HIRSP Agent Certification Training

1. HIRSP Agent Certification Training

2. Welcome! By completing today’s training session, you’ll be eligible to receive: • 2 Wisconsin CE credits at no cost (if you have not previously attended the training) • $100 referral fee for each approved HIRSP application (both State and Federal programs) • Listing on www.HIRSP.org

3. HIRSP Overview • An Introduction to HIRSP • Eligibility criteria for all plans • Plan design and options • Application process • Low-income subsidy application (State HIRSP) • Questions & Answers

4. An Introduction to HIRSP • The Health Insurance Risk Sharing Plan was created in 1979 to provide health insurance to Wisconsin residents who were unable to secure coverage through traditional channels. • Almost 24,000 Wisconsin residents currently get their health insurance through the state and federal HIRSP Plans.

5. HIRSP Governance • The HIRSP Authority Board of Directors consists of 14 members representing various facets of the health care and insurance industries, including HIRSP members, two Wisconsin insurance agents and a representative from the Office of the Commissioner of Insurance. • A Consumer Advisory Council also convenes quarterly and provides valuable insight from the member perspective.

6. New Federal Pool • In 2010, HIRSP began offering the Federal pre-existing condition insurance plan (PCIP) health benefit that resulted from the Affordable Care Act (Health Care Reform). • Currently, over 1,800 Wisconsinites get their coverage through HIRSP Federal.

7. HIRSP Funding • HIRSP is funded 60% by member premium payments, 20% by insurer assessments and 20% by provider contributions. • HIRSP Federal is funded through member premiums and federal funds appropriated under the Affordable Care Act. • HIRSP also receives a federal grant which helps fund the low-income subsidy program and offsets the costs of a diabetes chronic condition management program available to all members with diabetes.

8. HIRSP Benefits and Premium Rates HIRSP medical benefits are similar to many private insurance carriers in Wisconsin. HIRSP drug benefits are also comparable to, and in some cases, better than many private carriers. In 2012, HIRSP premium rates continue to be favorable compared to the private market depending on the deductible option selected by the applicant. HIRSP also offers a low-income subsidy program that can help make HIRSP more affordable for some applicants. Links to the HIRSP and HIRSP Federal rates, including the subsidy discounts, can be found online here: http://www.hirsp.org/plans/index.shtml

9. Eligibility: State HIRSP All applicants must be legal Wisconsin residents, under 65, who are not eligible for employer-sponsored coverage, Medicaid or BadgerCare Plus Standard Plan.

10. Medically Uninsurable Applicants may qualify as medically uninsurable if they: In the past nine months, received at least one of the following from insurers, based wholly or partially on medical underwriting considerations. A notice of rejection from one or more insurers. A notice of cancellation. A notice of significant reduction or limitation of coverage, including restrictive riders. A notice of an increase in their premium of 50% or more. Two or more offers for insurance with premiums at least 50% higher than what they would be charged for a standard individual policy with substantially the same coverage and deductibles as HIRSP. Are eligible for Medicare because of a disability, or Tested positive for the Human Immunodeficiency Virus (HIV).

11. HIPPA: State HIRSP Eligibility based on loss of group coverage The applicant did not voluntarily cancel their most recent period of creditable coverage. The applicant exhausted their continuation coverage under their employer-offered group health insurance, including state continuation coverage or Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage, if offered. Including this employer-offered group health insurance, the applicant has had continuous insurance coverage for at least 18 months with no gap in coverage greater than 63 days. The applicant does not have creditable coverage and is not eligible for Medicare or Medicaid. The applicant is applying to HIRSP within 63 days of losing their employer-offered group health insurance, including COBRA, if offered.

12. Eligibility Exceptions • Employer-sponsored coverage with an annual actuarial value of $100,000 or less is not considered employer-sponsored coverage for HIRSP eligibility. • Individuals whose COBRA premium is more expensive than the HIRSP premium for comparable coverage can apply to HIRSP as medically uninsurable without exhausting COBRA. These individuals would be subject to the six month waiting period for pre-existing conditions

13. Pre-Existing Condition Waiting Period Applicants who are eligible for HIRSP as medically uninsurable must serve a six month waiting period for coverage of their pre-existing conditions. Some exceptions are: • Applicants who apply within 45 days of losing Medicaid, BadgerCare Plus, Medicare or another state’s risk pool if they were enrolled in the other pool for at least 12 months. • Applicants applying due to a disability who would otherwise qualify due to loss of group coverage (under HIPAA), except for their Medicare eligibility. • Applicants who have received a 50% or more premium increase from the Farmers Health Cooperative (FHC), if they have been insured by FHC for at least 6 months. • Applicants who apply to HIRSP within 63 days after losing their individual insurance coverage because their insurer pulled out of the Wisconsin market, if the applicant had been covered under the policy for six months. • Applicants who apply to HIRSP within 45 days of losing eligibility for coverage under student health insurance (i.e. creditable coverage offered by a University or College for its enrolled students) if they had 18 months of creditable coverage prior to the requested effective date and meet current HIRSP eligibility criteria. Members who are eligible for HIRSP under HIPAA andHIRSP Federalmembers arenotsubject to a waitingperiod for coverage of their pre-existing conditions.

14. Pre-Existing Condition Waiting Period (Con’t) • A pre-existing condition is a condition which was diagnosed or for which medical advice, care or treatment was recommended or received in the six months prior to the effective date of coverage. • Use of prescription medication are considered treatment for a medical condition when determining whether the member is subject to the waiting period. • The six month pre-existing condition waiting period only applies to medical services. During the waiting period, members will have coverage for their prescription drugs. • The waiting period does not apply to hearing aid and cochlear implants for members under age 18.

15. Eligibility: HIRSP Federal • Legal Wisconsin residents who have had no creditable coverage for 6 months. AND • A written diagnosis from a physician for one of dozens of health conditions listed on the HIRSP website. The letter must be dated within nine months of applying and the applicant must have been diagnosed or treated within the previous five years. OR • A rejection, coverage reduction or cancellation of coverage from a private insurance carrier.

16. Coordination with Other Insurance • HIRSP members CANNOT be eligible for or enrolled in group-sponsored coverage or comprehensive Medicaid or BadgerCare Plus Standard Plan. • However, HIRSP members CAN be eligible for or enrolled in other individual insurance products or BadgerCare Plus Core, Benchmark or Basic plans. • In all cases except the BadgerCare Plus Basic Plan, HIRSP is the secondary payer. • HIRSP Federal Plan members CANNOT be enrolled in other creditable coverage and still maintain their HIRSP Federal eligibility/coverage, but they CAN be eligible for other creditable coverage, including group-sponsored coverage, Medicaid, Medicare or BadgerCare Plus.

17. Plan Options: State/Federal • HIRSP offers three standard deductible and coinsurance plans: $1,000, $2,500 and $5,000. • Two Health Savings Account (HSA) qualified plans: $2,500 and $3,500. HSA plans do not offer first dollar drug coverage. • One Medicare Supplement Plan: $500 deductible. • The HIRSP Federal Plan offers four standard deductible and coinsurance plans: $500, $1,000, $2,500 and $3,500. • HIRSP will be offering a $7,500 deductible plan starting in 2013.

18. Drug Benefit: State/Federal • HIRSP and HIRSP Federal offer a comprehensive drug benefit with both generic and brand name drug coverage. • Both plans require the use of generic medications, where available, for new prescriptions. • The HIRSP and HIRSP Federal formulary can be viewed here: https://www.medtrakservices.com/HIRSP_Drug_Lookup.aspx.

19. Drug Cost Sharing: State/Federal HIRSP currently uses a three tier formulary. Tier 1 copayments are $5 Tier 2 copayments are $55 Tier 3 copayments are $75 • The HIRSP Federal Plan formulary uses two tiers. • Tier 1 copayments are $5 • Tier 2 copayments are $45

20. Drug Out-of-Pocket: State/Federal The annual maximum drug out-of pocket cost for HIRSP members is $2,500 in 2012 and 2013. The HIRSP Medicare Supplement Plan annual maximum out-of-pocket cost is $1,750 in 2012 and 2013. The HIRSP Federal Plan annual maximum drug out-of-pocket cost for the $500, $1,000 and $2,500 deductible plans is $2,000 in 2012 and 2013. The HIRSP Federal Plan annual maximum drug out-of-pocket cost for the $3,500 deductible plan is $1,550 in 2012 and $1,750 in 2013.

21. Medical Coverage: State/Federal • HIRSP and HIRSP Federal offer comprehensive medical benefits, including first dollar coverage for one annual physical exam, preventive screenings such as colonoscopies, mammograms and pap tests, and many vaccinations, including flu shots at the pharmacy. • HIRSP and HIRSP Federal also offer comprehensive mental health benefits (parity).

22. Networks: State/Federal • The HIRSP and HIRSP Federal network consists of all Wisconsin Medicaid certified providers. • All Wisconsin hospitals are Wisconsin Medicaid certified. • HIRSP and HIRSP Federal members can also see out-of-state providers that are not Wisconsin Medicaid certified. In these cases, HIRSP or HIRSP Federal will pay it’s standard rate for services and the member may be balance billed by the provider.

23. Applying for HIRSP • Applications are available at www.HIRSP.org for either online form-fill or download/print/fill. • When applying online, agents and applicants can start an application without finishing and return later to finish by writing down the application number and reentering that number when they return to complete the application. • There is an “Eligibility Wizard” available on the HIRSP homepage that provides an initial eligibility determination in minutes. • Applying online or via fax (608.243.6136)are the quickest ways to get an application approved.

24. Applying for HIRSP • If applying due to loss of group coverage the applicant does NOT need to submit a letter of rejection, but MUSTsubmit a creditable coverage letter(s) showing 18 months of creditable coverage with no gap longer than 63 days. The most recent coverage must be under a group plan. • Please be sure to review the checklist at the end of the application to verify that the application submission is complete. • HIRSP can provide an effective date as of the date we receive a COMPLETED application packet. • HIRSP Federal effective dates are the 1st of the month following receipt of a COMPLETED application packet. • Review and approval time for completed applications are typically less than five business days. Please call Customer Service within 5 business days to check on the status of the application.

25. Applying for HIRSP • HIRSP and HIRSP Federal applications are held open for 30 days from the initial submission. • If only the creditable coverage letter is missing, the application will be held open for 45 days. • Please be sure to check the authorization box at the end of the “Agent Information” section of the HIRSP and HIRSP Federal applications so that you can call Customer Service at 1.800.828.4777 (HIRSP) or 1.888.253.2698 (Federal) to check on the status of your applications. If you are also a WPS certified agent you can check the status of your HIRSP applications by logging into the WPS website.

26. Low-Income Subsidy Application • Please note that the low-income subsidy program is only available to HIRSP members. HIRSP Federal Plan members are not eligible for a low-income subsidy. • At the time you submit the enrollment application, if your client’s annual household income is below $34,000, please also submit an application for reduced premium, deductible and drug out-of-pocket maximum. • Also, if you have clients whose financial situations have changed recently due to divorce, loss of employment or death of a spouse, you may also submit an emergency application for reduced premium, deductible and drug out-of-pocket maximum. • You will need the client’s most recent federal and state income tax return to submit with the application. • Both subsidy applications can be found here: http://www.hirsp.org/plans/state-low-income.shtml.

27. Accompanying Documentation Please include the following documentation with each application if applicable: • Signed and dated HIRSP or HIRSP Federal application. • Driver’s license, state ID, voter registration or Wisconsin tax return (for residency). • First month/quarter’s premium payment if your client elects quarterly direct billing or automatic withdrawal. If your client chooses credit card payments, you do not need to submit the initial premium payment. • Letter of rejection from a private carrier if applying for medical reasons or a physician letter if applying for HIRSP Federal. • Letter of creditable coverage if applying due to loss of group coverage. • If employed or spouse is employed, submit a letter from the employer stating they do not offer employer-sponsored coverage. • HIPAA Authorization Form: http://www.hirsp.org/policyholder/privacy.shtml. • Signed application for reduced premium, deductible and drug out-of-pocket maximum, if applicable, or signed and notarizedemergency subsidy application.

28. Referral Fee • HIRSP currently pays $40 for non-certified agents and $100 for certified agents for approved applications. • All agents attending a HIRSP Agent Certification Course will be considered “HIRSP and HIRSP Federal Certified” and will receive $100 for approved applications. • The $100 referral fee will apply to all applications approved after completion of the certification course.

29. QUESTIONS & ANSWERS