This Plan is a health maintenance organization (HMO). OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Group Health Cooperative of South Central Wisconsin holds the following accreditations: Health Plan Accreditation for Commercial HMO, Marketplace HMO, the local plans and the vendor that supports Group Health Cooperative of South Central Wisconsin holds accreditation from NCQA. To learn more about this plan’s accreditation(s), please visit the following websites: National Committee for Quality Assurance (www.ncqa.org).
We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory. We give you the choice of enrollment in a High Option or a Standard Option.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.
General features of our High Option and Standard Options
High Option Overview
- $0 Deductible
- $0 primary care provider office copayment
- $10 specialist office copayment. Nothing up to age 18.
- $10 urgent care copayment
- $75 emergency room copayment
- Pharmacy: Tier 1 $5; Tier 2 $20; Tier 3 $50; Tier 4 $100
Maximum-out-of-pocket: $7,150 Self only; $14,300 Self Plus One and Self and Family
Standard Option Overview
- Deductible: $1,000 Self Only; $2,000 Self Plus One and Self Plus Family
- 20% Coinsurance after Deductible
- $20 primary care provider office copayment. Nothing up to age 18.
- $40 specialist office copayment. Nothing up to age 18.
- $40 urgent care copayment
- $100 emergency room copayment
- Pharmacy: Tier 1 $5; Tier 2 $20; Tier 3 $50; Tier 4 $100
Maximum-out-of-pocket: $7,150 Self only; $14,300 Self Plus One and Self and Family
Our HMO offers benefits for covered services in a primary care setting and requires a referral to see specialty providers. There are no out-of-network benefits except for urgent/emergent issues while traveling outside of the service area.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).
Your Rights and responsibilities
OPM requires that all FEHB plans provide certain information to their FEHB members. You may request information about us, our networks, and our providers. OPM’s FEHB website (www.opm.gov/insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.
- Years in existence 48 (first clinic opened in 1976)
- Profit status Non-profit
You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, Group Health Cooperative-SCW www.ghcscw.com. You can also contact us to request that we mail a copy to you.
If you want more information about us, call 608-828-4853 or 800 605-4327, or write to GHC-SCW Member Services Department, PO Box 44971, Madison WI 53744-4971. You may also visit our website at www.ghcscw.com.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website Group Health Cooperative-SCW at www.ghcscw.com to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that notice.
Your medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.
Service Area
To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Service area means Dane County, Wisconsin. A member who resides outside of the Service Area is eligible for coverage provided his or her residence is located in contiguous counties to Dane County, Wisconsin:
Adams County Columbia County Dodge County Grant County Green County Iowa County Jefferson County
Juneau County Lafayette County Richland County Rock County Sauk County Vernon County
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for urgent emergency care benefits. We will not pay for any other healthcare services out of our service area unless the services have prior Plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.