Covered and Noncovered Services

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 services or medications related to a pre-existing injury or illness during your first six months of coverage. This pre-existing condition waiting period does not apply to you if you are eligible for HIRSP under "C" or apply within 45 days of losing your Medicaid coverage.

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.

Covered Services

HIRSP will cover medically necessary and appropriate services consistent with the HIRSP policy only when those services are received from Wisconsin Medicaid-certified providers. A partial list of covered services follows. Refer to the HIRSP policy for a full list of covered services, exclusions, conditions, and limitations.

• Hospital services.
• Basic medical-surgical services, including both in-hospital and out-of-hospital medical and surgical services, diagnostic services,
  anesthesia services, and consultation services.
• Inpatient treatment and outpatient services for alcohol or drug abuse and nervous and mental disorders.
• Prescription drugs and insulin.
• Home care.
• Durable medical equipment.
• Disposable medical supplies.
• Diagnostic X-rays and laboratory tests.
• Physical therapy services.
• Emergency ambulance services.
• Skilled nursing facility services.
• Hospice care.
• Services and supplies for treatment of diabetes.
• Chiropractic services.
• Maternity and newborn services.

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:

• Routine exams and related services.
• Cosmetic treatments.
• Eyeglasses.
• Hearing aids.
• Routine dental care.
• Custodial care.
• Infertility, impotence, and sterility 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.