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					     SHIBA HelpLine
  Statewide Health Insurance
       Benefits Advisors

       Health Care
Understanding Your Options

 Sponsored by the Office of the Insurance Commissioner
            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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               Do you know someone
                who doesn’t have
                health coverage?
               Can they afford the
                costs of the coverage
                they may have?
               What do they do when
                they get sick or hurt?

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                  Today’s overview
            1.   Health care coverage - what is it, why get it?
            2.   Low-cost health coverage options
            3.   Employer insurance & COBRA
            4.   Individual market insurance
            5.   Other options
            6.   Shopping for health insurance
            7.   Watch out for fraud
            8.   For more information

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                 Section 1:
                 What is health care

           Any kind of product or
            resource that helps to pay
            for medical services and
            other health care expenses

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                   Health care coverage is

           Uninsured people may avoid getting
           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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                   Section 2:
                   Low-cost health coverage
           Generally help people who cannot
            afford individual insurance or do not
            have access to employer insurance
           Programs for people with limited
            incomes and assets
           Programs for specific groups
               Children, pregnant women, disabled,
                elderly, veterans, etc.

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                Medicaid (DSHS) & CHIP

           Many different programs
           Often free, some have small premiums
           No pre-existing condition wait period
           Must be in “category”
           Enrollment based on income and assets

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                  Basic Health Plan

           Subsidized insurance for people living in the
            state of Washington
           Must meet income guidelines and other
           Examples of income guidelines (July 2008):
               Under $1,734 per month (single person)
               Under $3,534 per month (family of 4)

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                 “Safety Net” resources
                 for everyone

           Care at a community clinic
           If you get hospital care, request financial
            assistance or charity care
           Patient assistance programs for Rx

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                   Section 3:
           Every plan is different
           Often the most
           Get coverage through
            your own employment
           Get coverage through
            your spouse, domestic
            partner, or parents
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           Can’t reject you based on your health
           Usually lower cost
           Not all employers offer it
           Plans limited to what is offered

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                 COBRA - extending
                 employer coverage

           A way to continue employer coverage after
            you lose it
           Under federal law, “large group” employers
            (more than 20 employees) must offer it
           Extends employer health benefits to
            employees, spouse, and dependents for up
            to 36 months

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                   Section 4:
                   Individual Insurance
           Can buy for each family
           Variety of coverage
            options and plans
           Pre-existing condition wait
               6 month look back, 9 month
           10-day “Free Look” period
               If not satisfied for any
                reason, you can return for a
                full refund
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             Individual market plans

       Most applicants have to complete health
        screening questionnaire
       Plans vary from more comprehensive to
        high deductible “catastrophic” plans
       For info about plans sold in Washington,

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                  Health screening &
                  individual plans
           All applications include a health screening
           If you fail the questionnaire, you will
            receive an application for the Washington
            State Health Insurance Pool (WSHIP)
           For more information about the
            questionnaire, visit

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                People not required to
                complete the health screen
           Exhausted COBRA coverage
           Have 24 months of continuous coverage on a
            group plan that is exempt from COBRA
           Have moved out of existing plan’s service
            area (within Washington state)
           Are staying with a primary care doctor who
            left your existing plan

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             Washington State Health
             Insurance Pool (WSHIP)

       Provides coverage to people who are not able
        to get coverage in individual market
       Must have completed and failed the health
        screen questionnaire
       Premiums are higher than individual plans

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            Section 5:
            Other options

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                  Professional organization
                  & association plans

           Some professional organizations offer
            group health plans
           Often available to people in a specific
            industry or professional group
               Examples: chambers of commerce, religious or
                fraternal organizations, trusts and unions

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                   Discount plans

       Discounts for medical care or Rx
       Not considered insurance, not regulated by
       Complaints & inquiries handled by Office of
        the Attorney General
               1-800-551-4636

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                   Resources for
                   certain groups
           Programs for military and veterans
               VA benefits
               Military insurance, such as Tri-Care and
            Indian Health Services or Tribal Clinics
           Programs for specific illnesses or conditions
               Tuberculosis care
               HIV/AIDS
               Etc.
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               You might use more than
               one product or resource

           Sometime you must use them
           Sometimes they need to be
            pieced together
           Sometimes different family
            members will need different

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               Section 6:
               How to shop

    Check out the coverage:
     Benefits
     Limitations and exclusions
     Claims - how to file
     Costs
         Premiums
         Deductibles
         Co-pays or co-insurance

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                  Check out the
                  agent/broker and
                  insurance company
           Don’t be pressured
           Customer service
           Complaint history and licensing status
               Call OIC at 1-800-562-6900
               Visit

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            Section 7:
            Don’t be a victim of fraud

     What is fraud?
      Intentionally twisting the truth to
       mislead someone into parting with
       something of value.
      Billing for services or prescriptions not


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              Report fraud

        If you suspect fraud or
         abuse related to health
          care, gather the facts
          and report it by calling
             the Insurance
               Hotline at:
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            Section 8:
            For more information


             TDD: (360) 664-3154


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                   SHIBA HelpLine
                   volunteer opportunities
       Do you want to help explain health care
        benefits or options to:
               Friends?
               Neighbors?
               Community?
       Help people become better informed
       Call 1-800-562-6900

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