Frequently Asked Questions About HIRSP

My insurer refused coverage due to a medical condition. Am I eligible for HIRSP?
If you were rejected for coverage due to a medical condition, you will be eligible for HIRSP as long as:

  • You provide HIRSP with a letter documenting the rejection from two or more insurers
  • You are a Wisconsin resident.
  • You are younger than age 65.
  • You are not eligible for employer-offered group health insurance.
    (For more information, refer to Eligibility Requirements in the Outline of Coverage.)

What is employer-offered group health insurance?
Employer-offered group health insurance is insurance provided by an employer. It is not an insurance policy purchased by an individual or through an association.

I have exhausted the annual benefit under my employer-offered group health insurance. Am I eligible for HIRSP?
You are only eligible for HIRSP when the maximum lifetime benefit is met (not the maximum annual benefit).

I’ve lost my employer-offered group health insurance. Am I eligible for HIRSP?
If you lost your employer-offered group health insurance, you are required to meet all of the following requirements:

  • You are a resident of Wisconsin.
  • You did not voluntarily cancel your coverage, or lose coverage, for any reason related to fraud or intentional misrepresentation of material or a failure to pay premiums.
  • You are not eligible for employer-offered group health insurance, Wisconsin Medicaid, or Medicare.
  • You exhausted your continuation coverage under your employer-offered group health insurance, including state continuation coverage or COBRA coverage, if offered.
  • Including this employer-offered group health insurance, you have had continuous insurance coverage for at least 18 months with no gap in coverage greater than 63 days.
  • Your most recent period of health insurance coverage was under employer-offered 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.
  • You applied to HIRSP within 63 days of losing your employer-offered group health insurance.

For more information, refer to Eligibility Requirements in the Outline of Coverage.

Am I eligible for other programs, such as Medicaid?
Visit www.access.wisconsin.gov. This Web site is a quick and easy way for you to find out if you are able to get low or no-cost healthcare through Wisconsin’s health programs.

How do I know how much to pay for my first quarterly premium payment?
Current HIRSP premium rate tables are enclosed in the application packet. If you do not have a copy of the current rate tables, you may obtain one from the HIRSP Web site or HIRSP Customer Service.

How long will it take for HIRSP to process my application?
 After receiving your HIRSP application, and all required documentation, HIRSP has 30 days to process it. After HIRSP has made its decision, you will receive a letter either approving or rejecting your application.

How soon will I be covered under HIRSP?
 If HIRSP approves your application, your policy becomes effective on the date HIRSP received your completed application. You may request a later effective date as long as it is no more than 60 days after the date you signed your application. Reimbursement will be subject to:

  • The six-month waiting period for coverage of pre-existing conditions, if applicable.
  • Deductibles.
  • Coinsurance.
  • Copayments.
  • The conditions, limitations, and exclusions stated in the HIRSP policy.
    For more information, refer to Policy Effective Date in the Outline of Coverage.

Will HIRSP cover expenses for pre-existing conditions?
If you have a pre-existing condition, HIRSP will not cover expenses related to that condition for the first six months of coverage unless you are eligible for HIRSP because you lost your employer-offered group health insurance. A pre-existing injury or illness is a condition, whether physical or mental, regardless of the cause of the condition, which was diagnosed or for which medical advice, care, or treatment was recommended or received during the six months immediately preceding the policy effective date.(For more information, refer to Six-Month Waiting Period for Coverage of Pre-existing Conditions in the Outline of Coverage.

How do I know if HIRSP covers a certain medical service or supply?
If you are not certain whether HIRSP covers a certain medical service or supply, contact HIRSP Customer Service. HIRSP covers only medically necessary services and supplies.

Who can provide services?
HIRSP reimburses for covered services provided by Wisconsin Medicaid-certified providers. Prescription drugs must be purchased at a HIRSP certified network pharmacy.

How do I know a provider is Medicaid certified?
Most Wisconsin providers are Wisconsin Medicaid certified. If you are unsure if a provider is Wisconsin Medicaid certified, call HIRSP Customer Service or ask the provider.

Does HIRSP cover services provided outside Wisconsin?
HIRSP does cover major medical and prescription drug expenses provided outside Wisconsin in emergency situations.

In these situations, HIRSP will pay out-of-state providers at its current rates. If the provider is currently Wisconsin Medicaid certified, they cannot, by Wisconsin law (Chapter 149.142(2M)), balance bill you for the difference between their billed charges and the HIRSP payment. However, if they are not Wisconsin Medicaid certified they can balance bill you for the difference between the billed amount and what HIRSP pays, even in cases of emergency.