Eligibility Requirements

Note: If you have been without healthcare coverage for six months, you may be eligible for the HIRSP Federal Plan which does not impose a waiting period for pre-existing conditions. Learn more...

The HIRSP program imposes a preexisting condition waiting period of six months on medical services for new enrollees, except those who have lost their employer-sponsored coverage and apply to HIRSP under existing federal HIPAA guidelines. The HIRSP program does not apply a preexisting condition waiting period to drug coverage. HIRSP defines a preexisting condition as any condition whether physical or mental, regardless of the cause, 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.

Eligibility abc'sDetermining 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 five requirements:

A: Requirements for All Applicants
  • You are a resident of Wisconsin
  • You are under age 65, unless you are not eligible for Medicare
  • You are not eligible for employer-offered group health insurance
  • You are not eligible for comprehensive Wisconsin Medicaid services or BadgerCare Plus
  • You meet the requirements described under B or C that follow

If you do not meet all of 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 visit the following for more information on Medicaid or BadgerCare Plus.)

BEligibility for Applicants Who Lost Employer-Offered Group Health Insurance

If you meet all the requirements under A and B , you may be eligible for HIRSP. If you qualify for HIRSP under B, 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-offered group health insurance, you are required to meet all of the following requirements:

B: Requirements based on medical condition
  • You lost your 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 which HIRSP will verify (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-offered group health insurance, including state continuation coverage or Consolidated Omnibus Budget Reconciliation Act (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
  • You applied to HIRSP within 63 days of losing your employer-offered group health insurance, including COBRA if offered
  • You are not eligible for Medicare
    NOTE: If you are eligible due to loss of employer-offered group health coverage, you do not need to submit proof of medical condition.

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

CEligibility for Applicants Based on Medical Condition

If you meet all the requirements under A and at least one of the requirements under C , you are eligible for HIRSP.

If you qualify for HIRSP under C , you will be subject to a six-month waiting period for coverage of preexisting conditions, with limited exceptions (Refer to Six-Month Waiting Period for Coverage of Pre-existing Conditions).

You must be a Wisconsin resident for at least three months as of your HIRSP effective date unless you were enrolled in a state High-Risk Pool for one year and apply within 45 days of termination, and provide documentation that you meet at least one of the following requirements:

C: Eligibility for applicants who lost employer sponsored insurance.
  • 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, based wholly or partially on medical underwriting considerations:
    • A notice of rejection from one or more insurers
    • A notice of cancellation
    • A notice of reduction or limitation of coverage, including restrictive riders, resulting in substantially reduced coverage
    • 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 did not meet requirements in A and either B or C, you are not eligible for HIRSP.

Reductions

Available for policyholders with household incomes of less than $34,000.

HIRSP 1,000 / HIRSP 2,500 / HIRSP 5,000
subsidized premium, medical deductible, and drug out-of-pocket maximum

HIRSP Medicare Supplement
subsidized premium and drug out-of-pocket maximum

HIRSP HSA
subsidized premium and medical/drug deductible

Pre-existing Condition Waiting Period

Six-Month Waiting Period for Coverage of Pre-existing Conditions

If you are eligible for HIRSP based on your medical condition, HIRSP does not cover medical services related to a pre-existing injury or illness during your first six months of coverage. Prescription drugs are not subject to the six-month waiting period for coverage of pre-existing conditions. This pre-existing condition waiting period also does not apply under the following circumstances:

  1. If you are an eligible individual under B above;
  2. To those individuals who apply for coverage under this policy within 45 days of losing their coverage under: (1) Medicaid; (2) BadgerCare Plus; (3) Medicare; (4) a state health benefits risk pool, provided the individual was covered under that risk pool for at least 12 months; (5) a student health insurance plan or policy offered by a University or College for an enrolled student, provided the student had 18 months of continuous coverage; (6) or an individual policy that was terminated because the insurer no longer does business in Wisconsin. These individuals must qualify for coverage under this policy as medically uninsurable and meet all eligibility criteria associated with that designation;
  3. To health care services in connection with hearing aids and cochlear implants for members under the age of 18;
  4. To those individuals who apply due to a Medicare disability when we determine that the individual meets the eligibility requirements for both health reasons and for loss of group coverage, except for their Medicare eligibility, as described under B above;
  5. To those individuals applying due to a 50% or more rate increase for coverage under Farmers Health Cooperative, provided the individual was insured by Farmers Health Cooperative for at least 6 months.

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.