How to Apply for Coverage

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1. Has resided in Utah for 12 consecutive months immediately preceding the date of application for HIPUtah (the 12-month requirement can be waived if coming from another state's high risk pool);
2. Pays the established premium;
3. Meets the required health underwriting criteria established by the state of Utah; and
4. Does not fall into the ineligible categories listed later in this outline

OR

1. Pays the established premium;
2. Is HIPAA eligible and has at least 18 months of prior coverage, the most recent prior coverage being under a group health plan, government plan, or church plan, and has elected and exhausted COBRA or a state continuation plan where available;
3. Applies for HIPUtah coverage within 63 days of termination from prior coverage; and
4. Does not fall into the ineligible categories listed later in this outline.

Who is NOT Eligible?

A person is NOT eligible for HIPUtah coverage if any one of the following is true:

1. The person is eligible for benefits under Medicaid or Medicare except as provided in Utah Code Ann. -31A-29-112;
2. HIPUtah coverage has been terminated within the last 12 months unless the person demonstrates that continuous other coverage has been involuntarily terminated for any reason other than non-payment of premium, unless the person is HIPAA eligible;
3. The person has exhausted the maximum lifetime benefits of HIPUtah;
4. The person is an inmate of a public institution;
5. The person is eligible for a public health plan through which medical care is provided;
6. The person is eligible for a group health benefit through an employer plan;
7. The person is covered under any other health benefit plan;
8. The person's health condition does not meet the health underwriting criteria established by the state of Utah, unless the person is HIPAA eligible; or
9. The person has not resided in Utah for 12 consecutive months, unless HIPAA eligible.
10. The person's employer pays any part of the individual's health benefit plan premium, either as an insured or a dependent, for pool coverage.

Exclusion Periods

A medical condition that was present before the effective date of coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that day, known as a Pre-Existing Condition, will not be covered by HIPUtah for the first six months following the effective date of coverage except in the following instances when a person is:

• HIPAA eligible; or
• Transferring from an out-of-state high risk pool within established time regulations; or
• Involuntarily terminated from either individual or group coverage and has no other option for coverage.

HIPUtah will not cover services for a pre-existing pregnancy for the first ten months following the effective date of coverage, unless the enrollee is HIPAA eligible.

Are You HIPAA Eligible?

Under a federal law known as HIPAA, which stands for the Health Insurance Portability and Accountability Act, if you are an eligible individual, who has recently lost their employer or union sponsored group health plan you have a right to purchase individual health coverage through HIPUtah, the state of Utah's high-risk pool, without a preexisting condition exclusion.

In order to be HIPAA eligible, all of the following must apply:

• Your last health care coverage must have been under a group plan, governmental plan, or church plan, including COBRA or state continuation coverage, for an aggregate of at least 18 months during which there is no break of 63 or more complete days in a row. This prior health coverage is referred to as "creditable coverage."
• You are not eligible under a group health plan, Medicare, Medicaid, and/or do not have other health insurance coverage.
• You did not lose your latest health coverage due to nonpayment of premium or fraud.
• If you qualify for COBRA or state continuation coverage, you must accept the coverage and continue the coverage for the maximum time period allowed. (When an employer terminates its group health plan entirely, COBRA coverage ends and is considered exhausted.)

Once COBRA or state continuation coverage has been exhausted, you have 63 days to file an application to get a policy through HIPUtah as a HIPAA eligible individual. If you accept a conversion policy or a short-term policy after exhausting COBRA, you give up your HIPAA eligibility. It is important to know that a conversion policy is not a HIPAA policy.

When applying for the high-risk pool you can present a Certificate of Creditable Coverage from your insurance company or health plan showing that you have an aggregate of 18 months of creditable coverage as part of applying for coverage under HIPUtah. If a Certificate of Creditable Coverage is not available, you may document your prior health coverage by other means, including by telephone.

Just Remember, if you are interested in obtaining individual coverage and you meet the other criteria to be an eligible individual, you should apply for this coverage as soon as possible to avoid losing your eligible individual status due to a 63-day break.

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