What is Individual Health Insurance Coverage in Washington State? How Do I Find Help In Choosing The Right Plan For Me?
Washington State individual health insurance coverage is classified in two categories: comprehensive or catastrophic health care. Comprehensive coverage is characterized by lower deductibles and more complete benefit packages. Catastrophic coverage refers to higher deductible plans with certain benefits, like maternity, excluded. Both are considered major medical insurance policies since the insurance company assumes essentially all the risks after you meet your deductible and your percentage of shared expenses (co-insurance). Family insurance is simply an individual policy with more than one insured member of the family included in the application and coverage.
Individual plans are available is several designs and deductibles allowing you to choose options to keep your health care plan affordable. Generally if you purchase a policy that costs less in monthly premium, you will usually end up paying a greater share of the medical expenses when you are sick or hurt.
Some individual health insurance plans are managed care plans. This means you are required to use the plan doctors and clinic facilities. Most health insurance plans in Washington are Preferred Provider (PPO) plans. You receive the maximum benefit if you stay within the plan’s provider network, (physicians, hospitals, other medical providers). These providers have agreed to the insurance plan's schedule of payments for services performed. PPO plans usually allow you to receive healthcare services outside their network of providers, but at an additional cost to you. Some plans may require the selection of a Primary Care Physician (PCP), a personal physician who directs all your care and who's written referral you need prior to visiting a specialist.
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How Do I Apply?
In most cases, applying for health care coverage requires filling out a health questionnaire. The insurance company uses this to determine whether to approve you for coverage. If you are not approved, you are referred to the Washington State Health Insurance Pool (WSHIP), the state's high-risk pool. Do not try to hide information about your health condition. Hiding information can result in the insurance company retroactively cancelling your coverage back to its effective date. This will leave you responsible for all of your expenses, less any premiums paid. If you can answer yes to any of the nine questions below, you do not have to fill out a health questionnaire:
- Are you eligible for Medicare?
- Have you changed residences from one part of Washington state to another part where your current health plan is not offered, and you are submitting your application within 90 days of relocation?
- Is your health care provider no longer part of the provider network on your current individual health plan?
To answer yes, all of the following must be true:
- Your health care provider is on the new health plan you are applying for; and
- You received services from that provider during the 12 months before he or she left your current health plan; and
- You are submitting your application to the new health plan within 90 days of your provider leaving your current health plan's network.
- Are you applying for individual health coverage within 90 days of using up your COBRA* coverage? (This includes loss of COBRA coverage due to your employer going out of business or discontinuing its health plan while you are on COBRA.) To answer yes, you must have used up your COBRA coverage for any reason other than misrepresentation, gross misconduct, or failure to pay your premium.
- Have you been covered by a group plan provided by an employer that is exempt from COBRA, and you are applying for individual health coverage within 90 days of an event which would qualify you for COBRA if your employer had not been exempt from COBRA, and you had at least 24 months of continuous group coverage prior to such event?
- Are you applying for individual health coverage within 90 days of terminating your COBRA coverage and you had at least 24 months of continuous group coverage prior to termination? (Not applicable to BHP applicants.)
- Are you applying for individual health coverage within 90 days of an event which qualifies you for COBRA, and you had at least 24 months of continuous group coverage prior to such event but you choose not to take COBRA coverage? (Not applicable to BHP applicants.)
- Have you been enrolled in the Washington State Basic Health Plan for at least 24 continuous months, and you are submitting your application within 90 days of disenrollment?
- Are you adding coverage to your existing individual policy for your newborn or adopted child who has been born or placed for adoption with you within the last 60 days?
If you have not previously had coverage, the insurance company may impose a 9–month waiting period before your coverage starts for anything you were treated for, or should have sought treatment for, during the six months immediately prior to the start date of your new policy. If you had prior coverage, you will generally be given equivalent credit towards meeting this 9-month waiting period, provided you did not have a significant break in coverage between the two plans.