UTAH COMPREHENSIVE HEALTH INSURANCE POOL (HIPUtah)
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.
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
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.
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.
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.
must select a calendar year deductible of either $500 or $1,000.
This deductible applies only to services eligible for coverage in
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.
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
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
advice or treatment was recommended or received for the condition
within a period of 6 months before the effective date of coverage;
c. A HIP policy
may exclude coverage for pregnancies for 10 months following the
effective date of coverage.
pre-existing condition exclusion are waived to the extent to which
similar exclusions have been satisfied under any prior health insurance
a. Which was
involuntarily terminated, other than for nonpayment of premium;
b. Whose premium
rate exceeds the rate of the pool for equal or lesser benefits.
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.
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.
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).
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.