Form Et 4305 – Fill Out and Use This PDF

To escrow means to preserve or bank your sick leave credits for use at a later date. See the next page for additional important information and application deadlines. Make a copy for your records and return the original to ETF.

1. Information About You

2. Certification of Comparable Coverage (Required)

You must have comparable non-state health insurance coverage continuously throughout the escrow period and provide the policy information. Comparable coverage means a plan with hospital, medical and prescription drug benefits substantially equivalent to the state’s It's Your Choice (IYC) Access Plan or IYC Access Medicare Plus plan. See section 3 for a list of documents needed to verify comparable coverage.

I certify that I am currently insured by health insurance comparable to the coverage offered by the state group health insurance program IYC Access Plan or IYC Access Medicare Plus Plan.

Check one: 1. My health insurance is through an employer.

2.I have purchased health insurance myself.

3.I have VA benefits.

4.I have Tricare.

5.I live outside the U.S. in a country with universal health care. Country: ________________

6.I have coverage through ETF on my spouse's contract (list spouse's employer below).

3. Required Documentation, based on your selection in section 2

If you selected option 1 or 2 above, you must submit the Schedule of Benefits and/or Summary of Benefits and Coverage from your current health insurance provider. This should include information about your plan's deductibles, coinsurance amounts, out-of-pocket limits and pharmacy benefits.

If you selected option 1 above and your employer or spouse's employer funds a Health Savings Account (HSA)

or Health Reimbursement Account (HRA), attach documentation showing the amount they contribute to that account and any requirements, like wellness participation, they have put on the contribution.

If you selected option 3 above, you must submit the first page of Chapter 3 from your Veterans Health Benefits Handbook, indicating your priority group level.

If you selected option 4, 5, or 6 above, you don't need to submit any additional documentation.

4. Authorization

By signing this application, I attest that I have reviewed and understand the information provided on both pages of this form. I understand that Wis. Stat. § 943.395 provides criminal penalties for knowingly making false or fraudulent claims on this form. Accordingly, I hereby certify that the above information is true and correct, to the best of my knowledge and belief.

Note: Failure to notify ETF when you lose comparable coverage will result in forfeiture of your sick leave credits.

continuation rights. However, please be aware that if you do not apply to re-enroll in the State of Wisconsin Group Health Insurance Program within 30 days after your (pre COBRA) comparable coverage ends, your re-enrollment is restricted to enrolling during the annual health benefits open enrollment (referenced in number 1). There is no enrollment period available at the time that your COBRA coverage ends.

Your re-enrollment application must be received within 30 days of the date your non-state coverage ends. You must also send a letter from the employer or organization providing the health insurance coverage. ETF requires documentation including the following items on letterhead from the previous insurer and/or the former employer where at least the insurer’s document is dated and issued after termination of coverage. You may also submit a COBRA notice received from your former employer.

• name of organization formerly providing coverage,

• name of the insurance group,

•date coverage terminated,

Important Medicare Information

Upon re-enrolling, you and/or your insured dependents must be enrolled for both portions of Medicare (Hospital Part A and Medical Part B), when first eligible. This is required by state statute, as the program is designed to integrate with, rather than duplicate, Medicare benefits.

If your Medicare Parts A and B coverage are not effective on or before the first of the month in which you are required to be enrolled in Medicare, you may be liable for the claims that Medicare would have paid.

It is your responsibility to notify us when other family members covered under your policy become eligible for Medicare or become covered under an employer group health plan as a result of active employment and that policy is the primary payer for Parts A and B charges. This will ensure that your coverage and premium amount remain correct.

You may contact ETF at 1-877-533-5020 to speak with a specialist regarding your retirement benefits.

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Nondiscrimination and Language Access

42 U.S. Code § 18116