UWH Human Resources
301 S. Westfield Rd., Suite 200, Madison, WI 53717
Mail Code: 2409
Fax: (608) 263-5778
UWHC 2017 Domestic Partner Information Sheet
Domestic partners are treated similarly to spouses for the benefit plans administered by the Department of Employee
Trust Funds (ETF), as well as many of the optional benefit plans. Dependent children of your domestic partner are also
eligible for benefits.
Domestic partners must meet all of the following conditions:
Be at least 18 years of age and otherwise competent to enter into a contract;
Neither individual is married to or in a domestic partnership with another person;
Neither individual is related by blood in any way that would prohibit marriage under Wisconsin law;
The two individuals consider themselves to be members of each other’s immediate family;
The two individuals agree to be responsible for each other’s basic living expenses; and
The two individuals share a common residence.
Please access the ETF Domestic Partner Toolkit to learn more about domestic partner eligibility, requirements for
benefit coverage, and effective dates.
To establish a domestic partnership for benefits:
You must meet the eligibility criteria for domestic partnership; and
Submit a completed and notarized Affidavit of Domestic Partnership (ET-2371) directly to ETF for approval.
ETF will acknowledge your affidavit with a letter and provide you with the date of your established domestic
partnership. Please provide a copy of the ETF acknowledgement letter to Human Resources as the date of the
letter establishes the start of the 30-day period to enroll your domestic partner.
Please note there is no connection between the State of Wisconsin Domestic Partner Registry and the domestic
partner benefits administered by ETF and UWHC under Wisconsin chapter 770.
Once your domestic partnership is established, your domestic partner and his/her dependent children may be eligible
for the following benefits: health, supplemental Delta Dental, VSP Vision Care, EPIC Benefits+, State Group Life (SGL)
Spouse/Dependent coverage, Supplemental Life Spouse/Dependent coverage, and Wisconsin Retirement System and
Wisconsin Deferred Compensation program survivor benefits. Please see below for specific information on how to
enroll your domestic partner and his/her eligible dependents in your benefit plans.
If your domestic partner or your partner's eligible dependents are not considered tax dependents for health insurance
purposes under federal law, the Fair Market Value (FMV) of the UWHC contribution toward their health insurance
coverage is considered a taxable fringe benefit. This amount will be added to your earnings as imputed income and is
subject to tax withholding. The monthly Imputed Income Amounts vary by health plan and are listed below. Please note
that the imputed income amounts will be adjusted annually. If your non-tax dependent domestic partner and his/her
eligible dependents are enrolled in your Supplemental Delta Dental, EPIC Benefits+, or VSP Vision Plan, the benefit
premiums for these insurances will be deducted from your paycheck on a post-tax basis.
You are responsible for determining the tax dependent status of your domestic partner and his/her eligible dependents
when you add them to your insurances. In order to be considered a tax dependent, your domestic partner must meet
the federal qualifications for a "qualifying relative." Consult IRS Publication 501 or the IRS Form 1040 Instructions, pages
17-20, for more information.
In general, the IRS requires that a "qualifying relative" meet four tests:
1. The person does not meet the "qualifying child" tests;
2. The person must live with you all year as a member of your household (and your relationship must not violate local
3. The person’s gross income must be less than $4,000 for the year. (However, under Internal Revenue Service Notice
2004-79, this gross income limit does not apply for purposes of determining tax dependent status when you are
covering the person on your health insurance policy. For health insurance purposes, the domestic partner only needs
to meet the remaining three tests to be a qualifying relative).
4. You must provide more than half of the person’s support for the year.
The list above should not be used as the sole source of information for determination of your domestic partner’s tax
status. UWHC staff cannot provide tax advice. The IRS tests are described in detail in IRS Publication 501. In addition, you
should consult with your tax advisor or the IRS if you have questions on how the federal rules apply to your situation.
For additional information to help you determine if your domestic partner is considered a tax dependent, please review
page 5 of ETF’s Domestic Partner Benefits Brochure. Please consult your professional tax advisor before adding a
domestic partner to your benefits to fully determine how your specific tax situation may be affected.
To Establish your Domestic Partnership & Enroll your Domestic Partner and & his/her Dependents in Benefits
Please review ETF’s Getting Started with Domestic Partner Benefits and their Domestic Partner Benefits brochure.
Submit a completed and notarized Affidavit of Domestic Partnership (ET-2371) to ETF. Keep a copy of the affidavit
for your records.
You will receive a domestic partnership acknowledgement letter from ETF. Submit the ETF letter and a copy of
your Affidavit of Domestic Partnership (ET-2371) to Human Resources within 30 days of the date of domestic
partnership provided to you on your acknowledgement letter.
Submit a copy of your Affidavit of Domestic Partnership (ET-2371) at the same time you submit your Health
Insurance Application/Change Form to Human Resources. Do not wait to submit the health insurance form until you
receive your acknowledgement letter from ETF. Both must be received within 30 days of the date you submit
your Affidavit of Domestic Partnership (ET-2371) directly to ETF.
Supplemental Delta Dental, VSP Vision Care, and EPIC Benefits+
Submit the applicable benefit applications to Human Resources within 30 days of the date you submit your Affidavit
of Domestic Partnership (ET-2371) of domestic partnership to ETF. Do not wait to submit this document until you
receive your acknowledgement letter from ETF.
State Group Life (SGL) Spouse/Dependent insurance:
If you are currently enrolled in SGL Spouse/Dependent coverage, your domestic partner and his/her eligible
dependents will automatically be covered as of the date of your domestic partnership determined by ETF. You
do not have to submit a benefit application for coverage.
The establishment of your domestic partnership is a qualifying event to enroll or change your SGL coverage.
You may enroll in Basic coverage, or increase your employee coverage by one level, and enroll in one or two
units of Spouse and Dependent coverage provided an application is submitted to Human Resources within 30
days of the establishment of your domestic partnership..
If you terminate your domestic partnership or marry your domestic partner, you must notify Human Resources -
Benefits within 30 days.
For your convenience, links to the benefit applications are included at the end of this document.
Annual Opportunity to Change Domestic Partner Health Coverage
The annual It’s Your Choice enrollment period gives employees an opportunity to enroll or disenroll an established
domestic partner and his/her eligible dependents in health insurance coverage as of January 1
of the following calendar
To add or remove your previously established Domestic Partner and his/her eligible dependents to/from your health
insurance coverage, submit a Health Insurance Application/Change Form to Human Resources during the It’s Your
Choice benefit enrollment period in October.
Benefit Applications and other Important Domestic Partner Resources
Affidavit of Domestic Partnership (ET-2371)
Declaration of Tax Status Form
EPIC Benefits+ Application
ETF's Domestic Partner Benefits Brochure
ETF's Domestic Partner Toolkit
ETF's Getting Started with Domestic Partner Benefits
Health Insurance Application/Change Form
Health Insurance Fair Market Value/Imputed Income Rates
State Group Life Insurance Applications/Cancellation/Refusal
Supplemental Delta Dental Insurance Enrollment/Change/Waiver Form
VSP Vision Care Application
Wisconsin Retirement System (WRS) and SGL Beneficiary Designation
Mail Code: 2409
Fax: (608) 263-5778
UWHC 2017 Monthly Health Insurance Fair Market Value Rates
If your domestic partner or your partner's eligible dependents are not considered tax dependents for health
insurance purposes, the Fair Market Value (FMV) of the UWHC contribution toward their health insurance
coverage is considered a taxable fringe benefit. This amount will be added to your earnings as imputed
income and is subject to tax withholding. The monthly Imputed Income Amounts vary by health plan and are
listed below. Please note that the imputed income amounts will be adjusted annually.
Employees who cover domestic partners on their health insurance who are not tax dependents are
responsible for both state and federal withholding on the FMVs listed below.
Please complete the Declaration of Tax Status Form and submit to Human Resources-Benefits to ensure
that the taxation of your benefits is handled appropriately.
It’s Your Choice Health Plan
Regular, Temporary, LTE, & Per-Diem
Residents & Interns (Grad Assistants)
Health with Dental Health without Dental Health with Dental Health without Dental
Unity UW Health 437.20 904.60 418.80 866.60 397.40 694.70 373.50 652.90
Dean Health Insurance 420.20 869.40 401.80 831.40 359.60 628.70
Physicians Plus 445.90 922.50 427.50 884.50 391.10 683.70 367.20 641.90
GHC – South Central Wisconsin 422.40 874.00 404.00 836.00 382.80 669.30 358.90 627.50
Unity Community 493.60 1021.30 475.30 983.30 452.50 791.00 428.60 749.20
Access (Standard) Plan 920.20 1903.90 901.90 1866.00 912.00 1594.50 888.10 1552.70
Anthem Blue Preferred Northeast 512.50 1060.50 494.20 1022.50 438.60 766.80 414.70 725.00
Arise Health Plan 522.80 1081.80 504.50 1043.70 480.90 840.80 457.00 799.00
Dean Health Insurance – Prevea360 459.90 951.50 441.50 913.50 415.40 726.20 391.50 684.40
GHC - Eau Claire 507.70 1050.50 489.40 1012.50 466.20 815.00 442.30 773.20
Gundersen Health Plan 529.50 1095.50 511.10 1057.50 430.70 753.00 406.80 711.20
Health Tradition 524.30 1084.80 505.90 1046.70 452.30 790.70 428.40 748.90
HealthPartners 475.00 982.90 456.70 944.80 434.30 759.30 410.40 717.50
Humana Eastern 531.30 1099.30 513.00 1061.30 433.90 758.60 410.00 716.80
Humana Western 569.10 1177.60 550.80 1139.60 469.00 819.90 445.10 778.10
Medical Associates 464.60 961.30 446.30 923.30 392.60 686.40 368.70 644.60
MercyCare 419.20 867.40 400.90 829.40 337.50 590.00 313.60 548.20
Network Health – Northeast 505.30 1045.50 486.90 1007.50 463.80 810.90 439.90 769.10
Network Health – Southeast 499.10 1032.80 480.80 994.80 457.80 800.40 433.90 758.60
Security Health Plan – Central 561.00 1160.80 542.70 1122.90 518.20 906.00 494.30 864.20
Security Health Plan - Valley 544.00 1125.50 525.60 1087.50 501.60 876.90 477.70 835.10
State Maintenance Plan (SMP) 569.70 1178.60 551.30 1140.70 566.10 989.80 542.20 948.00
United Health Care of WI 509.50 1054.20 491.20 1016.20 462.60 808.70 438.70 766.90
WEA Trust - East 531.90 1100.50 513.60 1062.60 432.80 756.60 408.90 714.80
WEA Trust – Northwest Chippewa Valley 559.10 1156.70 540.70 1118.70 455.80 796.80 431.90 755.00
WEA Trust – Northwest Mayo Clinic 559.10 1156.70 540.70 1118.70 455.80 796.80 431.90 755.00
2017 Monthly Health Insurance Fair Market Value Rates
High Deductible Health Plan
(Residents/Interns Not Eligible)
Regular, Temporary, LTE, & Per-Diem Employees
Unity UW Health 374.00 776.40 355.90
Dean Health Insurance 359.60 746.50 341.50 708.90
Physicians Plus 381.30 791.70 363.20 754.00
GHC – South Central Wisconsin 361.40 750.30 343.30 712.70
Unity Community 422.00 876.00 403.80 838.40
Access (Standard) Plan 769.20 1596.90 751.10 1559.30
Anthem Blue Preferred Northeast 438.00 909.30 419.90 871.60
Arise Health Plan Northern 446.80 927.50 428.70 889.90
Dean Health Insurance – Prevea360 393.30 816.50 375.10 778.80
GHC - Eau Claire 434.00 900.90 415.80 863.20
Gundersen Health Plan 452.40 939.20 434.30 901.50
Health Tradition 448.00 930.00 429.90 892.50
HealthPartners 406.20 843.20 388.00 805.60
Humana Eastern 454.00 942.50 435.90 904.80
Humana Western 486.10 1009.20 468.00 971.60
Medical Associates 397.30 824.80 379.20 787.20
MercyCare 358.80 744.80 340.60 707.20
Network Health – Northeast 431.90 896.50 413.70 858.90
Network Health – Southeast 426.70 885.70 408.50 848.10
Security Health Plan – Central 479.20 994.90 461.10 957.20
Security Health Plan - Valley 464.80 964.90 446.60 927.20
State Maintenance Plan (SMP) 477.90 992.10 459.70 954.40
United Health Care of WI 435.50 904.10 417.30 866.40
WEA Trust - East 454.50 943.50 436.40 905.90
WEA Trust – Northwest Chippewa Valley 477.60 991.50 459.40 953.80
WEA Trust – Northwest Mayo Clinic 477.60 991.50 459.40 953.80