Participation means providing evidence and testimony necessary to explain the claim decisions made by the CONTRACTOR. The CONTRACTOR shall be responsible for any cost required for participation in the administrative hearings by the CONTRACTOR’S staff and any approved subcontractors, including but not limited to time spent at the hearing and travel time to and from the hearing. 150F Privacy Breach Notification The CONTRACTOR shall comply with all state and federal laws regarding patient privacy, as well as the confidentiality provision of terms and conditions of the CONTRACT. In addition to (and in accordance with) the provisions of section 22 of the Department Terms and Conditions, the CONTRACTOR shall notify the DEPARTMENT Program Manager and Privacy Officer within twenty-four (24) hours of discovering that the protected health information (PHI) and/or personally identifiable information (PII) of one (1) or more PARTICIPANTS may have been breached, or has been breached, as defined by state and federal law, including , HIPAA, and GINA. The CONTRACTOR is required to report using the form provided by the DEPARTMENT. Even if the full details are not known, the CONTRACTOR must report all identified information to the DEPARTMENT, then follow up to provide additional information as details are known, and as requested by the DEPARTMENT. At a minimum, the CONTRACTOR shall report to the DEPARTMENT the following: A description of the incident(s). The identified root cause(s). The actual or estimated number of PARTICIPANTS impacted. The actual impact list (as soon as known). A copy of any correspondence sent to affected PARTICIPANTS (this must be pre-approved by the DEPARTMENT). A description of the steps taken to ensure a similar incident will not be repeated. This notification requirement shall apply only to PHI or PII received or maintained by the CONTRACTOR pursuant to this AGREEMENT. The CONTRACTOR shall make good faith efforts to communicate with the DEPARTMENT about breaches by major provider groups if the CONTRACTOR knows those breaches affect PARTICIPANTS. The CONTRACTOR shall notify the DEPARTMENT Program Manager and Privacy Officer no less than one (1) BUSINESS DAY before any external communications are made regarding a data breach. 150G Department May Designate Vendor At its discretion, the DEPARTMENT may designate a common vendor who shall provide the annual description of BENEFITS and such other information or services it deems appropriate, including audit services.
Medicare Enrollment Denial The CONTRACTOR notifies the DEPARTMENT in writing if Medicare does not allow an enrollment due to a PARTICIPANT’S residence in a given area. The notification must be provided within five (5) BUSINESS DAYS of the later of receipt of the DEPARTMENT’S enrollment file or notification by Medicare. See . See description Transition Plan The CONTRACTOR provides a comprehensive transition plan in a mutually agreed upon format that provides a timeline of major tasks, activities, and information that will be provided to the succeeding vendor when relinquishing responsibilities at termination of the CONTRACT. See . During the implementation period, upon DEPARTMENT request, and prior to CONTRACT termination 310B Deliverables to Participants Deliverable Description Frequency ID CARDS The CONTRACTOR provides PARTICIPANTS with ID CARDS indicating, at a minimum, the EFFECTIVE DATE of coverage, and the emergency room and office visit copayment amounts. See . Upon enrollment and BENEFIT changes that impact the information printed on the ID CARDS Participant Enrollment Information The CONTRACTOR provides the following information, at a minimum, to PARTICIPANTS upon enrollment: Information about PARTICIPANT requirements, including PRIOR AUTHORIZATIONS and referrals. The PARTICIPATING PHARMACY directory or directions on how to request a printed copy of the provider directory. Directions on how to access the PARTICIPATING PHARMACY directory on the CONTRACTOR’S website. The CONTRACTOR’S contact information, including the dedicated toll-free customer service phone number, business hours, twenty-four (24)-hour nurse line, and website address. See . Upon enrollment SUBSCRIBER Notification of Changes The CONTRACTOR issues written notice to PARTICIPANTS enrolled in its benefit plan(s) prior to the IT’S YOUR CHOICE OPEN ENROLLMENT period identifying those PARTICIPATING PHARMACIES that will not be in-network for the upcoming benefit period and including any language directed by the DEPARTMENT summarizing any BENEFIT or other PHARMACY BENEFIT PLAN changes. See . September
Except as specifically stated for EMERGENCY and URGENT CARE (see Sections and ), YOU do not have coverage for services from OUT-OF-NETWORK PROVIDERS unless YOU receive a PRIOR AUTHORIZATION from YOUR TPA before such services are obtained. The covered benefits are subject to the following: DEDUCTIBLES, COINSURANCE and COPAYMENTS as described in this schedule: Benefit: State of Wisconsin Eligible PARTICIPANTS who are not eligible for nor enrolled in MEDICARE as the primary payor3 MEDICARE prime PARTICIPANTS High DEDUCTIBLE Health Plan for eligible PARTICIPANTS 3 Annual Medical DEDUCTIBLE $250 Individual/$500 Family When an individual within a family plan meets the $250 DEDUCTIBLE, COINSURANCE will apply to covered medical services. Medical DEDUCTIBLE does not apply to office visit COPAYMENTS or prescription drugs. None The DEDUCTIBLE must be met before coverage begins. The DEDUCTIBLEs are:$1,500 per individual plan $3,000 per family plan DEDUCTIBLE includes prescription drugs and applies to (OOPL). Limit
Annual Medical COINSURANCE After DEDUCTIBLE: 90%/10% applies to medical services except for office visits, and as described below. COINSURANCE applies to Out-of-Pocket-Limit (OOPL) except as described below. 100% except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. After DEDUCTIBLE: 90%/10% applies to medical services except for office visits, and as described below. COINSURANCE applies to OOPL except as described below. Annual Medical OOPL $1,250 PARTICIPANT/$2,500 aggregate family limit except as described below.1 None except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. 1 After DEDUCTIBLE: $2,500 per individual plan $5,000 per family plan except as described below. Routine, preventive services as required by federal law 100% 100% 100% Primary Care Office Visit COPAYMENT applies to: Family Practice General Practice Internal Medicine Midwives Nurse Practitioners Physician Assistants Chiropractic Mental Health Physical Therapy Occupational Therapy Speech Therapy $15, DEDUCTIBLE need not be met first COPAYMENT applies towards meeting the annual OOPL, but not the DEDUCTIBLE No medical COPAYMENTs After DEDUCTIBLE: $15 Primary Care Office Visit COPAYMENT applies towards meeting the annual OOPL Specialist COPAYMENT Applies to: Specialists $25 per visit, DEDUCTIBLE need not be met first No medical COPAYMENTs After DEDUCTIBLE: $25 per visit
Annual Medical COINSURANCE 100% except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to (OOPL). After DEDUCTIBLE: 90%/10% applies to medical services except for office visits, and as described below. COINSURANCE applies to (OOPL) except as described below. 100% except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. After DEDUCTIBLE: 90%/10% applies to medical services except for office visits, and as described below. COINSURANCE applies to (OOPL) except as described below. Benefit: Participating Wisconsin Public Employer’s (WPE) WPE eligible PARTICIPANTS in (Program Option PO 2 and MEDICARE eligible and enrolled in PO 6 and PO 7) WPE eligible PARTICIPANTS in PO 6 who are not eligible for nor enrolled in MEDICARE as the primary payor3 WPE eligible PARTICIPANTS in PO 4 including MEDICARE eligible and enrolled High DEDUCTIBLE Health Plan WPE eligible (PO 7) PARTICIPANTS 3 Annual Medical OOPL (OOPL) None except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. 1 $1,250 aggregate family limit except as described below.1 After $500 per individual $1,000 aggregate per family DEDUCTIBLE, none except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. 1 After DEDUCTIBLE: $2,500 per individual plan $5,000 per family plan except as described below. Routine, preventive services as required by federal law 100% 100% 100% 100% Primary Care Office Visit COPAYMENT applies to: No medical COPAYMENTs $15, DEDUCTIBLE need not be met first No medical COPAYMENTs After DEDUCTIBLE: $15
Family Practice General Practice Internal Medicine Midwives Nurse Practitioners Physician Assistants Chiropractic Mental Health Physical Therapy Occupational Therapy Speech Therapy COPAYMENT applies towards meeting the annual OOPL, but not the DEDUCTIBLE Primary Care Office Visit COPAYMENT applies towards meeting the annual OOPL Benefit: Participating Wisconsin Public Employer’s (WPE) WPE eligible PARTICIPANTS in (Program Option PO 2 and MEDICARE eligible and enrolled in PO 6 and PO 7) WPE eligible PARTICIPANTS in PO 6 who are not eligible for nor enrolled in MEDICARE as the primary payor3 WPE eligible PARTICIPANTS in PO 4 including MEDICARE eligible and enrolled High DEDUCTIBLE Health Plan WPE eligible (PO 7) PARTICIPANTS 3 Specialist COPAYMENT Applies to: Specialists URGENT CARE No medical COPAYMENTs $25 per visit, DEDUCTIBLE need not be met first COPAYMENTS count towards meeting the OOPL, but not the DEDUCTIBLE No medical COPAYMENTs After DEDUCTIBLE: $25 per visit COPAYMENT applies towards meeting the annual OOPL ILLNESS/INJURY related services beyond the office visit COPAYMENT (if applicable) 100% After DEDUCTIBLE: 90% (10% member cost to OOPL) 100% After DEDUCTIBLE: 90% (10% member cost to OOPL) EMERGENCY Room Copay (Waived if admitted as an inpatient directly from the EMERGENCY room or for $60 $75 COPAYMENT to OOPL. After COPAYMENT, DEDUCTIBLE and (10% member cost to OOPL) $60 After DEDUCTIBLE, $75 to OOPL. After DEDUCTIBLE and copay 90% (10% member cost to OOPL)