SHIBA Statewide Health Insurance Benefits Advisors

1. SHIBAStatewide Health Insurance Benefits Advisors Health Care CoverageUnderstanding Your Options Sponsored by the Office of the Insurance Commissioner

2. SHIBA HelpLine provides free, unbiasedinformation 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. SHIBA HelpLine mission statement

3. Statewide: 1-800-562-6900 Local: _____________ http://www.insurance.wa.gov/shiba SHIBA HelpLine contact info:

4. 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?

5. Today’s overview • Health care coverage basics • Options you may already have • Options based on income and assets • Options based on work • Options you may buy • Options if you have pre-ex. conditions • Other options • Shopping tips + watch out for fraud • For more information

6. 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

7. 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

8. 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

9. 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/champva.asp

10. 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)

11. 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

12. 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”

13. Options based on income and assets DSHS “categories” - People who: Apply/ask questions: • 1-877-501-2233 or 1-800-562-3022 • http://www.dshs.wa.gov/ • Your local Community Services Office • Are Age 65+ • Are Blind • Are Children under age 19 • Have a Disability • Are Expecting • Are in Families with kids under age 19

14. 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

15. 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/

16. 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

17. Options based on income and assets Clinic care • Community clinics: http://www.chs.hca.wa.gov/clinics.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

18. 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

19. 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

20. 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

21. Options based on work • Special options for • Small businesses • Self-employed • Sole proprietor • Get details from Insurance Commissioner’s 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/

22. Options based on work For more information: • Employer/benefits department • Insurance Commissioner’s 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

23. 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.)

24. 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

25. 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

26. 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

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

28. 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

29. Options you may buy Washington Health Program: • Folks must pass or be exempt from SHQ • Open to folks who live in Washington and don’t 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/

30. 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/

31. 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

32. 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/Rx’s • For more information: • 1-800-562-6900 – Ask for SHIBA! • http://www.insurance.wa.gov/consumers/health/cantafford.shtml

33. 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 Commissioner’s 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

34. 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

35. For more information 1-800-562-6900 TDD: (360) 664-3154 www.insurance.wa.gov

36. 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 SHIBA volunteer opportunities

37. 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 1-800-562-6900 www.insurance.wa.gov