the definition outlined in District plan. Unmarried 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 25 is attained. Dependent child must be a full time student or supported more than 50% by parent(s). 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.	Legally married spouse. Designated family partner meeting the definition outlined in District plan. Unmarried 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 25 is attained. Dependent child must be a full time student or supported more than 50% by parent(s), not married and not eligible for health insurance through an employer. 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 approval.	Legally married spouse. Designated family partner meeting the definition outlined in District plan. Unmarried 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 25 is attained. Dependent child must be a full time student or supported more than 50% by parent(s). 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.	Legally married spouse. Designated family partner meeting the definition outlined in District plan. Unmarried 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 25 is attained. Dependent child must be a full time student or supported more than 50% by parent(s). 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.
Physicians Office Visits	100% usual, customary and reasonable charges.	Subject to deductible and co-insurance.	Covered in full.	Subject to deductible.	Subject to deductible and co-insurance.
Regular Examinations	100% usual, customary and reasonable charges.	Subject to deductible and co-insurance.	Covered in full.	Subject to deductible.	Subject to deductible and co-insurance.
Pediatric Care	100% usual, customary and reasonable charges.	Subject to deductible and co-insurance.	Covered in full.	Subject to deductible.	Subject to deductible and co-insurance.
Immunizations	100% usual, customary and reasonable charges.	100% usual, customary and reasonable charges.	Covered in full. Travel Immunizations: contact GHC at 828-4853 directly for restrictions and co-payments pertaining to travel-related drugs.	Subject to deductible.	Subject to deductible and co-insurance.
Injections	100% usual, customary and reasonable charges.	Subject to deductible and co-insurance.	Covered in full.	Subject to deductible.	Subject to deductible and co-insurance.
Skilled Nursing Home	100 days per confinement at 100% usual, customary and reasonable charges.	100 days per confinement at 100% usual, customary and reasonable charges.	100 days per calendar year at 100%.	90 days/confinement subject to deductible	90 days/confinement subject to deductible and coinsurance
Psychiatric Care Outpatient/ Inpatient	Outpatient: Maximum 18 visits per calendar year at 100%. Inpatient: 20 days per calendar year covered at 100%. Transitional: Limited to 15 days per calendar year at 100%.	Outpatient: Maximum 18 visits per calendar year at 100%. Inpatient: 20 days per calendar year at 100%. Transitional: Limited to 15 days per calendar year at 100%.	Outpatient: Maximum 20 visits per calendar year. Includes all state mandates. Inpatient: 30 days per calendar year covered at 100%. Limited to $6,300 if out-of-area emergency. Transitional: Limited to 15 days per calendar year.	Outpatient: 100% of first $1,000 per policy year, subject to and in conjunction with the first 10-hour lifetime maximum benefit limit. 90% of the next $1,000 then 75% of the remaining charges thereafter per policy year. Inpatient: 100% of semi-private room and miscellaneous hospital expenses for 365 days per confinement less any state mandated benefit.	Outpatient: 100% of first $1,000 per policy year, subject to and in conjunction with the first 10-hour lifetime maximum benefit limit. 90% of the next $1,000 then 75% of the remaining charges thereafter per policy year. Inpatient: 90% of semi-private room and miscellaneous hospital expenses for 365 days per confinement less any state mandated benefit.
Alcohol & Drug Abuse Outpatient/ Inpatient	Outpatient: $1,800 per calendar year. Inpatient: $6,300 per calendar year or 30 days, whichever is less. Transitional: $2,700 per calendar year. Maximum combined benefit of $6,300 per calendar year.	Outpatient: $1,800 per calendar year. Inpatient: $6,300 per calendar year or 30 days, whichever is less. Transitional: $2,700 per calendar year. Maximum combined benefit of $6,300 per calendar year.	Outpatient: Maximum of $1,800 in billed services per calendar year. Inpatient: Lesser of 30 days per calendar year covered at 100% or $6300 per calendar year. Transitional: Maximum combined benefit of $6,300 per calendar year.	Outpatient: This is a combined benefit with psychiatric care. Inpatient: 100% of charges up to the lesser of the charges for the first 30 days of the confinement or $7,000 in charges for such services each policy year. Transitional: 90% of the first $3,000 in charges each policy year, then 75% of charges thereafter. Any additional benefits payable will not apply to the maximum stated below. Total benefits shall not exceed $8,000 per member.	Outpatient: This is a combined benefit with psychiatric care. Inpatient: 100% of charges up to the lesser of the charges for the first 30 days of the confinement or $7,000 in charges for such services each policy year. Transitional: 90% of the first $3,000 in charges each policy year, then 75% of charges thereafter. Any additional benefits payable will not apply to the maximum stated below. Total benefits shall not exceed $8,000 per member.
Vision Exams	Charges covered in full by listed provider. Non-listed optometrists covered in full. Limited to one exam per year.	100% usual, customary and reasonable charges. Limited to one exam per year.	Covered in full at GHC Optometry Dept. Note: $30.00 Contact Lens fitting fee is patient's expense.	Subject to deductible.	Subject to deductible and coinsurance.
Ambulance Service	100% of usual, customary and reasonable charges for licensed professional ambulance services for emergency medical care and transportation to the nearest hospital where appropriate medical care is available.	100% of usual, customary and reasonable charges for licensed professional ambulance services for emergency medical care and transportation to the nearest hospital where appropriate medical care is available.	Covered in full.	Subject to deductible. Licensed professional ambulance services for emergency medical care and transportation to the nearest hospital where appropriate medical care is available.	Subject to deductible. Licensed professional ambulance services for emergency medical care and transportation to the nearest hospital where appropriate medical care is available.
Home Care Benefit	50 visits maximum per calendar year. If terminally ill, an additional 40 visits are payable.	Subject to deductible and co-insurance. 50 visits maximum per calendar year. If terminally ill, an additional 40 visits are payable.	Covered in full when provided by a home health agency approved by GHC. (Homemakers services not included.)	40 visits maximum per calendar year. Subject to deductible.	40 visits maximum per calendar year. Subject to deductible and coinsurance.
Preventative Dental Care	Not covered.	Not covered.	Cleaning and Fluoride treatments twice a year for all family members. Covered in full.	Not covered.	Not covered.
Blood and Blood Plasma	Covered in full.	Subject to deductible and co-insurance.	Processing/administration and derivatives covered. Blood is covered. Autologous transfusion and storage will be a covered benefit.	Subject to deductible.	Subject to deductible and coinsurance.
Prosthetic Devices, Medical Supplies, Durable Medical Equipment (DME)	Covered at 100% of usual, customary and reasonable charges for specific supplies.	Subject to deductible and co-insurance.	GHC pays 80%, Member pays 20%. DME, non-diabetic Disposable supplies, and Prosthetic Appliances have a combined maximum out-of-poscket limit of $2,500 per member per calendar year. After the $2,500 maximum out-of-pocket limit GHC will pay 100% of prior authorized items. Prior authorization is required.	Subject to deductible.	Subject to deductible and coinsurance.
Extraction and Replacement of Teeth/Injury Services	100% of usual, customary and reasonable charges for extraction of seven or more natural teeth at one time; and repair of sound natural teeth due to injury, provided treatment begins within 90 days of injury.	100% of usual, customary and reasonable charges for extraction of seven or more natural teeth at one time; and repair of sound natural teeth due to injury, provided treatment begins within 90 days of injury.	Extractions and replacement of natural teeth due to accidental injury up to $1,500 per accident. Care must be initiated within ninety (90) days of the accident. Physical Therapy evaluation is required for treatment for TMJ before an intraoral splint is considered as a treatment option.	Subject to deductible. Dental repair of sound natural teeth due to injury, provided treatment begins within six (6) months of injury.	Subject to deductible and coinsurance. Dental repair of sound natural teeth due to injury, provided treatment begins within six (6) months of injury.
Cardiac Rehabilitation	Covered at 100% of usual, customary and reasonable charges. Outpatient cardiac rehabilitation is limited to phase II only, for 48 sessions per covered illness. Must be started within 21 days of discharge.	Subject to deductible and co-insurance. Outpatient cardiac rehabilitation is limited to phase II only, for 48 sessions per covered illness. Must be started within 21 days of discharge.	Limited to 36 sessions in a 12-week period following hospitalization. Must be approved by GHC.	Subject to deductible. Maximum of 48 supervised sessions for specific conditions. Must be started within 21 days of discharge.	Subject to deductible and coinsurance. Maximum of 48 supervised sessions for specific conditions. Must be started within 21 days of discharge.
Hearing Exams	Exams covered. Hearing aid(s) not covered.	Subject to deductible and co-insurance. Hearing aid(s) not covered.	Exams covered. Hearing aids: including initial evaluation and fitting of the hearing aid, will be covered at 50% of cost up to a max of $1000 per hearing aid. Limit one every 36 months.	Subject to deductible. Hearing aids not covered.	Subject to deductible and coinsurance. Hearing aids not covered.
Chiropractic Coverage	Covered as any other covered professional service.	Subject to deductible and co-insurance.	Covered in full at GHC contracted providers.	Subject to deductible. As any other covered professional service.	Subject to deductible and coinsurance. As any other covered professional service.
Transplants	Includes Medically Necessary transplants of kidney, non-experimental / investigational bone marrow, heart, heart/lung, liver and pancreas. Does not include purchase price of organ. Lifetime maximum of $500,000.	Subject to deductible and co-insurance. Includes Medically Necessary transplants of kidney, non-experimental / investigational bone marrow, heart, heart/lung, liver and pancreas. Does not include purchase price of organ. Lifetime maximum of $250,000.	Organ transplants limited to bone marrow, cornea, heart, heart/lung, kidney, liver, and pancreas in certain conditions. Subject to the approval of the Medical Director. Subject to $1,000,000 lifetime maximum benefit except as required for the treatment of kidney disease.	Subject to deductible. Limited to bone marow, corneal grafts, artificial limbs, eyes and kidney. $250,000 lifetime maximum for heart, lung, liver, pancreas, and heart/lung transplants. Preauthorization required.	Subject to deductible and coinsurance. Limited to bone marow, corneal grafts, artificial limbs, eyes and kidney. $250,000 lifetime maximum for heart, lung, liver, pancreas, and heart/lung transplants. Preauthorization required.
Acupuncture or Complimentary Services	Not covered.	Not covered.	Complimentary Services of Acupuncture, Massage Therapy, Stress Reduction, Yoga, Tai Chi, Movement Therapy, Lifestyle Change Classes, and more, as outlined in the Member Certificate Complimentary Medicine professional services, when provided by a GHC owned and operated facility will be covered at 50% of the first $500 in eligible charges, with a maximum payment by GHC of $250 per calendar year.	Acupuncture: Subject to deductible. Preauthorization is recommended after 17 visits.	Subject to deductible and coinsurance. Preauthorization is recommended after 17 visits.
Involuntary Infertility	Charges limited to infertility diagnostic service only. Artificial insemination is excluded.	Subject to deductible and co-insurance. Charges limited to infertility diagnostic service only. Artificial insemination is excluded.	Covered within the limits of the policy. Please refer to certificate. Limited to 50% of Covered Expenses up to a Lifetime Benefits Maximum for each Member of $30,000 with a maximum payment by GHC of $15,000.	100% of charges limited to infertility diagnostic service only.	100% of charges limited to infertility diagnostic service only.
Prescription Drugs	Legend drugs $6 co-pay prescription or refill for generic. Brand name drugs $12 prescription or refill. 34-day supply; 90-day supply for maintenance drugs. Insulin and Diabetic supplies - $10 copay. Oral contraceptives are included.	Legend drugs $6 co-pay prescription or refill for generic. Brand name drugs $12 prescription or refill. 34-day supply; 90-day supply for maintenance drugs. Insulin and Diabetic supplies - $10 copay. Oral contraceptives are included.	Legend drugs $6 co-prescription or refill for generic. Brand name drugs $12 prescription or refill. 1 co-pay for each 30 day supply. Co-payments for insulin prescriptions are limited up to a 30-day supply per prescription. Prescriptions must be purchased at GHC designated pharmacies. Includes oral contraceptives. Most prescriptions limited to a 30-day supply. Oral contraceptives available in a 90-day supply. Brand name prescription drug buy-option: if a member requests a brand name drug when its generic is available the member will be responsible for the difference in cost between the brand name and generic drugs, as well as the applicable brand name co-payment. New-Effective 7/1/06 GHC will offer a new program that allows qualifying drugs to be obtained from GHC mail pharmacy in 90-day quantities at a cost of only two co-payments instead of three, when program guidlines are followed. See program guidelines or call GHC Mail Pharmacy at 608-441-3289 or GHC Member Services at 608-828-4853.	Legend drugs $6 co-pay prescription or refill for generic. Preferred brand name drugs $15 co-pay prescription or refill. All other brand name drugs $25 co-pay prescription or refill. $250 annual maximum for brand name drugs on the third tier for which there is not a generic or 2nd tier drug available. 90 day supply. Oral contraceptives are covered. Insulin supplies are covered with no co-pay.	Legend drugs $6 co-pay prescription or refill for generic. Preferred brand name drugs $15 co-pay prescription or refill. All other brand name drugs $25 co-pay prescription or refill. $250 annual maximum for brand name drugs on the third tier for which there is not a generic or 2nd tier drug available. 90 day supply. Oral contraceptives are covered. Insulin supplies are covered with no co-pay.

This information is provided 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. This guide does not express all of the terms or conditions of those contracts. Therefore, if you have any questions concerning your benefits, please call the Benefits Division at 663-1746.

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Last updated: October 5, 2006 7:12 AM
Editor & Publisher: Christina Anderson
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