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About HIPUtah

UTAH COMPREHENSIVE HEALTH INSURANCE POOL (HIPUtah)

The Utah Comprehensive Health Insurance Pool is a state-run program for people with high health risks (called a high risk pool). HIP sells individual coverage to those who are federally eligible and to others with serious health conditions who cannot buy affordable coverage from private health insurance companies. Every health insurer writing individual health insurance in Utah must provide a written notice to each applicant for health insurance coverage that is denied coverage by the because of health condition. This notice must advise them of the availability of the HIP plan.

In 1990, the Utah Legislature passed the Comprehensive Health Insurance Pool Act to provide health insurance to individuals who are medically uninsurable. Lawmakers initially appropriated $2,000,000 in taxpayer funds with additional appropriations each year to subsidize the premiums paid by Enrollees. Regence BlueCross BlueShield of Utah was selected to administer the Utah Comprehensive Health Insurance Pool ("HIP").

HIP is operated by a Board of Directors appointed by the governor. As the HIP Administrator, Regence BlueCross BlueShield of Utah will issue health insurance to eligible applicants on behalf of HIP. Enrollment will be limited to make sure the program stays within its budget. Once the enrollment limit is reached, applicants are placed on a waiting list in order of receipt of a complete application. Applications are reviewed on a first-come, first-served basis.

Coverage in HIP is not guaranteed. Each application will be carefully reviewed to assure that all eligibility requirements met. If an applicant is eligible for coverage in the private market, he or she is not eligible for HIP.

For benefits to be paid, covered services must be provided or directly ordered by the Enrollee's Personal Physician or the Secondary Care Physician to whom the Enrollee was referred by the Personal Physician. A Secondary Care Physician is not authorized to refer the Enrollee to another physician. If the Personal Physician or Secondary Care Physician provides or directly orders services that are not covered, there are no benefits. A Personal Physician's referral is not a guarantee of payment.

Applicants must select a calendar year deductible of either $500 or $1,000. This deductible applies only to services eligible for coverage in HJP.

After deductible, HIP will pay 80% of eligible charges for services provided by participating providers. HIP will pay 60% of eligible charges provided by nonparticipating providers.

The amount an Enrollee must pay for deductible and coinsurance in a calendar year is $2,000 with the $1,000 deductible plan and $1,500 with the $500 deductible plan. After this amount, HIP will pay 100% of eligible expenses in that calendar year if covered services are provided by a participating provider, and 95% of eligible expenses in that calendar year if covered services are provided by a non-participating provider (the Enrollee must pay the balance for services by non-.participating providers).

A HIP policy may exclude coverage during a 6-month period following the effective date of plan coverage for a pre-existing condition as long as one of the following exists:

a. The condition occurred within a period of 6 months before the effective date of coverage in such a manner as would cause an ordinarily prudent person to seek diagnosis or treatment; or

b. Medical advice or treatment was recommended or received for the condition within a period of 6 months before the effective date of coverage; or

c. A HIP policy may exclude coverage for pregnancies for 10 months following the effective date of coverage.

The pre-existing condition exclusion are waived to the extent to which similar exclusions have been satisfied under any prior health insurance coverage:

a. Which was involuntarily terminated, other than for nonpayment of premium; or

b. Whose premium rate exceeds the rate of the pool for equal or lesser benefits.

The waiting period of a person with a pre-existing condition is waived if the waiting period was satisfied under a similar plan from another state and the other state's benefit limitation was not reached, or if the individual is HIPAA eligible.

Certain services require prior approval or referral from the Enrollee’s Personal Physician. It is the Enrollees responsibility to assure that such prior approval or referral is obtained prior to services being provided. These rules are modified for emergency services.

The maximum benefits provided by HIP are $200,000 each calendar year with a maximum lifetime benefit of $1,000,000. Certain benefits provided by HIP have specific maximum benefit limits that are provided in the HIP Policy (e.g., substance abuse, mental conditions).

This description is not an insurance policy and the information provided is governed by the specific terms and conditions of the HIP Policy issued to Enrollees.