Washington Health Insurance

Washington Health Insurance Information

Washington State has simplified the process of searching for health insurance through both the state’s medicaid program and the state’s exchange program. Washington Health Plan Finder (https://www.wahealthplanfinder.org/) is easy to use and helps identify publicly available plans. 

A Quick Guide to Understanding Insurance Terms

• Premium – This is the fee that you (the insured) pay to the insurance company to carry insurance for you. Even if you do not use the services, the insurance company charges this amount. It is typically billed on a monthly, semiannual, or annual basis. 
• Deductible – This is the amount of money that you will need to pay out of pocket before the insurance company begins paying your bills. This amount resets each year. Depending on your plan, not all services will be subject to a deductible. It is common for insurance companies to only charge a copay for primary care visits in order to encourage individuals to visit their healthcare provider before a condition worsens. 
• Copay – This is a set amount that you pay to a provider for a visit or service. Copays may vary depending on the specific type of provider, usually divided by primary care or specialists.
• Coinsurance – This is a percentage of the service bill for which you are responsible. This amount is based on the negotiated rate between the provider and the insurance company, not on the provider's billing.
• Out of Pocket Maximum – This is the maximum amount that the insurance company can ask you to pay before the company fully covers your costs. This is the sum of all deductibles, copays, and coinsurances.
• In-Network / Out-of-Network – Insurance companies have lists of providers with whom they contract for services. A provider with an agreement with a particular insurance company is said to be in-network. If the provider does not have a contract with a particular insurance company, they are said to be out-of-network. Insurance companies will typically pay less, if any, of an out-of-network providers’ bill. 
• Plan year - The contract dates of a plan which also determines when deductibles and out of pocket expenses reset. Often, this is January 1 to December 31 of a calendar year, but may vary depending on the plan. 

Where can I find information about my coverage?

Insurance law requires that insurance companies make available two documents:

• Summary of Benefit and Coverage – This document is typically 2 - 5 pages long and provides a short explanation of what is covered, the amounts of coinsurances, copays, and deductibles, and limitations, exceptions, and other important information using charts. This is helpful for a quick overview of your plan. 
• Benefit Booklet – This document is typically 50+ pages and provides a comprehensive list of your benefits and the limitations. This is helpful for looking up a specific condition, treatment, medication, or understanding the details of the plan.

A practical example: 

While running, Sam Student injures their leg. They go to an in-network primary care who orders an MRI. Sam’s provider charges $180 for the visit which is reduced to $110 because of the contract between Sam’s provider and Sam’s insurance company. Sam’s insurance waives deductibles for primary care but does require a $20 copay to the provider. Sam then goes to the local in-network diagnostic imaging clinic for an MRI. The clinic charges $2000 for the MRI which is reduced to $600 because of the agreement between the clinic and the insurance company. For this service, Sam has a 20% coinsurance after deductible. This time, Sam must pay the $100 before their insurance starts paying, after which they owe another $100 for coinsurance on the remaining bill. This brings Sam’s total out-of-pocket expenses at this point to $220. 

The MRI finds that Sam has torn multiple ligaments in his ankle and must have surgery. The total cost of the surgery is $32,000 between hospitals fees, surgeons fees, and anesthesiologists fees. This has all been negotiated by the insurance company and Sam owes for coinsurance of 20% which would normally be $6,400, but Sam’s maximum out of pocket expense is $2,500, so Sam only owes $2,280 which is the maximum less the other copays, coinsurances, and deductible. This was Sam’s only doctor’s visit during that plan year, but if Sam had been to the doctor earlier that plan year, the amount owed would have been reduced by any other amounts that Sam paid. If Sam has more follow up visits or new issue visit with their doctor during the plan year, then Sam cannot be charged any amount, because they have reached their out-of-pocket maximum. 

This is provided as a general example for illustrative and educational purposes only. Your plan may vary. The best way to understand what your plan will cover is to call and speak with a representative from your insurance carrier. These calls are generally recorded, so it's a good idea to take careful notes and include the day and time of your call and the name of the person with whom you spoke in case there are discrepancies.