SHIBA Statewide Health Insurance Benefits Advisors

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SHIBA Statewide Health Insurance Benefits
Advisors
Health Care Coverage Understanding Your Options

• Sponsored by the Office of the Insurance
  Commissioner

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SHIBA HelpLine mission statement

• SHIBA HelpLine provides free, unbiased
  information about health care coverage and access
  to help improve the lives of all Washington state
  residents.  We cultivate community commitment
  through partnership, service and volunteering.  

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SHIBA HelpLine contact info

• Statewide 1-800-562-6900
• Local _____________
• http//www.insurance.wa.gov/shiba

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Questions

• Do you know someone with no health coverage?
• Can they afford the costs of coverage they may
  have?
• What do they do when they get sick or hurt?

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Todays overview

1. Health care coverage basics
2. Options you may already have
3. Options based on income and assets
4. Options based on work
5. Options you may buy
6. Options if you have pre-ex. conditions
7. Other options
8. Shopping tips watch out for fraud
9. For more information

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Health care coverage

• What is it?
• Any product or resource that helps pay for
  medical services and other health care costs
• You may have to pay a portion of costs
  (especially with insurance plans)
• Premium monthly charge
• Deductible what you pay at the start of
  calendar year before plan starts to pay
• Copay/coinsurance your cost per visit

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Health care coverage

• Why get it?
• Uninsured people may avoid getting treatment
• Small medical conditions can become major health
  and financial problems
• Think about how much you are willing and able to
  risk

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Health care coverage

• You might use more than one product or resource
• Some you must use alone
• Some you may piece together
• Sometimes family members will need different
  things

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Options you may already have

• VA benefits for some veterans
• 1-800-562-2308 (Washington state)
• http//www.dva.wa.gov/
• TRICARE military insurance
• 1-800-538-9552 or 1-888-874-9378
• http//www.tricare.mil/
• ChampVA survivors of veterans
• 1-800-733-8387
• http//www.va.gov/hac/forbeneficiaries/champva/cha
  mpva.asp

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Options you may already have

• Indian Health Services or Tribal Clinics
• Each tribe sets criteria and benefits
• May also cover children of tribal members
• Contact Tribal clinics directly
• Contact IHS at 503-414-5555 or
  http//www.ihs.gov/
• Urban Indian Clinics (King and Spokane counties)

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Options based on income and assets

• Not available for everyone
• Some programs for specific groups (children,
  pregnant women, disabled, etc.)
• Often specific criteria to qualify
• SHIBA can help you!
• Screening to see if you may qualify
• Refer you to where to apply

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Options based on income and assets

• State Medicaid (DSHS)
• Many different programs
• Apple Health for Kids
• Provider One
• Often free, some have small premiums
• No wait period for pre-existing conditions
• Enrollment based on income and assets
• Must be in a category

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Options based on income and assets
DSHS categories - People who

• Are Age 65
• Are Blind
• Are Children under age 19

• Have a Disability
• Are Expecting
• Are in Families with kids under age 19

• Apply/ask questions
• 1-877-501-2233 or 1-800-562-3022
• http//www.dshs.wa.gov/
• Your local Community Services Office

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Options based on income and assets

• Apple Health for Kids (DSHS)
• Low-cost coverage for kids under age 19
• In 2011, folks qualify with income less than
• 3,678/month for a family of two
• 5,589/month for a family of four
• Contact Apple Health for Kids
• 1-877-543-7669
• http//hrsa.dshs.wa.gov/applehealth/
• Your local Community Services Office

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Options based on income and assets

• Basic Health
• Coverage for some people ages 19-64
• Must prove citizenship and have income under 133
  FPL
• Under 1,734 per month (single person)
• Under 3,534 per month (family of 4)
• A long wait list but some folks may bypass
• Contact Basic Health
• 1-800-660-9840
• http//www.basichealth.hca.wa.gov/

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Options based on income and assets

• Basic Health Who can join right away?
• Foster parents and personal care workers
• Health Coverage Tax Credit recipients
• Tribal sponsored account recipients
• Some Washington National Guard members and
  reservists
• Basic Health Plus and Maternity applicants BH
  referred to DSHS, if DSHS found them ineligible
• BH recipients who left for Medicaid and then lost
  Medicaid

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Options based on income and assets

• Clinic care
• Community clinics http//www.chs.hca.wa.gov/clin
  ics.html
• Rural health clinics http//www.doh.wa.gov/hsqa/
  ocrh/RHC/Fed_DesignRHCs.pdf
• Charity care
• Hospitals must write off (or not collect) all or
  part of some bills
• Other providers may do this as well

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Options based on work

• Health insurance through work
• Every plan is different
• What it covers
• Who it covers
• What it costs
• May be through your own job
• May be through job of your spouse, domestic
  partner, or parents
• May cover adult children up to age 26
• Retiree coverage Through former work

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Options based on work

• COBRA coverage
• A way for workers (and people their policy
  covers) to keep coverage they might lose
• Many large employers (20 workers) must offer it
  for qualifying events
• Job loss or reduction of hours
• Death or divorce of covered spouse, etc.
• Extends coverage up to 36 months
• Costs to keep coverage may be very high

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Options based on work

• Other continuation coverage
• Option to keep coverage you might lose
• Through some COBRA-exempt employers
• Ask employer/benefits dept. for details
• Association plans through some professional
  groups or trade associations
• Often available in specific industries
• May be through chambers of commerce, religious or
  fraternal organizations, trusts and unions

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Options based on work

• Special options for
• Small businesses
• Self-employed
• Sole proprietor
• Get details from Insurance Commissioners Office
  1-800-562-6900 or http//insurance.wa.gov
• Health Ins. Partnership (HIP)
• Help some small businesses cover workers
• 1-800-377-0976 or http//www.hip.hca.wa.gov/

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Options based on work

• For more information
• Employer/benefits department
• Insurance Commissioners Office
• 1-800-562-6900
• http//insurance.wa.gov/
• Based on whether the plan follows state or
  federal law, they may also refer you to U.S.
  Department of Labor 1-866-444-3272

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Options you may buy

• Individual insurance
• Buy insurance directly from ins. company
• Variety of coverage options and plans
• Costs vary greatly based on
• Your age
• Whether you smoke
• Where you live (county)
• How many people you want to cover (yourself or
  other family members)
• Plan benefits (size of deductible, catastrophic
  or comprehensive coverage, etc.)

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Options you may buy

• Individual Insurance
• May have a wait period before covering
  pre-existing conditions
• 9 month wait
• 6 month look back for pre-existing conditions
• Plans may waive this if you had comprehensive
  coverage right before buying individual insurance

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Options you may buy

• To buy individual insurance
• Most applicants must first complete and pass
  Standard Health Questionnaire (SHQ)
• Written health screening
• Same screening used by all insurers
• See example and scoring information at
  https//www.wship.org/
• Some people may buy without SHQ
• Kids Sep. 15-Oct. 3

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Options you may buy

• When can I buy health insurance without SHQ?
• Move within state outside plan service area
• Follow doctor from one plan network to another
• Use up COBRA/lose it when your old job stops
  offering
• After 24 mos. continuous group coverage and you
• Lose a COBRA-exempt group plan due to qualifying
  event
• Qualify for or drop COBRA or leave Basic Health
• Lose your plan because your employer went out of
  business
• Add a newborn/newly adopted child to the plan
• Ask about your situation 1-800-562-6900 or
  http//www.insurance.wa.gov/index.asp

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Options you may buy

• Individual insurance
• Compare plans and benefits
• http//www.healthcare.gov
• http//www.insurance.wa.gov
• Call the Insurance Commissioners Office at
  1-800-562-6900 for detailed questions about
• SHQ
• Wait periods
• Portability (going from one plan to another)
• Comprehensive and catastrophic plans

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Options you may buy

• Washington Health Program
• Limited benefit plan
• Covers up to 75,000 or 100,000 per year
• Premiums may be lower than for individual ins.
• If you have higher medical costs in a year than
  the limit, you may be responsible for those
  bills!
• Premiums based on your age, county, tobacco use,
  number of covered family members, and benefit
  limit you choose (75,000/100,000)
• You also pay deductibles and coinsurance

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Options you may buy

• Washington Health Program
• Folks must pass or be exempt from SHQ
• Open to folks who live in Washington and dont
  have Medicare, Medicaid, or WSHIP
• HCA decides if you qualify
• You get insurance through a private company
• For more information
• 1-800-660-9840
• http//www.washingtonhealth.hca.wa.gov/

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Options if you have pre-existing conditions

• Pre-existing Condition Ins. Plan (PCIP)
• For people who
• Fail the SHQ, or would likely fail
• Live in WA state and are in US legally
• Have been uninsured for 6 months or more
• Same premium rates as individual insurance
• Details list of qualifying med. conditions
• 1-877-505-0514 or
• https//www.wship.org/PCIP-WA/

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Options if you have pre-existing conditions

• Washington State Health Insurance Pool (WSHIP)
• Provides coverage to people unable to buy
  individual insurance due to health
• Must have completed and failed the SHQ
• Premiums are higher than individual plans
• Get details about coverage and discounts at
• 1-800-877-5187
• https//www.wship.org/default.asp

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Other options

• Programs for specific illnesses or conditions
• Student insurance plans at colleges
• Care at community clinics or free clinics
• Financial help/charity care with hosp. bills
• Patient assistance programs for Rx
• Discount plans Discount on medical/Rxs
• For more information
• 1-800-562-6900 Ask for SHIBA!
• http//www.insurance.wa.gov/consumers/health/canta
  fford.shtml

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Shopping Tips

• Take your time and ask the plan
• Benefits, limitations, exclusions?
• Claims - how to file?
• What doctors can you see?
• Costs (premiums, deductibles, copays,
  coinsurance, non-covered services)?
• Ask the Insurance Commissioners Office
• Are there complaints against insurance plan,
  agent, or broker? Is agent or broker licensed?
• 1-800-562-6900
• http//www.insurance.wa.gov/index.asp

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Watch out for fraud!

• What is fraud?
• Intentionally twisting the truth to mislead
  someone into parting with something of value.
• Billing for services or prescriptions not
  provided
• If you suspect fraud/abuse related to health care
  coverage, please call the Insurance Commissioner
  Hotline at
• 1-800-562-6900

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For more information

• 1-800-562-6900
• TDD [phone]
• www.insurance.wa.gov

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SHIBA volunteer opportunities

• Do you want to help explain health care benefits
  or options to
• Friends?
• Neighbors?
• Community?
• Help people become better informed consumers?
• Call 1-800-562-6900

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Need help with other insurance questions?
The Office of the Insurance Commissioner can also
help you with questions, information and
complaints about all types of insurance, such
as

• Homeowner
• Auto
• Life

• Annuities
• Health
• And more!

Call our Insurance Consumer Hotline [phone]
www.insurance.wa.gov