Frequently Asked Questions

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 one 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)

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 of your group coverage has been met (not the maximum annual benefit).

I’ve lost my employer-offered group health insurance. Am I eligible for HIRSP?
You may be eligible due to loss of employer-offered group health insurance. See eligibility requirements.

If I have Medicare, am I eligible for any of the other HIRSP plans?
Applicants eligible for Medicare and under the age of 65 are only able to enroll in the HIRSP Medicare Supplement plan.

Am I eligible for other programs, such as Medicaid or BadgerCare Plus?
Visit www.access.wisconsin.gov or call 1-800-362-3002. 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.

Do I qualify for HIRSP if I am eligible for BadgerCare Plus?
Applicants eligible for the BadgerCare Plus Benchmark or Core Plan are eligible for HIRSP. Those eligible for BadgerCare Plus Standard Plan are not eligible for HIRSP. For information on BadgerCare Plus visit www.badgercareplus.org.

How do I know how much to pay for my premium payment?
Current HIRSP premium rate tables are enclosed. You may also obtain a copy from HIRSP Customer Service. How long will it take for HIRSP to process my application? Upon receipt of your application, you will receive an ackowledgement letter within 14 days. HIRSP has 30 days to process your application. (All required documentation must be received by HIRSP within these 30 days.)

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 HIRSP Policy for Effective Date.)

Will HIRSP cover expenses for pre-existing conditions?
 If you have a pre-existing condition, HIRSP will not cover medical 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 or recently lost Medicaid, BadgerCare Plus or other state risk pool 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. (For more information, refer to Six-Month Waiting Period for Coverage of Preexisting Conditions).

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 medical services provided by HIRSP-certified providers. Prescription drugs must be obtained at a HIRSP-certified network pharmacy.

How do I know a provider is HIRSP-certified?
Most Wisconsin providers are HIRSP-certified. If you are unsure if a provider is HIRSP-certified, call HIRSP Customer Service or ask the provider. We can narrow down the search by knowing what specialty and service area (ZIP code) you are looking for.

Does HIRSP cover services provided outside of Wisconsin?
HIRSP does cover major medical expenses provided outside of Wisconsin. If you receive health care services from a health care provider outside of Wisconsin who is not a HIRSP-certified health care provider, HIRSP will pay benefits for those health care services up to the HIRSP allowed amount. You are responsible for any amount billed over the HIRSP allowed amount, which may be up to 40% of the billed charge and also, for any applicable deductible and coinsurance amounts.

How do I know if my drug is Tier 1 or Tier 2?
You can visit the HIRSP Web site at www.hirsp.org/policyholder/ pharmacy.shtml for a listing of covered drugs and information on each Tier. (HIRSP Medicare Supplement pays for drugs that are included on your Medicare Part-D formulary. Check with your Part-D provider for more information on their formulary.)

What is the difference between coinsurance and copayment (copay)?
Coinsurance is a percentage of the covered expense that a policyholder is responsible for (after the deductible is met). Copay is a fixed amount for a covered service/prescription that the policyholder pays.

I am Medicare eligible, but understand that I need to take out a prescription drug plan prior to being eligible for HIRSP Medicare Supplement. Who can I go to for assistance with choosing and enrolling in a prescription drug plan? When choosing a Medicare prescription drug plan, it is important to enroll with a carrier that will suit your prescription needs and meet your premium requirements. Assistance with researching the prescription drug plans you are eligible for is available through Medicare by calling 1-800-633-4227 or by contacting the Wisconsin State Health Insurance Assistance Program (SHIP) at 1-800-242-1060. You may also research your options online at www.medicare.gov.

How does having a Medicare prescription drug plan affect my HIRSP prescription drug coverage?
Your Medicare prescription drug plan will be primary to your HIRSP coverage. Prescriptions must be processed by Medicare and must be on your prescription drug plan’s formulary as covered medications prior to being submitted to HIRSP for secondary coverage. There are a few prescriptions that Medicare excludes that HIRSP will cover such as benzodiazepine and barbiturates. For more information on these covered medications, please see www.hirsp.org/policyholder/pharmacy.shtml.

Where can I get more information on the Health Savings Account?
A Health Savings Account (HSA) is an alternative to traditional health insurance and is one example of “consumer driven health care”. It can be used to not only pay for health related expenses, but can also be used as a mechanism to save for future qualified medical and retiree health expenses on a tax-free basis. For more information visit the United States Department of the Treasury Web site.

Can the funds in an HSA be invested?
You can invest the funds in your HSA. You will want to consult with your financial advisor to determine the benefits of HSA qualified plans.

How do I use my HSA to pay my physician when I’m at the physician’s office?
If you are covered by the HIRSP Health Savings Account plan and have not met your policy deductible, you will be responsible for 100% of the amount HIRSP would have paid (the HIRSP rate) to the physician had you already met your deductible. Your physician may ask you to pay for the services provided before you leave the office. If your HSA custodian (i.e. your bank or other financial institution) provides you with a checkbook or debit card, you can pay your physician directly from the account. If the custodian does not offer these features, you can pay the physician with your own money and reimburse yourself for the expense from the account after your visit.

My spouse and I both want an HSA. How much can we contribute?
Each spouse is eligible to contribute to a health savings account in their own name, up to the statutory limit ($3,050 for 2010)

May a self-employed person contribute to an HSA on a pre-tax basis?
No, self-employed persons may not contribute to an HSA on a pre-tax basis and may not take the amount of their HSA contribution as a deduction for self-employment tax (SECA) purposes. However, they may contribute to an HSA with after-tax dollars and take the above-the-line deductions (contributions to HSA made by the individual).