Washington Health Insurance Guide
Washington Health Insurance Resources, Health Organizations, and Online
Insurance Quotes for WA State Residents
As a resident of Washington you can choose from a variety of private health insurance plans including plans for individuals and group plans provided by an employer. Depending on your income or employment status, you may also be eligible for Washington State-funded affordable health insurance for individuals and families, and federal programs such as Medicaid and COBRA.
Washington is not a guarantee issue state for individual health insurance policies in the strictest sense of the term. Insurance companies are allowed to determine your eligibility by assigning points based on the answers you supply about your health history on your application. If you amass fewer than 325 points, you cannot be turned down. However, if you amass over 325 points, you can be denied coverage. The point system does not apply if you are merely moving somewhere else in Washington State that your current insurer does not service or if you need to change insurance plans to keep your doctor. But note that you can be denied enrollment if a health insurer currently has too many enrollees. In Washington, health insurers are permitted a nine-month exclusionary period and a six-month look-back person (also called a prudent person rule) to check for pre-existing conditions, which can include pregnancy, unless you can show adequate proof of prior creditable coverage. In Washington, health insurers cannot base your premium on your health, but can base them on your age, lifestyle, family size, plan selected and other factors.
Insurers are required by law to offer one standardized plan, the Washington Basic Health Plan, for individuals and small groups. Coverage cannot vary but premiums may, depending on the provider.
Washington is a guarantee issue state for group health plans issued to small businesses, as long a participation requirements and other employment eligibility criteria are met. If your Washington health insurance is provided through your employer, your coverage cannot be denied because of your past or current health. The insurer can impose a nine-month exclusionary period and a six-month look-back period for pre-existing medical conditions, but must give credit for prior creditable coverage if there has been no more than a 63-day break in coverage. Your employer may impose a waiting period for eligibility for new hires, but it must be applied equally to all new hires. Premiums for small group health insurance are based on a community rating, age of plan participants, your family size and the location of the company. Small group insurers can charge a premium not to exceed 375% of the standard rate if your group has a history of unfavorable health.
Washington is a guaranteed renewal state. Regardless of your health, your insurer must renew your individual health insurance policy as long as you’ve paid your premiums on time and haven’t defrauded the company, or in the case of some HMOs, as long as you haven’t moved out of the service area. However, your premiums can be increased to reflect your current health status. Your policy can be canceled if your insurer discontinues a plan or no longer sells insurance in the state.
Washington Mandated Health Benefits
Washington laws require private health insurance policies to cover several state-mandated benefits. These currently include:
- Alcoholism and Drug Abuse Treatment
- Birthing Centers/Midwives
- Breast Reconstruction
- Cleft Palate
- Colorectal Cancer Screening
- Contraceptives
- Dental Anesthesia
- Diabetes Supplies and Self Management
- Emergency Services
- Home Health Care
- Hospice Care
- HPV Vaccine
- Mammograms
- Maternity and Maternity Stays
- General Mental Health
- Neurodevelopment Therapy
- Off-Label Drug Use
- PKU/Formula
- Port Wine Stain Elimination
- Prescription Drugs
- Prostate Cancer Screening
- Second Surgical Opinion
- TMJ Disorder
- Coverage for newborns under their parent's policy
- Coverage for adopted children under their parent's policy
- Coverage for handicapped dependents under thier guardian's policy
- Coverage for continuation/dependents under their guardian’s policy
- Coverage for conversion to non-group
- Coverage for continuation/employees
- Coverage for domestic partners
Types Health Insurance Plans Available in Washington
The following major medical health insurance plans are generally available in Washington. Major medical plans cover illness and injury, hospitalization, prescription drugs and office visits, as well as the mandated services stated above.
Indemnity plans - Typically the most flexible and therefore highest priced choice, an indemnity plan lets you select your health providers and facilities. Depending on your plan, you will have to pay a deductible or co-insurance.
Preferred provider organization plans (PPOs) - You select from a network of preferred health care providers and facilities, and receive services at an agreed-upon discounted rate. You also have the option of going outside the network, but typically at a higher cost. You do not need a referral from a primary care physician to see a specialist. Premiums may be less than an indemnity plan but more than an HMO. You will have to pay a deductible or co-insurance.
Health maintenance organizations (HMOs) - HMOs plans require you to select a primary care physician from a prescribed network of providers, who must issue a referral before you can see a specialist. Services and covered costs are typically more comprehensive than those provided by a PPO. HMOs offer the advantage of affordable premiums and low out-of-pocket costs, with an emphasis on preventive care. Non-emergency services out of network are usually not reimbursed.
Alternative Health Programs in Washington
Washington State Health Insurance Pool
WSHIP is the state-sponsored high-risk pool that offers health insurance if you are a Washington resident and cannot obtain private health insurance because of a pre-existing condition. Other eligibility requirements apply. Three PPO plans are offered, each with various deductible levels, coinsurance requirements and maximum out-of-pocket expenses. The plan is also available as a Health Savings Account Plan. Coinsurance for most treatments is 20%. Maximum out-of-pocket includes the deductible and varies depending on deductible level selected. After deductible is satisfied, plans pay 100% of covered services. Premiums are based on the plan you select and your age but are capped between 110% and 150% of the rate charged for similar coverage in Washington. Enrollment is open. There may be a six-month waiting period for pre-existing conditions, but credit will be given for prior creditable coverage.
Washington Children’s Health Insurance Program
Washington CHIP provides comprehensive free or low-cost health care for resident children up to age 19, whose families meet income requirements and other eligibility requirements. There are two plans to select from including a fee-for-service plan and a managed care plan. Assignment will depend on where you live. Modest premiums of $15 per month per child are assessed monthly. There are no co-pays for covered services. There may be a four-month waiting period under certain circumstances, but it can be waived. Enrollment is open but is subject to review and renewal every six months.
Regulating Agency
The Washington State Office of the Insurance Commissioner is responsible for regulating Washington’s health insurance industry.
Get access to Washington health insurance quotes from http://www.einsurance.com/health-insurance.
Washington State Office of the Insurance Commissioner
PO Box 40256
Olympia, WA 98504-0256
(800) 562-6900
http://www.insurance.wa.gov
Washington State Insurance Pool (WSHIP)
PO Box 1090
Great Bend, KS 67530
(800) 877-5187
https://www.wship.org
Washington Children’s Health Insurance Program
PO Box 45449
Olympia, WA 98504
(877) KIDS-NOW
(NAIC) National Association of Insurance Commissioners
The National Association of Insurance Commissioners (NAIC) is the organization of insurance regulators from the 50 states, the District of Columbia and the five U.S. territories. The NAIC provides a forum for the development of uniform policy when uniformity is appropriate. NAIC members are the elected or appointed state government officials who along with their departments and staff regulate the conduct of insurance companies and agents in their respective state or territory.
http://www.naic.org/
Insurance Information Institute (I.I.I)
The mission of the Insurance Information Institute (I.I.I.) is to improve public understanding of insurance -- what it does and how it works.
Contact info:
110 William Street
New York, NY 10038
212-346-5500
http://www.iii.org/