Two Rivers district to switch to partially self-funded medical plan, expand network and change pharmacy program

Two Rivers Public School District staff and benefits vendors outlined a plan to move the district’s employee medical coverage to a partially self-funded model that takes effect July 1, with open enrollment running May 8 through May 20.

The change, presented May 8 at an employee meeting, replaces the district’s prior reimbursement approach with a new plan design that lowers single and family deductibles, qualifies employees for Health Savings Accounts (HSAs) and expands provider access, officials said. USI Consulting’s Rayan Bodri, vice president and practice leader for employee benefits in Wisconsin, said the partially self-funded structure gives the district more flexibility to manage costs and “repurpose some of those funds and do better things in our health plan in the future.”

Why it matters: The redesign alters employees’ potential out-of-pocket exposure and where they can receive care. Vendors emphasized three near-term, concrete effects: (1) the district will move to an HSA‑qualified plan, (2) the single deductible will be $3,600 and the embedded family deductible $7,200, and (3) the payroll-based provider network will widen so employees can access most major Northeast Wisconsin systems.

Plan design and money: Pete Derer of USI said the district eliminated the prior reimbursement (HRA) program after payment problems and collections issues under the old approach. He described the new core numbers: a $3,600 single deductible and a $7,200 family deductible (embedded) with co‑insurance that becomes 100% after those levels are met. On HSAs, vendors walked through 2024 IRS contribution limits ($4,150 single, $8,300 family) and said the district will seed accounts with $700 for single plans and $1,500 for family plans (timing—quarterly or biannual—will be determined). "You are not a guinea pig," Rayan said, adding that other Wisconsin districts have used similar models.

Network and billing changes: Presenters said the district will replace a narrow-network product with a broad network that includes systems such as Aurora and other major providers in the region. Paul, representing the network/billing vendor, described a combined monthly bill/EOB statement and said the vendor will pay providers directly and then collect from members via the vendor portal; he also described interest-free payment plans for members who need them.

Pharmacy changes and specialty drugs: Becky Maoy (SER URX) and on-site pharmacists outlined a closed, select formulary that prioritizes generics and preferred brands and described new specialty-drug management. Specialty medications will require prior authorization and vendor staff will work with physicians and manufacturers to enroll eligible patients in manufacturer or patient-assistance programs. Becky said the coordinated approach is intended to reduce members’ cost share; in describing the assistance program she said, "you will be paying zero dollars for this medication" when manufacturer or patient-assistance funding applies. The vendor also offered an RX valet shipping option for certain high-cost drugs while assistance efforts proceed.

Administration, timing and logistics: Veronica of Professional Benefit Administrators (PBA), the district’s third-party administrator, said PBA will begin processing claims under the new plan July 1 and urged employees to present new ID cards at their first post‑implementation medical or pharmacy visit to avoid misdirected billing. Vendors announced expanded customer-service hours and multiple opportunities for one-on-one meetings with clinical pharmacists over the next two days and beyond.

Enrollment and next steps: Open enrollment opens May 8 and closes May 20; benefit elections take effect July 1 and the first payroll deduction under the new schedule will be Aug. 30. Vendors urged employees to complete enrollment forms (including required SSNs for dependents) by May 20 and to sign up for pharmacist meetings if they take specialty medications that will require coordination.

Claims and concerns raised at the meeting: Presenters repeatedly acknowledged operational problems under the prior HRA model, including failed HRA payments and bills sent to collections by Holy Family providers; USI and vendor representatives said the new design is intended to prevent similar problems. Several speakers urged staff to contact vendors or the district if they receive a provider bill after the changeover.

What’s next: Vendors will distribute ID cards and implementation materials ahead of July 1, and staff can meet one-on-one with pharmacists and benefit representatives in the days following the presentation. The district will finalize HSA account setup with Associated Bank and confirm how the district seed contributions will be distributed.

Sources: Presentation to Two Rivers Public School District employees by USI Consulting, PBA, HPS/HBS, SER URX and APAC agents on May 8; vendor and district remarks at the meeting.