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Health Insurance

Who is Eligible? 

Health insurance is available to regular employees who are scheduled to work 19 or more hours per week, or have a contract of at least 50%. The District offers comprehensive health insurance from two different providers for eligible employees. You may enroll in health insurance through either Group Health Cooperative of South Central Wisconsin (GHC) or Dean Health Plan. These carriers provide you with a diverse range of networks and providers, yet have the exact same type of coverage (co-pays, etc.), but with slightly different employee premiums (what you pay per period for your coverage). 

Plan Options

For either carrier (GHC or Dean Health Plan), you can enroll in the Health Maintenance Plan (HMO), the Point-of-Service Plan (POS) or the Preferred Provider Organization Plan (PPO). The PPO plan is only available to employees who do not live in South Central Wisconsin. The POS and PPO plans provide greater access to non-network services when referrals are not available. The POS and PPO plans have higher employee premiums and all out-of-network services are subject to an annual deductible and insurance co-pay.

The HMO plan allows you to use in-network providers – GHC Clinics, UW Hospital and Meriter Hospital on the GHC Plan and SSM/Dean Clinics and SSM Hospital for the Dean Plan. If you see an in-network provider, the plan covers all expenses (excluding copays). If you need to see an out-of-network provider, such as provider at Mayo Clinic or specialty care at another hospital, your primary doctor will request a referral to these providers. Normally, the referral is approved if there are no in-network providers that can treat the condition. 

Under the POS plan, you have the option to use in-network providers as above but you are also able to use out-of-network providers without pre-approval or a referral. With out-of-network providers, you have a $250 individual annual deductible and 20% co-insurance (you pay the first $250 of services and then 20% of everything after that). 

Some employees have elected the POS plan for the flexibility to see out-of-network providers, even if it may never happen. As a reminder, if you needed a referral to an out-of-network provider due to a medical condition that primary-care is unable to treat, you can request a referral to a specialist that can treat that condition. Other employees have selected the POS plan due to dependents who live outside of the area, such as college students, or due to significant family travel needs. The HMO plan covers urgent care and emergency care anywhere within the USA. If you or a family member needs urgent or emergency care, the HMO plan will cover those costs.  By enrolling the POS plan and not using out-of-network providers, you are incurring additional costs (higher premiums out of your paycheck and district resources) and you may be enrolled in a plan that doesn’t meet your medical needs.

There are, though, times where the POS plan may be the best plan to be enrolled in. But, be mindful that the premium contribution difference between the HMO and POS plan may be more than what it would cost you to pay for the out-of-network medical care out of your pocket (not through insurance).

There is also a large cost different, in employee premiums, between the HMO and POS plans, as you pay double the Employee Premium Contribution Percentage if enrolled in the POS plan.    

How Much Does it Cost?

Health insurance premiums are based on the carrier you select (GHC or Dean Health Plan), the plan type you choose (HMO or POS), the coverage tier (single/family) and your payroll frequency.  Your premium contribution rate is based on a sliding scale and varies by type of employee and plan type. Contributions for HMO plans are between 2.5% and 12% of the total monthly cost of the insurance. Contributions for POS plans are between 5% and 24%.  As a benefit to its employees, the District pays the remaining percentage. Premiums are paid by pre-tax payroll deductions. See the Resources box on this page to determine what your cost will be.

Additional Benefits

Listed below are some of the programs in place to help you utilize all of the benefits available through the health insurance plans:

Have Questions? Contact the Benefits Helpdesk at benefits@madison.k12.wi.us or at (608) 663-1692