Utah has a high risk pool, called HIPUtah to provide coverage for people who are unable to buy private health insurance because of their health status.  This program is administered by a private insurance company called SelectHealth.

When can I get coverage from HIPUtah?

• If you are HIPAA eligible, you can apply for health insurance from HIPUtah. If HIPUtah reaches its enrollment cap and is not accepting new members, you will be guaranteed access to an individual policy through a private individual health insurer.

To be HIPAA eligible, you must meet certain criteria

If you are HIPAA eligible you are guaranteed the right to buy some kind of individual coverage in every state and are exempted from pre-existing condition exclusion periods.  In Utah, HIPAA eligible individuals can buy coverage from HIPUtah. To be HIPAA eligible, you must meet all of the following:

• You must have had 18 months of continuous creditable coverage, at least the last day of which was under a group health plan.
• You also must have used up any COBRA or state continuation coverage for which you were eligible.
• You must not be eligible for Medicare, Medicaid or a group health plan.
• You must not have health insurance. (Note, however, if you know your group coverage is about to end, you can apply for coverage for which you will be HIPAA eligible.)
• You must apply for health insurance for which you are HIPAA eligible within 63 days of losing your prior coverage.

HIPAA eligibility ends when you enroll in an individual plan, because the last day of your continuous health coverage must have been in a group plan.  You can become HIPAA eligible again by maintaining continuous coverage and rejoining a group health plan.

• If you are not HIPAA eligible, you can buy coverage from HIPUtah if you have lived in Utah for at least 12 months. In addition, you must show proof of uninsurability. Your may meet HIPUtah’s definition of uninsurable if you were denied coverage by a private health insurer based on your health condition. You will have to provide information about the denial on your application.

You can also apply directly to HIPUtah without having first been denied by a private insurer if you have a health condition (such as cancer, diabetes, or heart disease) that you think would qualify you as uninsurable.  You will have to provide access to your medical records or a doctor’s letter describing your condition.

• If HIPUtah decides that you do not meet the criteria for being uninsurable, you will be so notified and you will then be able to apply for coverage from a private insurers, including the insurer who turned your own initially. Insurers will be required to accept you as long as you apply within 45 days and meet certain other requirements.
• HIPUtah may sometimes be closed to new enrollees due to a lack of funds. If this happens, you will be able to buy an individual policy from a private insurer, unless all the insurers in the state have already taken their share of uninsurable persons. In that case, you may have to wait up to 6 months for coverage.

If you have questions about the eligibility rules for HIPUtah, contact the Utah Department of Insurance.

• HIPUtah only offers individual coverage, so each member of your family needs to qualify on his or her own for a HIPUtah policy.

What will HIPUtah Cover?

• You can choose from 4 plan options under HIPUtah. Covered benefits are the same under all three plans, but the annual deductible varies. You have a choice of three HMO plans with annual deductibles of $500, $1,000 or $2500 or a High Deductible Health Plan with an annual deductible of $5,000.

• o Under the HMO plans, after a deductible, HIPUtah pays 80% of covered services by participating providers and 60% of covered services by non-participating providers.

• o Under the High Deductible Health Plan, benefits are covered at 100% after a deductible. The maximum out-of-pocket liability per plan year is $3,500 in coinsurance plus the annual deductible. After this maximum is reached, HIPUtah will pay 100% of covered services by participating providers and 95% of covered services provided by non-participating providers. There is a separate prescription deductible of up to $500.
• o Covered benefits include hospital and physician care, prescription drugs, home health, and other services. There is an annual limit of $300,000 and a lifetime limit of $1 million per person on covered benefits.

What about coverage for my pre-existing condition?

• If you are HIPAA eligible, you will not receive a pre-existing condition exclusion when you enroll in HIPUtah.
• If you are not HIPAA eligible, you may have a 6-month pre-existing condition exclusion period when you first enroll in HIPUtah. When you enroll, HIPUtah will look back 6 months to see if you had a condition for which you actually received - or for which most people would have sought - a diagnosis, medical advice, or treatment. This is called the prudent person rule. Pregnancy can be considered a pre-existing condition and can be excluded for 10 months following the start of your HIPUtah coverage.
• HIPUtah will credit prior continuous coverage toward your pre-existing condition exclusion if you apply for HIPUtah coverage within 63 days of losing your prior coverage.

What can i be charged for HIPUtah coverage?

• Premiums will vary based on your age and the plan you choose. For example, the monthly premium for a 24-year-old male range from $169 to $347, depending on the coverage option selected. The monthly premium for a 64-year-old male range from $408 to $794.

How long does HIPUtah coverage last?

HIPUtah policies are renewable as long as you pay your premiums, continue to reside in Utah, and meet other eligibility requirements.  If HIPUtah decides not to renew your policy because your condition is no longer uninsurable, it will provide you with a certificate that will enable you to obtain a private health insuran