NA 4 Rates Local Deductible Plan PO4
User Manual: NA-4
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EMPLOYEE AND NON-MEDICARE RETIREE RATES The employee and non-Medicare Retiree1 health plan rates on this page and Medicare Retiree Rates on the back of this sheet reflect total monthly premium rates for each health plan. See footnotes below and on the back of this sheet for more information. Medical with Dental Single Family Medical without Dental Single Family Anthem Blue Preferred Northeast 691.90 1,720.90 665.60 1,655.20 Anthem Blue Preferred Southeast 769.00 1,913.60 742.70 1,847.90 Arise Health Plan 1,011.80 2,520.60 985.50 2,454.90 Arise Health Plan - Aspirus Arise 968.60 2,412.60 942.30 2,346.90 Dean Health Insurance 713.30 1,774.40 687.00 1,708.70 Dean Health Insurance - Prevea360 691.20 1,719.10 664.90 1,653.40 GHC of Eau Claire 980.60 2,442.60 954.30 2,376.90 GHC of South Central Wisconsin 640.30 1,591.90 614.00 1,526.20 Gundersen Health Plan 775.00 1,928.60 748.70 1,862.90 Health Tradition Health Plan 681.90 1,695.90 655.60 1,630.20 HealthPartners Health Plan 873.90 2,175.90 847.60 2,110.20 Humana - Eastern 1,131.50 2,819.90 1,105.20 2,754.20 Humana - Western 1,182.00 2,946.10 1,155.70 2,880.40 IYC Access Health Plan - Balance of State5 1,178.30 2,939.50 1,152.00 2,873.80 IYC Access Health Plan - Dane6 1,096.10 2,734.00 1,069.80 2,668.30 IYC Access Health Plan - Milwaukee 1,270.60 3,170.20 1,244.30 3,104.50 IYC Access Health Plan - Waukesha 1,178.30 2,939.50 1,152.00 2,873.80 NA4 NA4 NA4 NA4 Medical Associates Health Plans 644.30 1,601.90 618.00 1,536.20 MercyCare Health Plans 674.60 1,677.60 648.30 1,611.90 Network Health - Northeast 734.30 1,826.90 708.00 1,761.20 Network Health - Southeast 781.50 1,944.90 755.20 1,879.20 Physicians Plus 693.20 1,724.10 666.90 1,658.40 1,013.50 2,524.90 987.20 2,459.20 State Maintenance Plan (SMP) 792.50 1,974.30 766.20 1,908.60 UnitedHealthcare of Wisconsin 870.00 2,166.10 843.70 2,100.40 Unity Health Insurance - Community 659.30 1,639.40 633.00 1,573.70 Unity Health Insurance - UW Health 605.60 1,505.10 579.30 1,439.40 WEA Trust - East 787.50 1,959.90 761.20 1,894.20 WEA Trust - Northwest Chippewa Valley 994.70 2,477.90 968.40 2,412.20 WEA Trust - Northwest Mayo Clinic Hlth. Sys. 994.70 2,477.90 968.40 2,412.20 WEA Trust - South Central 608.60 1,512.60 582.30 1,446.90 Health Plan Name 7 8 IYC Medicare Plus4 Security Health Plan NA = not applicable 1 Members of new participating employers may have a surcharge added to their rates. Your employer will inform you. Contact your payroll office with questions. 2 Medicare 1 = Family coverage with at least one insured family member enrolled in Medicare Parts A, B and D. 3 Medicare 2 = Family coverage with all insured family members enrolled in Medicare Parts A, B and D. 4 Members with IYC Access Health Plan or SMP coverage who become enrolled in Medicare Parts A and B will automatically be moved to the IYC Medicare Plus plan. All other non-Medicare family members remain covered under the IYC Access Health Plan or SMP. Local Deductible Plan (Revised 9/16/15) It’s Your Choice 2016 MEDICARE RETIREE RATES Medical with Dental Single Medicare Medicare 12 23 Health Plan Name Medical without Dental Single Medicare Medicare 23 12 Anthem Blue Preferred Northeast 566.50 1,252.50 1,140.20 540.20 1,199.90 1,074.50 Anthem Blue Preferred Southeast 605.10 1,368.20 1,217.40 578.80 1,315.60 1,151.70 Arise Health Plan 726.50 1,732.40 1,460.20 700.20 1,679.80 1,394.50 Arise Health Plan - Aspirus Arise 704.90 1,667.60 1,417.00 678.60 1,615.00 1,351.30 Dean Health Insurance 570.30 1,277.70 1,147.80 544.00 1,225.10 1,082.10 Dean Health Insurance - Prevea360 559.80 1,245.10 1,126.80 533.50 1,192.50 1,061.10 GHC of Eau Claire 609.50 1,584.20 1,226.20 583.20 1,531.60 1,160.50 GHC of South Central Wisconsin 540.70 1,175.10 1,088.60 514.40 1,122.50 1,022.90 Gundersen Health Plan 498.70 1,267.80 1,004.60 472.40 1,215.20 938.90 Health Tradition Health Plan 641.80 1,509.80 1,290.80 518.80 1,168.50 1,031.70 HealthPartners Health Plan 641.80 1,509.80 1,290.80 615.50 1,457.20 1,225.10 Humana - Eastern 434.10 1,559.70 875.40 407.80 1,507.10 809.70 434.10 1,610.20 875.40 407.80 1,557.60 809.70 4 1,606.50 NA4 NA4 NA4 1,524.30 NA4 1,751.40 NA4 NA4 1,698.80 NA4 NA4 1,659.10 NA4 NA4 1,606.50 NA4 IYC Medicare Plus4 480.80 NA4 970.20 454.50 NA4 904.50 Medical Associates Health Plans 454.90 1,093.30 917.00 428.60 1,040.70 851.30 MercyCare Health Plans 536.30 1,205.00 1,079.80 510.00 1,152.40 1,014.10 Network Health - Northeast 587.70 1,316.10 1,182.60 561.40 1,263.50 1,116.90 Network Health - Southeast 611.30 1,386.90 1,229.80 585.00 1,334.30 1,164.10 Physicians Plus 567.20 1,254.50 1,141.60 540.90 1,201.90 1,075.90 Security Health Plan 616.80 1,624.40 1,240.80 590.50 1,571.80 1,175.10 State Maintenance Plan (SMP) NA4 1,273.30 NA4 NA4 1,220.70 NA4 UnitedHealthcare of Wisconsin 634.60 1,498.70 1,276.40 608.30 1,446.10 1,210.70 Unity Health Insurance - Community 524.10 1,177.50 1,055.40 497.80 1,124.90 989.70 Unity Health Insurance - UW Health 499.90 1,099.60 1,007.00 473.60 1,047.00 941.30 WEA Trust - East 516.50 1,298.10 1,040.20 490.20 1,245.50 974.50 WEA Trust - NW Chippewa Valley 589.10 1,577.90 1,185.40 562.80 1,525.30 1,119.70 WEA Trust - NW Mayo Clinic Hlth. Sys. 589.10 1,577.90 1,185.40 562.80 1,525.30 1,119.70 WEA Trust - South Central 453.90 1,056.60 915.00 427.60 1,004.00 849.30 Humana - Western IYC Access Health Plan - Balance of State NA 4 1,659.10 NA IYC Access Health Plan - Dane6 NA4 1,576.90 IYC Access Health Plan - Milwaukee7 NA4 IYC Access Health Plan - Waukesha8 5 4 NA IYC Access Health Plan rates are determined by the employer county or the retiree county of residence. Counties are divided into the following rate categories: 5 Balance of State: All other Wisconsin counties not listed below. (Code A4) 6 Dane: Dane, Grant, Jefferson, La Crosse, Polk and St. Croix. (A1) 7 Milwaukee: Milwaukee County. Also applies to retirees and continuants living out of state. (A2) 8 Waukesha: Kenosha, Ozaukee, Racine, Washington and Waukesha. (A3) Local Deductible Plan (Revised 9/16/15) It’s Your Choice 2016
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