Am I eligible to purchase an individual health plan?

• You have been a Washington state resident for at least 30 days prior to applying for a plan (Regence BlueShield and Asuris Northwest Health requirement) or are a permanent Washington state resident (all other carriers); and
• You are not eligible for Medicare Part A or Part B (including entitlement due to disability). If you are eligible for Medicare Part A or Part B, please contact us to obtain information about Medigap plans.
   

DO CARRIERS OFFER THEIR PLANS IN all areas of
Washington State?

How do I apply for coverage?

You may also need to provide proof of Washington State residency (it is not required when you apply, but may later be requested by the carrier) by providing a copy of your Washington State driver’s license or ID card, or a copy of a utility bill showing your name and home address. If both you and your spouse are applying for the same plan, a copy of the driver's license or ID card would be needed only for whichever of you is the "applicant."

 

Are there any EXCEPTIONS TO COMPLETING a Standard Health Questionnaire?

• Addition of: a newborn, newly adopted child or a child placed for adoption. You must apply within 60 days of the date of birth, date of adoption or placement for adoption. For an adopted child, include documentation showing the date of adoption or placement for adoption.
  
• Loss of employer plan not subject to COBRA or loss of Basic Health Plan (BHP) coverage: you have lost or are losing coverage under an employer's plan that was not subject to COBRA (an employer normally employing less than 20 employees or a church group) or losing coverage under the BHP. You must have had at least 24 months of continuous coverage before such loss. You may apply to a carrier within the period beginning 90 days before the date coverage will end, and no later than 90 days after the date coverage ended. The effective date of the individual coverage must be on, or within 90 days after, the date coverage ended. Include a letter of verification from your employer or verification of your BHP coverage.
  
• Relocation within Washington State: you are applying for coverage with a new carrier because you changed residences from one part of Washington state to another part where your current health plan is not offered. You must apply to the new carrier within 90 days from the date you moved. Include a copy of a recent utility bill in your name from the prior address, and a letter of verification from your prior carrier stating that because you have moved, you no longer reside in their service area and they cannot provide health insurance at your new location.
  
• Provider network cancellation: your doctor or other health care provider stopped being a part of the provider network on your current individual medical plan. In order for this exception to apply:
  (a) your provider must participate in the network of the new plan for which you are applying;
  (b) you must have had some service from that provider during the 12 months before they stopped participating in your current plan's network; and
  (c) you must submit your application to the new carrier with 90 days from the date your provider stopped participating in the current plan's network. Include a letter of verification from the provider or carrier.
  
• COBRA coverage exhausted: you have used up all the available time on your COBRA coverage. You must apply to the new carrier within 90 days from the date COBRA coverage ended. Include a copy of your Certificate of Creditable Coverage or other proof verifying that you have exhausted your COBRA benefits.
  
• COBRA termination: the employer who provided you with health coverage has gone out of business while you were on COBRA coverage, and you are applying for individual coverage with a new carrier within 90 days from the date that coverage ended. Include a letter of verification from your employer or carrier.
   

Will my coverage be guaranteed, or is there
a chance I MAY BE DENIED COVERAGE?

But if not, then coverage is not guaranteed and may be denied depending on whether you have health conditions or a history of health conditions, and the nature of those conditions. Each carrier uses the Standard Health Questionnaire to determine your acceptance for an individual health insurance plan. Your health conditions are assigned points depending on the type of condition. If you have 325 or more points, you may be denied coverage. Carriers cannot deny coverage if you have less than 325 points.

The links in (a), (b) and (c) below provide information about the number of points assigned to health conditions.

(a)		conditions in the same order as shown on the Standard Health       Questionnaire
(b)		conditions in alphabetical order
(c)		alphabetical listing of diagnoses and to which condition they belong

What happens if I AM DENIED COVERAGE? Is any other plan available?

How can I find out if my DOCTOR OR OTHER HEALTH CARE PROVIDER belongs to A CARRIER'S Network?

How soon CAN MY PLAN START AND WHAT'S THE DEADLINE TO APPLY?

Assurant Health: your effective date can be the 1st or 15th day of a month. The application and Standard Health Questionnaire must be received by Assurant Health in their Milwaukee, Wisconsin office no later than the 15th for coverage to be effective the first day of the following month, or by the 31st for coverage to be effective the 15th day of the following month. You can also apply online by the 15th or 31st. Payment is not required when you apply. If you are accepted, Assurant Health will auto-withdraw the amount needed by Electronic Funds Transfer (EFT)/ Check-o-Matic (COM). This is the only way Assurant accepts payment, i.e., monthly paper billing statements are not available.

LifeWise Health Plan: your effective date can be the 1st or 15th day of a month. The application and Standard Health Questionnaire must be sent (postmarked) to LifeWise by the 20th if you want to apply for the 1st of the following month, or by the 5th if you want to apply for the 15th of that month. You can also apply online by those dates. Payment is not required when you apply. If you are accepted, you'll be billed.

Regence BlueShield and Asuris Northwest Health: your effective date will be the 1st day of a month. The application and Standard Health Questionnaire must be sent (postmarked) to them no later than the 20th for coverage to be effective the first day of the following month. You can also enroll online with these carriers by the 20th. Payment is not required when you apply. If you are accepted, you'll be billed.

Group Health and KPS Health Plans: your effective date will be the 1st day of a month. The application, Standard Health Questionnaire and first month's payment must be received in their main office no later than the 20th for coverage to be effective the first day of the following month. You can also enroll online with these carriers by the 20th.

Missing information or a delay in sending the information by the dates shown above could cause a delay in the effective date of your plan.
 

Can I enroll my spouse and children?

What is a pre-existing condition?

Are pre-existing conditions covered?

Do I get credit for a pre-existing condition if I was  covered by a prior plan?

In certain circumstances, the carriers will credit or waive the nine-month waiting period for pre-existing conditions based on prior coverage. 

The pre-existing condition waiting period will be credited (shortened by the length of time you were covered by a prior plan) if one of the following criteria is satisfied.

• Your prior benefits are equal to or better than the plan for which you are applying, and you were covered by the prior plan within 63 days of applying for the new plan; or
• You moved out of your prior health plan’s service area in Washington state and your prior plan is not available at your new Washington state address, and you were covered by the prior plan within 63 days of applying for the new plan; or
• Your doctor or other health care practitioner no longer participates in your prior plan’s network but does participate in the network of the plan for which you are applying, and you were covered by the prior plan within 63 days of applying for the new plan. The doctor must have treated you in the prior 12 months.

The pre-existing condition waiting period will be waived (eliminated) if you are considered eligible under “HIPAA” (the federal “Health Insurance Portability and Accountability Act of 1996”). You are eligible if all of the following criteria are satisfied.

• You’ve had at least 18 months of continuous creditable coverage, the most recent being under a group plan, government plan or church plan.
• You must have used up any COBRA or similar Washington State continuation of coverage for which you were eligible.
• You must not be eligible for Medicare, Medicaid or a group health plan.
• You must not have health insurance (but if you know your group coverage is about to end, you can apply for coverage to begin after the group coverage ends).
• You must apply for health insurance within 63 days of losing your prior coverage.

Generally, if you have been uninsured for more than 63 days before     applying for an individual health plan, you will be subject to the 9-month pre-existing condition waiting period.

 

Are there any other waiting periods?

Are there any benefit limitations or exclusions?

Are prescription drugs covered?

KPS Health Plans: only the Sound Harbor Elite and Essential Plus plans cover prescription drugs. The maximum benefit is $2,000 per person, per calendar year. There is no deductible for generic drugs; you pay $10 (Sound Harbor Elite) or $15 (Essential Plus). Only the Sound Harbor Elite plan covers brand-name drugs after a $200 deductible is satisfied; after that, you’ll pay 50% (with a $45 minimum copay). You can view KPS’s formulary by clicking here.

Group Health: plans that cover prescription drugs (only the $500 and $1,000 deductible plans) require you to pay $20 for each generic or $40 for each brand-name formulary drug. There is no deductible, and Group Health Cooperative will pay a maximum benefit of $2,000 per calendar year. Prescriptions must be dispensed by a Group Health Cooperative facility. Non-formulary drugs are not covered. To view Group Health Cooperative's drug formulary click here.

Asuris Northwest Health: in the Clarity 70 plan, there is no deductible for drugs. The maximum benefit per year is $3,000, and you'll pay $10 for each generic drug, 30% for each brand-name formulary drug or 50% for a brand-name non-formulary drug.  The HSA Healthplan Comprehensive also covers prescriptions, but not until after the annual deductible is satisfied; they are paid at 50% to a maximum benefit of $2,000 per person, per calendar year.

 

Is maternity/pregnancy covered?

It depends on the plan. Refer to the “Individual Health Insurance Benefits & Rates Comparison” to see which plans cover maternity. The “Maternity” column will show “Covered” or “Not covered.”

Also, remember that maternity expenses may be considered a pre-existing condition according to the “What is a pre-existing condition?” definition shown above.

 

How do I pay for my first month's premium?

Assurant Health: do not send money. If you are accepted, Assurant Health will auto-withdraw the amount needed by Electronic Funds Transfer (EFT)/ Check-o-Matic (COM) on the day you are approved. This is the only way Assurant accepts payment, i.e., monthly paper billing statements are not available.

LifeWise Health Plan, Regence BlueShield and Asuris Northwest Health:
do not send money. If your application is accepted, the carrier will send you a letter asking for payment to be made directly to them.

KPS Health Plans: send a check or money order for the first month’s premium for all family members listed on the application. The check should be made payable to KPS Health Plans.

Group Health: send a check or money order for the first month’s premium for all family members listed on the application. The check should be made payable to Group Health. Or you can also pay for the first month with a credit card (Visa, MasterCard or Discover) by providing information on the application form.

 

what are my future premium payment options?

Assurant Health: monthly billing statements are not available. The only way Assurant Health accepts payment is by Electronic Funds Transfer (EFT)/ Check-o-Matic (COM). After the first payment, they'll automatically withdraw the monthly premium on the same day of the month as your effective date, i.e., the 1st or 15th.

LifeWise Health Plan: they'll send you a monthly billing statement, or you may elect “Monthly Automatic Funds Transfer” withdrawn on the first day of every month. Select the option you’d like on the application form. 

Regence BlueShield and Asuris Northwest Health: they offer the greatest variety of payment options. They'll send you a billing statement monthly, quarterly, semi-annually or annually and also offer monthly “Automatic Bank Withdrawal” withdrawn on the 15th or 25th (your choice) of each month for the following month. Select the option you’d like on the application form. If choosing "Automatic Bank Withdrawal," also complete the "Subscriber Agreement for Preauthorized Bill Payment" form.

KPS Health Plans: they'll send you a monthly billing statement, or you may have your payments automatically withdrawn from your bank account on or about the 10th of a month for the following month. If you want automatic bank withdrawal, complete the "Sure Pay Automatic Premium Payment" form.

Group Health: they'll send you a monthly billing statement, or you may elect automatic transfer of funds withdrawn between the seventh and tenth day of every month for the current month. If you want automatic transfer of funds, complete the "Transfer of Funds for Monthly Dues Payment" form.

 

What if I change my mind? What's my obligation to continue the plan?

Can the carrier cancel my health plan?

Your coverage cannot be canceled because you get sick or have an accident. This is called "guaranteed renewability".

Your coverage will not be canceled unless:
1) you do not pay the premium on time;
2) you falsify information or in any way try to defraud the carrier; or
3) move outside the carrier’s service area.

 

When can my monthly rate change?

Every so often, usually once a year, carriers may change rates for all their individual health plan customers. The timing of when this occurs varies by carrier as highlighted by carrier below. This is the contract anniversary (renewal) date.

If you have a birthday that places you in a higher 5-year age bracket during the contract year, the rate for your new age bracket will begin to apply at the next renewal date.

Assurant Health: your rate may change 12 months from your initial effective date. For example, if your coverage is effective February 1, 2009, your rate could change on February 1, 2010.

LifeWise Health Plan: your rate may change every January 1, regardless of when your plan became effective. For example, if you enrolled on October 1, your rate could change on January 1, even though that is less than 12 months from your effective date. This is what’s called a “common anniversary date.” After that, your rate would not change again until each January 1^st thereafter.

Regence BlueShield and Asuris Northwest Health: same as above,
except the common anniversary date is August 1^st.

KPS Health Plans: same as above, except the common anniversary date is
May 1^st.

Group Health: same as above, except the common anniversary date is July 1^st.

In all cases, carriers reserve the right to change rates during the middle of your contract if they are faced with any unexpected mandated benefit changes imposed by the Washington state or federal government, or if any government imposes or changes a tax on the carriers' premium income.