Eligibility Requirements

Determining whether you should apply for HIRSP coverage is as easy as A, B, C. There are three elements to HIRSP eligibility.
If you meet the requirements under A and either B or C, you are eligible for HIRSP.

"A" Requirements for All Applicants

All applicants for HIRSP are required to meet all of the following four requirements:

• You are a resident of Wisconsin.
• You are not eligible for employer-sponsored
  group health insurance.
• You are not eligible for Wisconsin Medicaid or
  BadgerCare.
• You meet the requirements described
  under B or C that follow.

If you do not meet all these requirements, you are not eligible for HIRSP.

(To find out if you are eligible for Medicaid or Badgercare, please visit www.access.wisconsin.gov. Please click on the following links for more information on Medicaid or Badgercare Plus.)

"B" Eligibility for Applicants Based on Medical Condition

If you meet all the requirements under A and at least one of the requirements under B, you are eligible for HIRSP. If you qualify for HIRSP under B, you will be subject to a six-month waiting period for coverage of pre-existing conditions (Refer to Six-Month Waiting Period for Coverage of Pre-existing Conditions) in the Outline of Coverage.

*Note- If within the last 45 days you lost Medicaid coverage, you will not be subject to the six-month waiting period for coverage of pre-existing conditions. You will still need to meet the following requirements.

If you are applying for HIRSP because of your medical condition, you are required to be younger than age 65, have lived in Wisconsin for at least three months as of your HIRSP effective date and provide documentation that you meet at least one of the following requirements:

• You are eligible for Medicare because of a disability.
• You tested positive for the Human Immunodeficiency Virus (HIV).
• In the past nine months, you received at least one of the following from insurers:
  • A notice of rejection from two or more insurers.
  • A notice of cancellation.
  • A notice of significant reduction or limitation of coverage (including riders).
  • A notice of an increase in your premium of 50% or more.
  • Two or more offers for insurance with premiums at least 50% higher than what you would be charged for a standard individual policy with substantially the same coverage and deductibles as HIRSP.

If you do not meet at least one of the requirements under B, you may be eligible for HIRSP if you meet all the requirements that follow underC.

"C" Eligibility for Applicants Who Lost Employer-Sponsored Group Health Insurance

If you meet all the requirements under A and C, you are eligible for HIRSP. If you qualify for HIRSP under C, you will not be subject to a six-month waiting period for coverage of pre-existing conditions.

If you are applying for HIRSP because you lost your employer-sponsored group health insurance, you are required to meet all of the following requirements:

• You lost your employer-sponsored group health insurance. As documentation, you are required to provide HIRSP with a certificate of creditable coverage from past insurers or employers, or other forms of proof of coverage (e.g. explanation of benefits, health insurance ID card(s)).
• You did not voluntarily cancel your coverage.
• You exhausted your continuation coverage under your employer-sponsored group health insurance, including state continuation coverage or Consolidated Omnibus Budget Reconciliation Act coverage, if offered.
• Including this employer-sponsored group health insurance, you have had continuous insurance coverage for at least 18 months with no gap in coverage greater than 63 days.
• You applied to HIRSP within 63 days of losing your employer-sponsored group health insurance.
• You are not eligible for Medicare.

If you did not meet requirements in A and either B or C, you are not eligible for HIRSP.