The Health Insurance Risk Sharing Plan of Wisconsin (HIRSP) was the state’s high-risk pool.
Due to underwriting changes issued by the Affordable Care Act,
ALL PRE-EXISTING CONDITION PROGRAMS (PCIPs) in the U.S. have CLOSED.
Please contact the Wisconsin Department of Health Services to review your low-cost or FREE health insurance options.
Department of Health Services
1 West Wilson Street
Madison, WI 53703
TTY: 711 or 800-947-3529
Prior to the Affordable Care Act removing this program, HIRSP was in place for more than 30 years to help individuals who lost their benefits or were continually declined by insurers.
About the former HIRSP Program in Wisconsin
Members receive health benefits through comprehensive plans offered through HIRSP that compare to a private health plan, minus the rate increases.
In 2010, HIRSP also adopted the federal temporary high risk pool Pre-Existing Condition Insurance Plan (PCIP). PCIP offers coverage specifically to individuals who have been uninsured for at least six months and have a condition that has caused them to be uninsurable. Unlike the state program, which imposes a six month waiting period for pre-existing conditions, coverage for conditions starts instantly in the federal plan.
HIRSP is a part of the National Association of State Comprehensive Health Plans (NASCHIP), the organization establishing regulations and quality guidelines for state high-risk pools. They also offer coverage through a Medicare Supplement plan, which covers those who are already enrolled in HIRSP when they turn 65, or those who have a disability.
In order to qualify for most HIRSP plans, you must not have access to coverage through an employer, the government, or any other source, and provide adequate documentation of your uninsurability. All who are eligible must be Wisconsin residents, and under age 65, unless you are not eligible for Medicare. The Wisconsin risk pool does not have any income requirements. By either loss of coverage through employer-sponsored benefits, or rejection by insurers due to a pre-existing condition, you can enroll in HIRSP. For each group of individuals, the following guidelines apply.
Loss of Group Coverage
Proving your eligiblity for HIRSP after losing coverage through an employer, you have to meet each of the requirements below. Those who apply for coverage in this category will not experience a waiting period for pre-existing conditions.
- You have lost your employer-sponsored health benefits. To provide documentation, you must send HIRSP a certificate of creditable coverage from past insurers or employers, or other proof such as your health insurance ID card.
- Your coverage was not canceled voluntarily.
- You exhausted your coverage continuation benefits, including COBRA, if offered.
- Including the group health plan, you have had continuous coverage for at least 18 months with no breaks in coverage over 63 days.
- You apply for HIRSP within 63 days of losing group coverage and COBRA, if offered.
- You do not qualify for Medicare.
If you have meet one of the following requirements, you are able to receive coverage through HIRSP. Those with pre-existing conditions are subject to a six month waiting period for benefits related to their condition only. Applicants with medical conditions must be residents of Wisconsin for at least three months as of your effective date in the high risk pool, except for those who have been enrolled in another state high risk pool for one year and apply within 45 days of your plan’s end. Applicants must be able to document one of the following criteria:
- Medicare eligible due to a disability
- Received one of the following from insurance companies in the past 9 months:
- Rejection notice from one or more insurers
- Benefit termination notice
- Notice of reduction or limitation of coverage, including restrictive riders
- Notice of premium increase of at least 50 percent
- Two or more insurance quotes with premiums at least 50 percent higher than a standard comprehensive policy similar to HIRSP coverage
Like a private insurer, HIRSP offers plans in deductibles of $1,000 to $7,500, with monthly premiums varying based on age and tobacco use. All comprehensive plans provide 80 percent coverage for medical care after deductible, with out-of-pocket limits that vary with each deductible. Prescription drugs are included for a copay with each tier, starting at $5 for Tier 1. There are also Health Savings Account plans for those who want a federally qualified high deductible plan. HSAs include all benefits in the deductible, offering no services for a copay. Coverage is also 80 percent after deductible with HSA plans.
HIRSP plans cover any services viewed as medically necessary and appropriate according to their company policy. This includes preventive services and many other types of care that and individual may need based on their age, gender, health status, and lifestyle traits that may put them at risk. Preventive care is covered at 100 percent for any plan member in need of routine exams, immunizations, screenings, or any other appropriate service. Prescription drugs can be filled through a HIRSP contracted pharmacy. Prior Approval may be needed for certain services, with the exception of those on the HIRSP Medicare Supplement plan. Many benefits including those listed below are covered by HIRSP plans.
- Preventive care
- Physician office visits
- Prescription drugs
- Home health care
- Surgical services
- Laboratory and X-ray
- Skilled nursing services
- Annual physical exam
- Hospice care
- Pap test and pelvic exam
All care can be obtained through a certified Medicaid provider anywhere in Wisconsin. To locate a certified provider, call 800-828-4777.
HIRSP Federal Plans
The HIRSP Federal Plan has several different qualities and eligibility requirements from the state plan. Those who qualify must be Wisconsin residents and be U.S. citizens or legal immigrants, but they must also not have coverage of any sort for at least six months prior to the HIRSP Federal Plan start date. You must either have a physician’s statement confirming you have a qualifying medical condition, or provide documentation of rejection from an insurer; reduction or limitation on benefits, including riders; a premium increase of at least 50 percent; or two or more quotes with premiums at least 50 percent above average.
Plans are offered in deductibles ranging from $500 to $3,500, and cover 80 percent after deductible for medical expenses. Federal Plans cover all the same services as the state HIRSP plans, and are available through Medicaid providers. Premiums vary based on age and tobacco use, and coverage starts immediately, even for care related to your pre-existing condition. These plans are better for those who need treatment for their medical problem right away and perhaps want a lower deductible.
How to Apply
Visit the HIRSP website and go through the easy online application process. It will ask you questions regarding eligibility and guide you towards the right plan to fit your needs.
1. HIRSP. “About HIRSP.” http://www.hirsp.org/about/.
2. HIRSP. “HIRSP (State Level) Plans – Eligibility.” http://www.hirsp.org/plans/state-eligibility.shtml.
3. HIRSP. “HIRSP (State Level) Plans – Covered Services.” http://www.hirsp.org/plans/state-coverage.shtml.
4. HIRSP. “HIRSP Federal Plan – Eligibility.” http://www.hirsp.org/plans/federal-eligibility.shtml.
5. HIRSP. “HIRSP Federal Plans.” http://www.hirsp.org/plans/federal-plans.shtml.