Covered and Noncovered Services

The services outlined under Covered and Noncovered Services on this page apply to all HIRSP plans. HIRSP offers the following plans:

  • HIRSP 1,000, HIRSP 2,500, HIRSP 5,000 and HIRSP Health Savings Account (HSA), are for people who are not eligible for Medicare. These options have identical coverage that differ only in the amounts of premiums, and deductibles.
    • HIRSP 1,000 has a lower deductible with a higher premium
    • HIRSP 2,500 has a moderate deductible with a moderate premium
    • HIRSP 5,000 offers the highest deductible with a low premium
    • HIRSP HSA 2,500 has a $2,500 medical/drug deductible and qualifies you to open a health savings account
    • HIRSP HSA 3,500 has a $3,500 medical/drug deductible and qualifies you to open a health savings account
  • HIRSP Medicare Supplement is for all Medicare eligible applicants who:
    • Enrolled in Medicare Part A, B and D and met one of the following:
    • Qualify for Medicare due to a disability and are younger than age 65
    • Qualify for Medicare and reach age 65 while enrolled in HIRSP

For details, refer to Comparison of HIRSP Plans Table.

Covered Services

HIRSP will cover medically necessary and appropriate services consistent with the HIRSP policy. Prescription drugs must be obtained at a HIRSPcertified network pharmacy. A partial list of covered services follows.
Refer to the HIRSP policy for a full list of covered services, exclusions, conditions, and limitations.

Covered Services

  • Medical-surgical services
  • Anesthesia services
  • Consultations
  • Prescription drugs
  • Home care
  • Radiology services
  • Laboratory services
  • Pap test and pelvic exam
  • Prostate cancer screening
  • Skilled nursing care
  • Hospice care
  • Services and supplies for treatment of diabetes
  • Yearly routine exam

Covered Services Requiring Prior Approval

Note: Prior approval does not apply to the HIRSP Medicare Supplement plan

  • Transplant services
  • Durable medical equipment costing more that $1,500 or rented for more than three months
  • Prosthetics costing more than $1,500
  • Surgical services for morbid obesity
  • Reduction mammoplasty, septoplasty and blepharoplasty
  • Spinal surgeries*
  • PET scans*
  • MRA studies*
  • Dental repair related to an injury*
  • Inpatient non-emergency admissions, at least 3 business days prior to confinement
  • Outpatient visits and transitional treatment for treatment of alcoholism, drug abuse and nervous or mental disorders beyond 50 visits per calendar year
  • Pain management procedures, including injections
  • Spinal cord stimulator
  • Implantable infusion pain pump
  • Genetic testing services for treatment of an illness
  • Home Intravenous (IV) therapy or home infusion therapies including Total Parenteral Nutrition (TPN) and antibiotic therapy.
  • Prior Approval Request Form
    * Prior approval not required in the event of an emergency

For more specific information about covered services, refer to the HIRSP policy or contact HIRSP Customer Service.

Noncovered Services

The following is a partial list of treatments, services, supplies and expenses that HIRSP does not cover:

  • Cosmetic treatments
  • Eyeglasses
  • Hearing aids
  • Routine dental care
  • Health care services performed by members of your immediate family or anyone else living with you
  • Any services covered by any other policy of healthcare insurance
  • Custodial care
  • Infertility, impotence and sterilization services or drugs
  • Charges for procedures or services that are determined as not medically necessary and appropriate
  • Expenses incurred for procedures or services that are of questionable medical value, experimental or investigative (except drugs for the treatment of HIV infection)

For more specific information about services that HIRSP does not cover, refer to the HIRSP policy or contact HIRSP Customer Service.

Grievance and Appeal Rights
HIRSP has a grievance and appeal process if you disagree with a HIRSP decision, such as:

  • Denial or termination of coverage
  • Denial or reduction of claim payment
  • Denial of an application for a reduction of HIRSP premium, deductible or drug out-of-pocket maximum
  • Denial of prior approval

For more information about grievance and appeal rights, you may refer to the HIRSP policy received upon HIRSP’s approval of coverage or contact HIRSP Customer Service.