Wisconsin maintains a high risk pool, called the Wisconsin Health Insurance Risk Sharing Plan or HIRSP.  HIRSP provides insurance coverage for residents of Wisconsin who, because of health conditions, are unable to obtain private health insurance and for people who are HIPAA eligible.

When can I get coverage from HIRSP?

• If you are HIPAA eligible, you can buy health insurance from the HIRSP. You will not have a pre-existing condition exclusion period.

To be HIPAA eligible, you must meet certain criteria

No matter where you live in the U.S., if you are HIPAA eligible you are guaranteed the right to buy individual health insurance of some kind with no pre-existing condition exclusion period.  In Wisconsin, you are only guaranteed the right to buy coverage from the HIRSP.  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 an employer-sponsored 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 insurance from HIRSP if you are a Wisconsin resident and can demonstrate proof of uninsurability. You are considered uninsurable if you meet one of the following:
• o You have tested positive for HIV;
• o You are eligible for Medicare because of a disability;
• o You have, in the last nine months, received one of the following:
• A notice indicating that you have been turned down for coverage from two or more insurance companies;
• A notice of cancellation of coverage from one or more insurance companies;
• A notice of reduction or limitation in health insurance coverage including exclusionary riders that substantially reduces coverage compared to the coverage of other individuals considered to be of standard health risk;
• A notice that your health insurance premium has been increased by 50% or more, unless such an increase applies to substantially all of an insurer’s health insurance policies; or
• A notice that the premium for health insurance you applied for but do not yet have in effect is at least 50% higher than the premium charged to a person of standard risk.
• HIRSP does not offer family coverage. Each member of your family who wants to enroll in HIRSP will have to qualify on his or her own.

What will HIRSP cover?

• HIRSP offers two types of policies. Plan 1 is for people not eligible for Medicare and it offers two choices of annual deductible levels. Plan 2 is only for people who are eligible for Medicare.

Plan 1 Option A has an annual deductible of $1,000 and Plan 1 Option B has an annual deductible of $2,500.  After the deductible is met, HIRSP pays 80% of the claims until your out-of-pocket limit for the plan is met.  The maximum out-of-pocket limits for the two deductible options are $2,000 and $3,500 respectively.  There is a separate prescription out-of-pocket maximum of $750 and $1,000.  HIRSP pays 100% for most covered services once the annual deductible has been met. 

Plan 2 is only for persons eligible for Medicare. After a $500 annual deductible is met, HIRSP pays 100% of all allowable amounts for covered expenses not payable by Medicare Parts A and B for the remainder of the year.

• HIRSP covers hospital and physician care, prescription drugs and insulin, maternity care, and other services. Total coverage is subject to a lifetime maximum of $1,000,000.

WHAT ABOUT COVERAGE FOR MY PRE-EXISTING CONDITION?

• If you are HIPAA eligible, you will not be subject to a pre-existing condition exclusion when you enroll in HIRSP.
• If you are not HIPAA eligible, you will have a 6-month pre-existing condition exclusion period when you first enroll in HIRSP. When you enroll, HIRSP will look back 6 months to see if you had a condition for which you actually received a diagnosis or for which medical advice or treatment was recommended or received. Pregnancy can be considered a pre-existing condition, but not genetic information. HIRSP does not have to give you credit for your prior coverage.

What can I be charged for HIRSP coverage?

• Premiums will vary based the plan you choose. In addition, HIRSP charges enrollees different rates based on their age, gender, and where they live. Under Wisconsin law, HIRSP rates cannot be more than twice as high as the average premium a healthy prison would pay if he or she bought a similar plan sold by a private insurer in Wisconsin.

HIRSP requires you to submit the first three months of premiums with your application.  You will be billed on a quarterly basis thereafter.

The quarterly HIRSP premium for a 24-year old man (not eligible for Medicare) ranges from $423 to $660, depending on which plan option is selected; and the quarterly premium for a 64-year old man (not eligible for Medicare) ranges from $2,097 to $3,606.

• If your annual household income is less than $25,000, you may qualify for reductions in premiums, deductibles, and drug coinsurance. Reductions are available for enrollees in Plan 1 Option A and Plan 2 only. For more details, contact HIRSP Customer Service at (800) 828-4777 or (608) 221-4551.

How long does HIRSP coverage last?

• HIRSP policies are renewable as long as you pay your premiums, continue to be a resident of Wisconsin, and meet other eligibility requirements.