HIRSP Agent Certification Training August 21, 2013

1. HIRSP Agent Certification Training August 21, 2013

2. Welcome! By completing today’s training session, you’ll be eligible to receive: • A $100 referral fee for each approved HIRSP application. • A listing on www.HIRSP.org for members seeking new coverage in 2014.

3. HIRSP Overview • An Introduction to HIRSP • Eligibility criteria for all plans • Plan design and options • Application process • Low-income subsidy application • 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 25,000 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 2,200 Wisconsinites get their coverage through the HIRSP Federal Plan. • Enrollment in the HIRSP Federal Plan was suspended effective March 2, 2013.

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 2013, 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 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. 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.

16. Plan Options • HIRSP offers four standard deductible and coinsurance plans: $1,000, $2,500, $5,000 and $7,500. • 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.

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

18. Drug Cost Sharing HIRSP currently uses a three tier formulary. Tier 1 copayments are $5 Tier 2 copayments are $55 Tier 3 copayments are $75

19. Drug Out-of-Pocket The annual maximum drug out-of pocket cost for HIRSP members is $2,500 in 2013. The HIRSP Medicare Supplement Plan annual maximum out-of-pocket cost is $1,750 in 2013.

20. Medical Coverage • HIRSP offers 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 also offers comprehensive mental health benefits (parity).

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

22. 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. • Applying online or via fax (608.243.6136)are the quickest ways to get an application approved.

23. 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. • 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.

24. Applying for HIRSP • HIRSP 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 applications so that you can call Customer Service at 1.800.828.4777 (HIRSP) 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.

25. Low-Income Subsidy Application • 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.

26. Accompanying Documentation Please include the following documentation with each application if applicable: • Signed and dated HIRSP 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. • 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.

27. 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 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. HIRSP Application Number • Save this number • Print or Copy • Leave at any time • Number is only available for 10 days from the last time you visit the online application

30. Help text is found on the right side of the application • Important Message

34. Initial premium paymentIf auto withdrawal or credit card is selected as the payment option and the initial premium payment is not submitted with the application, we will withdraw the payment from the applicant’s bank account or charge the credit card the initial premium payment upon the approval of the application.

36. Healthcare Reform • For weekly reform updates please provide your email address using the “Healthcare Reform Notifications” button on the HIRSP homepage. • To review a detailed list of frequently asked questions about HIRSP and reform, please visit the HIRSP Healthcare Reform webpage at: http://www.hirsp.org/reform/index.shtml.

37. Healthcare Reform • HIRSP and HIRSP Federal Plan members must enroll in a new health plan by December 15, 2013 to ensure continuous coverage beginning January 1, 2014. • If members do not enroll in a new health plan by December 15th, the earliest they can get coverage is February 1, 2014. • If members do not enroll in a new health plan by March 31, 2014 they will not be able to enroll in new coverage for the remainder of 2014 unless they have a qualifying event.

38. Healthcare Reform & Medicare • HIRSP Medicare Supplement members will need to select a commercial Medicare Supplement Plan (Medigap) after they receive their HIRSP termination notice, but no later than December 31, 2013, or a Medicare Advantage Plan (Part C) during the Medicare Annual Enrollment Period from October 15, 2013 through December 7, 2013 for coverage to take effect on January 1, 2014. • If a member does not choose a commercial Medigap Plan by December 31st, they will have a special 63 day enrollment period beginning January 1, 2014 to purchase a Medigap policy. • For members who prefer to enroll in an Advantage Plan, they will qualify for a Special Election Period for two months after the last date of HIRSP coverage to select a new Medicare Part D plan or to select an Advantage Plan with Part D coverage. • Members who are on kidney dialysis are not eligible for Medicare Advantage or Cost Plans.

39. QUESTIONS & ANSWERS