Common Ground Healthcare Cooperative has partnered with Covering Wisconsin to bring easy to understand information to you.  This includes an explanation of terms such as deductible, coinsurance, copay and out of pocket maximums.  Please visit our resources page to learn more.

In many ways, cooperatives behave much like any other health insurance company. We meet the same laws and regulations, and we provide medical insurance and prescription drug coverage. What makes us different is that we are a nonprofit organization that is owned and governed by its customers. We answer to our members, not corporate shareholders, so we have absolutely no motivation to raise prices simply to make more money. Our Board is made up of individuals buying our insurance, who are elected by the entire membership. The member-governed board has the authority to approve our budget, approve our rates and oversee our operations.

If you are eligible for an “Advanced Premium Tax Credit” from the federal government, or APTC, it means that the federal government is paying a portion of your health insurance bill every month. You will see this reflected on your monthly invoice. You can only get tax credits if you buy health insurance through Healthcare.gov, whether that is with the help of an insurance agent, Common Ground Healthcare Cooperative staff or on your own. The amount you receive is based on the income you’ve reported to the federal government on your taxes or on your health insurance application. That is why it is very important to report any changes (income, births, moves and so on) to the federal government as soon as possible, so you do not receive more or less than you should. Either way, your tax credit will be “settled up” at tax time. You can also opt out of advanced payment of the tax credit by contacting www.Healthcare.gov, but then you will have to pay the full amount for your health insurance.

You must pay your premium by the 25^th of the month prior to coverage (for example, by May 25^th for June coverage) to avoid any interruptions in your coverage. If you do not pay your bill on time, you will enter into a grace period that you cannot get out of until you pay your total balance due in full as of the date your payment processes. We have several options for payment, including online recurring payments. Click here to learn more.

If you are receiving a tax credit for your coverage, or if you have otherwise purchased health insurance through Healthcare.gov (even through an agent or CGHC), then you are required by law to report any address or other life changes (marriages, births, change of residence, etc) to Healthcare.gov. We cannot update our records until the federal Marketplace (Healthcare.gov) updates its records. If you do not receive a tax credit and purchased coverage off the Marketplace (Healthcare.gov), then you may call us at 877.514.2442 to report any changes.

Many times when a member talks with the federal government-run Marketplace (Healthcare.gov) they think they are talking with us, their health insurance company. It’s important to understand we are very separate organizations, and we generally talk to each other electronically through data files. If you have a concern about the service you’ve received through Healthcare.gov, there is little we can do to influence that. But, we can help you understand how to navigate Healthcare.gov, including how we might help report errors and open up complaint tickets. Just call us at 877.514.2442 so we can explain what we can help with, versus what the federal government will need to help you with.

We maintain an internal process for the timely investigation and resolution of complaints and grievances. Members may file a complaint/grievance regarding any aspect of care or service provided to them by CGHC or our contracted providers. The internal complaint/grievance process includes steps to ensure careful and complete consideration is given to each complaint/grievance. More information about the complaint/grievance process is on our website. You may also call Member Services at 877.514.2442.

If you feel you have made an over payment and are owed a refund, please contact our Member Services department at 877.514.2442. We do our best to issue refunds  within 30 days of any over payment.

Yes. If you do not pay your bill on time, we will give you a short grace period to help you catch up and keep your health insurance coverage. This is very important, because once you lose coverage for nonpayment of premiums, that coverage cannot be reinstated.  This means you are not eligible for another plan until January 1 of the following year, unless you have a qualifying life event. The length of the grace period that applies depends on whether or not you are receiving a tax credit (APTC) for the purchase of insurance through Healthcare.gov.

If you are NOT receiving a tax credit for the purchase of health insurance, we will give you 31 days to bring your account up to date. During this time, you are responsible for the cost of any health claims and we will not pay for your prescriptions at the pharmacy until you bring your account fully up to date.

If you are receiving a tax credit for purchase of health insurance, we will continue paying for covered claims in the first 30 days of your grace period. We will begin to “pend” coverage of your healthcare claims after the first 30 days. Pending your claims means that we will hold on to them without paying them until you bring your account fully up to date. We will also let your doctor know you are in your grace period. You are responsible for your health claims after 30 days and we will not pay for your prescriptions at the pharmacy until you bring your account fully up to date. When your account is 90 days past due, your plan will be terminated retroactive to the date you last paid premium through.

Remember, to end a grace period you must pay all past due balances as of the day your payment processes so your account is fully up to date. Partial payment will not extend the grace period.

To check if your doctor is in our health plan network or to find a doctor in your area, go to our provider directory. If you don’t get your insurance through your employer, click here to access our directory. If you get insurance through your employer or your spouse’s employer, click here to see the networks we offer to our small business members. You can always check with our member services department too by calling 877.514.2442.

All our health plans include prescription drug coverage. Some plans are copay plans where you pay a set amount for various drug “tiers,” while others require you to satisfy your deductible before we begin to cover some or all of the cost. Please check our online formulary to determine if your prescription medication is on our list of generic and preferred drugs. Keep in mind that the formulary describes different “tiers” of drugs, with generic and preventive prescriptions generally costing you the least out of pocket.

Yes, we offer individuals and families a Silver HSA and a Bronze HSA. You would contact your own financial institution to administer the HSA. For more information, call our Sales department at 855.494.2667 or view our plans online.

Click here to learn more about Health Savings Account health plans.

Health Savings Account eligible health plans are health insurance products with a deductible that is high enough to qualify you for tax-advantaged savings on health expenses. To qualify as an HSA-eligible plan, the health plan can only pay for preventative care services and nothing else before the deductible is met.

Purchasing an HSA eligible health plan is just the first step in gaining tax-advantages when paying for medical expenses. The second step is to open an HSA account at your bank or credit union. Any money you put into your HSA account can be used to pay for deductibles, copays and out-of-pocket healthcare costs. The money deposited into an HSA account is not taxed at the time of deposit or upon withdrawal as long as you spend it on qualified medical expenses. It’s all documented on your tax return. Best of all, the money is yours to keep and rolls over from year to year. Click here to learn more.

Our benefits are described in our Certificates of Coverage.
View our Certificate of Coverage for Individuals and Families
View our Certificate of Coverage for Employers and their Employees
Services requiring prior authorization are described in the certificate, as are exclusions and limitations. If you have any questions about our Certificates of Coverage, please call member services at 877.514.2442.

Medical necessity describes care that is reasonable, necessary and/or appropriate, based on evidence-based clinical standards of care. CGHC covers only services deemed medically necessary, and therefore your claims may occasionally be subject to review for medical necessity.

In addition, some of the services we cover require prior authorization. A prior authorization is a written form completed by your physician requesting approval for you to seek certain services.  A prior authorization request must be approved by CGHC prior to services being received in order for them to be covered by your plan. The Prior Authorization request must be received at least five business days prior to the anticipated date of your service or procedure. Please note that for urgent or emergency admissions, prior authorization must be obtained within 24 hours of the admission or the next business day. When circumstances such as these occur, please call 877-779-7598 as soon as possible and submit a request for an expedited Prior Authorization review of an urgent claim. A decision will be made within 24 hours of receiving the requested information.

If you fail to obtain written prior authorization for designated services, eligible charges will be reduced by 50% up to a maximum penalty of $1500. The 50% penalty will apply first, before deductibles, coinsurance, or any other plan payment or action. The 50% penalty does not apply toward your maximum out-of-pocket. To obtain prior authorization, call 1-877-779-7598. This call starts the utilization review process.

Click here to learn more and download a list of services requiring prior authorization.

Click here to download a list of prescription drugs requiring prior authorization.

Click here to download a list of our exclusions and limitations.

If an authorization has been denied, you have the right to appeal that decision. Our cooperative fully supports this process and may change its decision if there is a good reason for doing so based on additional information that you provide. CGHC must complete the appeals process within 30 days. If you aren’t happy with the outcome of an appeal, you can also ask for an external independent review to be conducted. Complete instructions on how to file an appeal are available on our website or call Member Services at 877.514.2442 for more information.

Pharmacy or medication denials are subject to similar appeal steps and rights described on these pages. Members can submit this type of appeal to: OptumRx, Prior Authorization Department, PO Box 5252, Lisle, IL 60532. This same procedure applies to requests for exceptions to gain access to medications not listed on our formulary. Or, you can call OptumRx at 855.577.6545.

Small employers can enroll in our employer health insurance plans at any time and may contact our Sales department at 855.494.2667 for assistance. Most individuals and families can only enroll during open enrollment. The next open enrollment period runs from November 1, 2017 and is scheduled to end on December 15, 2017. During open enrollment you will be able to purchase CGHC coverage directly through our website, by calling our Sales team at 855.494.2667, through your own insurance agent, or by going online to www.Healthcare.gov.

If you did not enroll during open enrollment, you can only enroll if you’ve had a significant life event that qualifies you for a special enrollment period. Events may include losing health coverage involuntarily, getting married, having a baby or adopting a child, losing a dependent, gaining citizenship, moving your residence, divorcing your spouse or having a change in income. To find out if you are eligible for a special enrollment period, call our sales department at 855.494.2667. Don’t delay because most special enrollment periods are only available for 60 days after the life event occurs.

Healthcare.gov is the federal government-run marketplace for health insurance. You can find out if you qualify for tax credits online by visiting their website at Healthcare.gov, by calling 800.318.2596, by calling our Sales team at 855.494.2667, or by talking to your health insurance broker. The only way to receive a tax credit is for you to buy insurance through Healthcare.gov, although our company or an insurance broker can help you with that at no cost to you.

A broker is independent of a health insurance company. Brokers are licensed with the state to sell health insurance, so they know all of the plans the different health carriers offer. A broker can meet with you in person and spend the time needed to explain the coverage that would best meet your needs. There should be no cost to you when you choose to work with a broker.

A broker will continue to work with you after you have enrolled in a health plan. He or she will help you with claims or billing questions and each year at renewal time they will meet with you to explain any new options. To find a broker please call our Sales department at 855.494.2667. A Sales team member will provide a list of independent brokers in your area.

If you enrolled between November 1st and December 15th as part of the open enrollment period, your health insurance coverage began on January 1st. The deadline for 2018 coverage is only 45 days this year. You will not be able to enroll in coverage for 2018 after December 15th unless you qualify for a special enrollment period.

Common Ground Healthcare Cooperative automatically renews individuals and small employer members into their existing plans unless we receive a termination notice in writing. However, we STRONGLY encourage our members to actively renew with us. You can do this with our help, your broker’s help or through Healthcare.gov. This is the safest way to avoid any miscommunication we might receive from the federal Marketplace (Healthcare.gov), especially during the busy open enrollment period.

Once you enroll in a health insurance plan and pay your first month’s premium, it will generally take about two weeks for us to generate your membership materials and send them to you. You can view materials and print a temporary ID card by going to our member portal.

As long as you have enrolled and paid your premium, you are covered as of your effective date even if you haven’t received your member packet and ID card. You can always call us at 877.514.2442 for assistance if you need it.

CGHC’s mission is to make coverage for our members as affordable as possible while maintaining sufficient funds to pay all claims and administrative expenses. New medications, procedures and technologies improve health and save lives, but they can be costly. Pharmaceutical companies and health providers have to be paid from member premiums.

In addition, people get older every year. All insurance companies charge more the older you get, so this increase will always be a part of your insurance renewal. If you get a tax credit, this can also change from year to year and impact your share of your premium.

One thing you can depend on is that Common Ground Healthcare Cooperative will set its premiums responsibly and fairly to ensure premiums cover our costs, and that we have a sustainable cooperative in the future for our members. We do not operate for profit, so that will never be part of the consideration, and our rates will always be approved by our member-governed Board of Directors based on the best information available to us at the time of our rate filing.

Click here to learn more about how to keep your out-of-pocket healthcare costs down.

EPO stands for Exclusive Provider Organization. This change means that members with individual and family plans will only have coverage for care received from in-network providers. If you see an out-of-network provider, the services will not be covered except for emergency care, urgent care outside of our service area, or when there are not any in-network providers that are qualified to treat your condition when we approve a written referral from an in-network doctor prior to services being received.

Urgent care is when you need non-emergency medical attention and cannot wait to schedule a doctor’s visit. Only if the urgent care service is provided outside of our 19-county service area will you have coverage at out-of-network facilities. In that case, the urgent care visit will apply to your in-network benefits including deductibles, coinsurance and copayments. Please be aware that you may have to make additional payments if the out-of-network provider bills you for the difference between what they charge and our “maximum allowable fee” (the appropriate payment amount) based on what other payers pay for the service. If you are inside of our service area, you will need to visit an in-network urgent care facility for the service to apply to your benefits.

Emergency care means that you have a serious of life threatening condition that needs immediate attention. A medically necessary emergency care visit will apply to your in-network benefits including deductibles, coinsurance and copayments. When you are traveling and there is an emergency you should always go to the nearest emergency room. However, you may have to make additional payments if the out-of-network provider bills you for the difference between what they charge and our maximum allowable fee (or appropriate payment amount) for the service. Please understand that once you are no longer in need of emergency care, you will need to transition to an in-network facility for follow-up care for these services to be applied to your benefits.

If the service is not for an emergency or urgent service outside of CGHC’s service area, you will owe the entire bill to the provider except in very limited circumstances where a) an in-network provider is not able to provide the service AND b) an in-network provider submits a referral for you to see an out-of-network provider AND c) CGHC approves the referral prior to you receiving the service AND d) the service is medically necessary and meets our coverage requirements outlined in the 2018 Certificate of Coverage available at CGCares.org/Certificate.

Please understand even if you visit an out-of-network provider for (a) an emergency or (b) urgent care visit outside of our 19 county coverage area or (c) in an approved referral situation, you could still be balance billed for the service. Balance billing occurs if the provider charges you the difference of your billed charges and the maximum allowable fee CGHC pays toward the service. Our maximum allowable fee is based on the amount other payers pay for the service.

A referral is a CGHC form that your in-network provider must complete prior to you receiving out-of-network services if you meet the criteria stated in the question above. The referral form is submitted to CGHC for review and both you and the out-of-network provider will receive written confirmation of approval or denial of the requested services. Services received without an approved referral will be denied and the payment will be the responsibility of the CGHC member. A referral is not required for urgent or emergency services.

It is important to note that a referral is separate from a prior authorization. A referral provides approval for you to utilize an out-of-network provider and the prior authorization process reviews the treatment to ensure it is medically necessary. To view the list of services that require prior authorization please review the Certificate of Coverage at CGCares.org/Certificate.

For 2018, you do not have to select a primary care physician nor do you need a referral to see in-network specialists. Even though it is not a requirement, it is always a good idea to find a primary care physician who can help you navigate the health care system should you ever need it. We recommend that you receive your preventive care services from a primary care doctor that practices general, internal, family and geriatric medicine, including some pediatricians and ob/gyns.

Qualified dependents who are currently living away from home are covered for urgent or emergency care that need immediate attention. Follow-up care and any covered elective procedure must be obtained from in-network providers. Costs related to medically necessary urgent and emergency care will apply to your in-network benefits and will be paid by CGHC at our maximum allowable fee (or appropriate payment amount).

Dependent full-time student members that attend an Institute of Higher Learning within the state of Wisconsin, but outside of the CGHC 19-county service area, have coverage for one clinical assessment by an out-of-network provider and a total of five counseling visits for outpatient behavioral health, substance abuse treatment or any combination of the two. These students will also have the same access to emergency and urgent care as described above. Please refer to the 2018 Certificate of Coverage online for further details at CGCares.org/Certificate.

Out-of-network care is very costly to cover because we do not hold an agreement with out-of-network providers which allows them to charge as they see fit. Considering that the majority of our members don’t utilize out-of-network care and it was increasing costs for everyone, the member-governed Board of Directors decided to end coverage for out-of-network care except in the circumstances outlined above.

Because CGHC now offers Exclusive Provider Organization (EPO) plan designs for individuals and families, our members do not have out of network benefits except in case of emergencies, urgent care services outside of our service area among others. For more details please review the 2018 Certificate of Coverage. For limited circumstances, we will consider approving out of network care if an in-network provider is not qualified to provide the medically necessary covered service. An in-network provider must submit a referral form for us to review before out of network services can be received.

Small group plans will remain Preferred Provider Organization (PPO) plans. For group plans, the are deductibles and maximum out of pockets (or moops) are two times the in-network rate. Typically, your coinsurance rate is higher out of network.

Because we don’t have a contract with out-of-network providers, we have a maximum allowed amount that we will pay toward out-of-network care. If the doctor’s charge is higher than our maximum allowed amount, the doctor (or facility) could decide to bill you for the difference. This is called “balance billing.”  While we can and do prohibit balance billing from occurring with our in-network providers, we cannot stop it from happening if you use an out of network provider.

Please know that in a true emergency situation, we will pay for emergency care at the maximum allowed amount and it will be applied to your in-network copays, deductibles, coinsurance and MOOP if applicable. Once again, you should be aware that you may be balanced billed for out-of-network emergency services.

Click here to learn more about how to keep your out-of-pocket healthcare costs down.

Typically, healthcare providers, including pharmacies, will submit medical and pharmacy claims to Common Ground Healthcare Cooperative on your behalf. If a claim is not submitted by your provider, we have no way of knowing that you received services.

If for some reason your provider fails to submit claims for you, please submit an itemized bill and receipt within 90 days of the last day on which you received services. No payment will be made on any claim that we receive more than one year after the last day on which you received services. Claims should be itemized and state the provider of the service, diagnosis, date of service, services provided, and amount charged for the services. If you have questions, please contact us at 877.514.2442.

For pharmacy claims, please click here and complete our pharmacy claim form.

For medical claims, if you are an individual or small group member and enrolled in one of our Envision plans, please send your itemized bill and receipt to:

Common Ground Healthcare Cooperative, Attn: Claims
PO Box 1630
Brookfield, WI 53008-1630

If you are enrolled in one of our Empower (Trilogy) small group plans, Submit Claims to:

Trilogy
CGHC Claims
PO Box 1171
Milwaukee, WI  53201

If you have questions about any decision we make regarding coverage of medical or pharmacy treatment, you can call us at 877.514.2442. If you do not agree with any part of the decision we made on your claim, you can file an appeal within 180 days, but not later than 3 years from the date found on this notification. Appeals must be sent to Common Ground Healthcare Cooperative (“CGHC”) Member Appeals and Grievances, P.O. Box 1630, Brookfield, WI 53008-1630. Your complaint will be reviewed by the Common Ground Healthcare Cooperative Grievance Committee and a decision will be issued within 30 days of receipt of your appeal, unless additional time is requested. You have the right to attend the Committee meeting by telephone, in person, or you may send an authorized representative in your place. You should provide all information you want considered with your appeal. Complete details regarding filing an appeal can be found in your Certificate of Coverage/policy.

Pharmacy or medication denials are subject to similar appeal steps and rights described on these pages. Members can submit this type of appeal to: OptumRx, Prior Authorization Department, PO Box 5252, Lisle, IL 60532. This same procedure applies to requests for exceptions to gain access to medications not listed on our formulary. Or, you can call OptumRx at 855.577.6545.

You have the right to pursue an independent external review if the denial of your claim is based on medical judgment (for example, medical necessity, experimental and investigational treatment, and appropriateness of health care setting). In most cases, you must go through CGHC’s internal grievance procedure first and you must file for the review with 4 months after the date you receive the CGHC decision. External reviews are conducted by the federal Department of Health and Human Services (“HHS”) through the MAXIMUS Federal Services process. Requests for review must be made in writing to: HHS Federal Review Request, MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534, or fax to 888.866.6190.

You may request an expedited review if you believe the time period for resolving your appeal will result in jeopardizing your health. In urgent situations, the internal review process can be done at the same time as the expedited review process. The expedited process will produce a binding result within 72 hours. To request an expedited review, in addition to the methods listed above, you can also call 888.866.6205.

You may also contact the Wisconsin Office of the Commissioner of Insurance for questions at 608.266.0103/toll free 800.236.8517 or send an email to ocicomplaints@wisconsin.gov. Complaints can be mailed to the following address: Office of the Commissioner of Insurance, Complaints Department, P.O. Box 7873, Madison, WI 53707-7873. Complaints may be faxed to 608.264.8155.

If your plan is employer-sponsored and governed by ERISA, you may contact the Employee Benefits Security Administration at 866.444.3272 or askebsa.dol.gov. You may file a civil action under section 502(2) of the Employee Retirement Income Security Act (ERISA) once you exhaust the grievance procedure.

If you or your family members have other insurance coverage that provides benefits that are the same or similar to this plan, we will coordinate your CGHC benefits with your other coverage. Generally, this includes other group insurance coverage and Medicare benefits.

We have developed an entire webpage dedicated to how to read your Explanation of Benefits (EOB). Click here to view the webpage. 

It is generally not Common Ground Healthcare Cooperative’s practice to deny claims retroactively. There are only a few circumstances in which this could happen:

• You become retroactively eligible for Medicaid or Medicare and request that we retroactively terminate your coverage, or
• The federal Marketplace retroactively terminates your coverage, or
• We discover after payment that you have other coverage that requires coordination of benefits, or
• We discover after payment that your injury is work related and therefore subject to workers’ compensation coverage, or
• We discover information that makes you ineligible for CGHC coverage.

To avoid any instance of retroactive denials:

• Provide full and honest answers on your insurance application;
• Notify the marketplace and/or CGHC of any changes in address or other life changes;
• Be sure to document when injuries are work-related;
• Pay your premiums on time;
• Provide documentation to the Marketplace as requested and understand the amount of your advanced premium tax credits;