Adjusted Community Rating. A requirement that Washington health insurance companies establish a rate for each individual and small group policy that does not vary due to the health status of those who buy that health insurance. For individual health insurance policies, premiums may only vary based on age, family size, where you live or what plan you seek. Individuals can earn wellness activity discounts and tenure discounts. For small employer group health plans, premiums can only vary based on age, family size, where your business is located, and what plan you seek. Discounts may be earned for wellness activities. See also Wellness Activity Discounts, Tenure Discounts.
Affiliation Period. The time an HMO may require you to wait after you enroll and before your coverage begins. HMOs that require affiliation periods cannot exclude coverage of pre-existing conditions. Premiums cannot be charged during HMO affiliation periods. Washington law does not allow for the use of HMO affiliation periods. See also HMO.
Alternative Trade Adjustment Assistance (ATAA). ATAA is a benefit for workers at least 50 years old who have obtained different, full-time employment within 26 weeks of the termination of adversely-affected employment. These workers may receive 50% of the wage differential (up to $10,000) during their 2 year eligibility period. To be eligible for the ATAA program, workers may not earn more than $50,000 per year in their new employment. Also, the firm where the workers worked must meet certain eligibility criteria.
Basic Health (WBH). The system created and administered by the state of Washington to enable low income individuals, families to purchase basic health care services through participating managed health care plans. WBHPP is administered by the Health Care Authority, available to Washington residents who meet income guidelines, are not eligible for Medicare, and are not institutionalized at the time of enrollment. Premiums are based on age and income.
Basic Health Plus (BHP). A Medicaid Program administered by the Department of Social and Health Services and the Health Care Authority for children from low income families. There are no premiums or co payments.
Catastrophic Policy. In Washington, a health insurance policy covering an individual which requires a calendar year deductible of $1,750 or more in addition to $3,000 or more in annual out-of-pocket costs is a catastrophic policy. In the case of a health insurance policy covering a family a catastrophic policy is one that requires a calendar year deductible of $3,000 or more in addition to $6,000 or more in annual out-of-pocket costs. Finally, a catastrophic policy is also one that provides benefits for hospital inpatient and outpatient services, professional and prescription drugs in conjunction with such hospital inpatient and outpatient services and excludes or substantially limits outpatient physician services and those services usually provided in an office setting.
Certificate of Creditable Coverage. A document provided by your health plan that lets you prove you had coverage under that plan. Certificates of creditable coverage will usually be provided automatically when you leave a health plan. You can obtain certificates at other times as well. See also Creditable Coverage.
COBRA. Stands for the Consolidated Omnibus Budget Reconciliation Act, a federal law in effect since 1986. COBRA permits you and your dependents to continue in your employer’s group health plan after your job ends. If your employer has 20 or more employees, you may be eligible for COBRA continuation coverage when you retire, quit, are fired, or work reduced hours. Continuation coverage also extends to surviving, divorced or separated spouses; dependent children; and children who lose their dependent status under their parent’s plan rules. You may choose to continue in the group health plan for a limited time and pay the full premium (including the share your employer used to pay on your behalf) plus a 2% administrative fee. COBRA continuation coverage generally lasts 18 months, or 36 months for dependents in certain circumstances. See also State Continuation Coverage.
Continuous Coverage (Self-Insured Plans). Under federal rules, health insurance coverage that is not interrupted by a break of 63 or more days in a row. Employer waiting periods and HMO affiliation periods do not count as gaps in health insurance coverage for the purpose of determining if coverage is continuous. Federal rules apply to you if you are joining a self-insured group health plan. See also Creditable Coverage, Federally Eligible.
Continuous Coverage (Fully Insured Group and Individual Health Insurance Policies). Under Washington rules, health insurance coverage that is not interrupted by a break of more than 90 days in a row. Employer waiting periods do not count as gaps in health insurance coverage for the purpose of determining if coverage is continuous. Washington state rules apply to you if you are joining a fully insured group health plan. When buying individual health insurance, you cannot have a break in coverage of 63 or more days in a row.
Conversion Policy. Your right, when leaving a fully insured group health plan in Washington, to convert your policy to an individual health insurance policy. You will not face a new pre-existing condition exclusion period.
Comprehensive Individual Health Insurance Policy. An individual health insurance policy is suppose to be more comprehensive that a catastrophic policy. All comprehensive individual health insurance policies must cover, at a minimum, the same benefits that are required by plans offered through Washington Basic Health. Even with these requirements, insurers can cap coverage for benefits under comprehensive policies. For example, some insurers offer individual policies with a cap of $2,000 on covered pharmaceutical benefits per year. Cost sharing requirements cannot reach the limits that define a catastrophic policy. See also Washington Basic Health and Catastrophic Policy
Creditable Coverage. Health insurance coverage under any of the following: a group health plan; an individual health insurance policy; Medicare; Medicaid; CHAMPUS (health coverage for military personnel, retirees, and dependents); Federal Employees Health Benefits; Indian Health Service; Peace Corps; or a state health insurance high risk pool. Used in this definition, health insurance coverage includes any time spent under a pre-existing condition exclusion period. See also Continuous Coverage, Group Health Plan, Individual Health Insurance Policy.
Elimination Rider. A feature permitted in individual health insurance policies that permanently exclude coverage for a health condition, body part, or body system. Elimination riders are not permitted in health insurance plans sold by insurers in Washington.
Enrollment Period. The period during which all employees and their dependents can sign up for coverage under an employer group health plan. Besides permitting workers to elect health benefits when first hired, many employers and group health insurers hold an annual enrollment period, during which all employees can enroll in or change their health coverage. See also Group Health Plan, Special Enrollment Period.
Family and Medical Leave Act (FMLA). A federal law that guarantees up to 12 weeks of job protected leave for certain employees when they need to take time off due to serious illness, to have or adopt a child, or to care for another family member. When you qualify for leave under FMLA, you can continue coverage under your group health plan.
Fully Insured Group Health Plan. Health insurance purchased by an employer from an insurance company. Fully insured health plans are regulated by the state of Washington. See also Self-Insured Group Health Plans.
Genetic Information. Includes information about family history or genetic test results indicating your risk of developing a health condition. A health plan cannot consider pre-existing (and therefore exclude coverage for) a condition about which you have genetic information, unless that health condition has been diagnosed by a health professional.
Group Health Plan. Health insurance (usually sponsored by an employer, union or professional association) in the state of Washington that covers at least 1 employee or a self-employed person. See also Fully Insured Group Health Plan, Self-Insured Group Health Plan.
Guaranteed Issue. A requirement that health plans must permit you to enroll regardless of your health status, age, gender, or other factors that might predict your use of health services. Plans that are guaranteed issue can turn you away for other reasons.
Guaranteed Renewability. A feature in health plans that means your coverage cannot be canceled because you get sick. HIPAA requires all health plans to be guaranteed renewable. Your coverage can be canceled for other reasons unrelated to your health status.
Health Coverage Tax Credit (HCTC). The Health Coverage Tax Credit (HCTC) is a program that can help pay for nearly two-thirds of eligible individuals’ health policy premiums. In general, in order to be eligible for the health coverage tax credit, you must be 1) receiving Trade Readjustment Allowance benefits (TRA), or 2) will receive TRA benefits once your unemployment benefits are exhausted, or 3) receiving benefits under the Alternative Trade Adjustment Assistance (ATAA) program, or 4) aged 55 or older and receiving benefits from the Pension Benefit Guaranty Corporation (PBGC).
Health Insurance or Health Plan. In this guide, the term means benefits consisting of medical care (provided directly or through insurance or reimbursement) under any hospital or medical service policy, plan contract, or HMO contract offered by a health insurance company or a group health plan. It does not mean coverage that is limited to accident or disability insurance, workers’ compensation insurance, liability insurance (including automobile insurance) for medical expenses, or coverage for on-site medical clinics. Health insurance also does not mean coverage for limited dental or vision benefits to the extent these are provided under a separate policy.
Health Status. When used in this guide, refers to your medical condition (both physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence), and disability. See also Genetic Information.
HIPAA. The Health Insurance Portability and Accountability Act, better known as Kassebaum-Kennedy, after the two senators who spearheaded the bill. Passed in 1996 to help people buy and keep health insurance, even when they have serious health conditions, the law sets basic requirements that all health plans must meet. Since states can and have modified and expanded upon these provisions for state regulated health plans (fully insured group and individual plans), consumers’ protections vary from state to state.
HIPAA Eligible. Status you attain once you have had 18 months of continuous creditable health coverage. To be federally eligible, you also must have used up any COBRA or state continuation coverage; you must not be eligible for Medicare, Medicaid, or a group health plan; you must not have other health insurance; and you must apply for individual health insurance within 63 days of losing your prior creditable coverage. See also COBRA, Continuous Coverage, Creditable Coverage, State Continuation Coverage.
HMO. Health maintenance organization. A kind of health insurance plan. HMOs usually require you to get care from doctors who work for or contract with the HMO. They generally do not require deductibles, but often do charge a small fee, called a co-payment, for services like doctor visits or prescriptions. HMOs in Washington cannot require affiliation periods. See also Affiliation Period.
Individual Health Insurance. Policies for people not connected to an employer group. Individual health insurance policies are regulated by the state of Washington. Not all residents can buy coverage for themselves and their families. If you are sick, based on the results of a standardize health questionnaire, you may be denied coverage by a private insurance company. All individual policy premiums are based on an adjusted community rate. See also Adjusted Community Rating.
Kassebaum-Kennedy. See HIPAA
Large Group Health Plan. One with more than 50 employees.
Late Enrollment. Enrollment in a health plan at a time other than the regular or a special enrollment period. Washington requires fully insured group plans to cover you if you are a late enrollee. However, you may be subject to a longer pre-existing condition exclusion period. See also Special Enrollment Period.
Look Back. The maximum length of time, immediately prior to enrolling in a health plan, that can be examined for evidence of pre-existing conditions. See also Pre-existing Condition.
Managed Care Plan. A kind of health insurance plan. Like an HMO, managed care plans can limit coverage to health care provided by doctors or hospitals who work for or contract with them — also called “network” providers. Often, managed care plans will require you to get permission (a “referral”) from your family doctor before you get care from a specialist in their network. Some managed care plans will cover your care at a lower rate if you go to a non-network provider, or if you get specialty care without a referral. The Washington Basic Health Plan offers managed care plans. See also HMO, Washington Basic Health Plan.
Medicaid. A program providing comprehensive health insurance coverage and other assistance to certain low-income Washington residents. All other states have Medicaid programs too, though eligibility levels and covered benefits will vary.
Nondiscrimination. A requirement that group health plans not discriminate against you based on your health status. Your coverage under a group health plan cannot be denied or restricted, nor can you be charged a higher premium, due to your health status. Group health plans can restrict your coverage based on other factors (such as part time employment) that are unrelated to health status. See also Group Health Plan, Health Status.
Pension Benefit Guaranty Corporation (PBGC). PBGC is a federal government corporation established by Title IV of the Employee Retirement Income Security Act of 1974 ( ERISA) to encourage the continuation and maintenance of defined benefit pension plans, provide timely and uninterrupted payment of pension benefits to participants and beneficiaries in plans covered by PBGC. It currently guarantees payment of basic pension benefits earned by American workers and retirees participating in private-sector defined pension plans. The agency receives no funds from general tax revenues. Operations are financed largely by insurance premiums paid by companies that sponsor pension plans and by PBGC’s investment returns.
Pre-existing Condition (Self-insured Group Health Plans). Any condition (either physical or mental) for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period immediately preceding enrollment in a group health plan. Pregnancy cannot be counted as a pre-existing condition. Genetic information about your likelihood of developing a disease or condition, without a diagnosis of that disease or condition, cannot be considered a pre-existing condition. Newborns, newly adopted children, and children placed for adoption covered within 30 days cannot be subject to pre-existing condition exclusions.
Pre-existing Condition (Fully Insured Large Group Plans). Any condition (either physical or mental) for which medical advice, diagnosis, care, or treatment was recommended or received within the 3-month period immediately preceding enrollment in a group health plan. Pregnancy cannot be counted as a pre-existing condition. Genetic information about your likelihood of developing a disease or condition, without a diagnosis of that disease or condition, cannot be considered a pre-existing condition. Newborns, newly adopted children, and children placed for adoption covered within 60 days cannot be subject to pre-existing condition exclusions.
Pre-existing Condition (Fully Insured Small Group Plans). Any condition (either physical or mental) for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period immediately preceding enrollment in a group health plan. Pregnancy cannot be counted as a pre-existing condition. Genetic information about your likelihood of developing a disease or condition, without a diagnosis of that disease or condition, cannot be considered a pre-existing condition. Newborns, newly adopted children, and children placed for adoption covered within 60 days cannot be subject to pre-existing condition exclusions.
Pre-existing Condition (Individual Health Insurance). Any condition for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period immediately preceding enrollment in a health plan, or for which an ordinarily prudent person would have sought medical advice, care or treatment during that period. Under individual health insurance policies, pregnancy can be counted as a pre-existing condition. Newborns and newly adopted children covered within 60 days cannot be subject to pre-existing condition exclusions. See also Prudent Person Rule.
Pre-existing Condition Exclusion Period. The time during which a health plan will not pay for covered care relating to a pre-existing condition. See also Pre-existing Condition.
Prudent Person Rule. In individual health insurance policies only, a rule that permits insurers to exclude as pre-existing any condition for which - in the insurer’s judgment - most people would have sought care or treatment in the 6 months prior to enrolling in an individual health insurance policy. See Pre-existing Condition (Individual Health Insurance).
Self-Insured Group Health Plans. Plans set up by employers who set aside funds to pay their employees’ health claims. Because employers often hire insurance companies to run these plans, they may look to you just like fully insured plans. Employers must disclose in your benefits information whether an insurer is responsible for funding, or for only administering the plan. If the insurer is only administering the plan, it is self-insured. Self-insured plans are regulated by the U.S. Department of Labor, not by the state of Washington.
Small Group Health Plans. Plans with no more than 50 employees and plans for the self employed.
Special Enrollment Period. A time, triggered by certain specific events, during which you and your dependents must be permitted to sign up for coverage under a group health plan. Employers and group health insurers must make such a period available to employees and their dependents when their family status changes or when their health insurance status changes. Special enrollment periods must last at least 30 days. Enrollment in a health plan during a special enrollment period is not considered late enrollment. See also Late Enrollment.
State Children’s Health Insurance Program (SCHIP). The State Children’s Health Insurance Program is a state run program for low-income children under the age of 19 who are uninsured or underinsured and who are not eligible for Medicaid.
State Continuation Coverage. A program similar to COBRA for some small employers. In Washington, if you are in a fully insured group health plan sponsored by an employer with 2 to 19 employees, you may have rights to continue your health coverage when your job ends, if your employer chose to offer this benefit in its plan. See also COBRA.
Supplemental Security Income (SSI). A program providing cash benefits to certain very low income disabled and elderly individuals. When you qualify for SSI, you generally also qualify for Medicaid. In addition, Medicaid coverage often continues for a limited time if your income increases so that you no longer qualify for SSI. See also Medicaid.
Temporary Assistance for Needy Families (TANF). A program (also known as the Family Assistance Program or FAP) that provides cash benefits to low-income families with children. When you qualify for TANF, you generally also qualify for Medicaid. In addition, Medicaid coverage often continues for a limited time or longer if you no longer qualify for TANF. See also Medicaid.
Tenure Discount. A discount in the price of your individual health insurance policy premium that may be applied if you have been continuously enrolled in the health plan for 2 or more years. The discount may be as much as 10%.
Trade Adjustment Assistance (TAA) Program. A program authorized by the Trade Adjustment Assistance Reform Act of 2002. This program provides aid to workers who lose their job or whose hours or work and wages are reduced as a result of increased imports. The TAA program offers six benefits and reemployment services to assist unemployed workers prepare for and obtain new suitable employment. In addition, TAA offers a significant tax credit that covers 65% of health insurance premiums for certain plans.
U.S. Department of Labor. A department of the federal government that regulates employer provided health benefit plans. You may need to contact the Department of Labor if you are in a self-insured group health plan, or if you have questions about COBRA or the Family and Medical Leave Act. See also COBRA, Family and Medical Leave Act.
Waiting Period. The time you may be required to work for an employer before you are eligible for health benefits. Not all employers require waiting periods. Waiting periods do not count as gaps in health insurance for purposes of determining whether coverage is continuous. If your employer requires a waiting period, your pre-existing condition exclusion period begins on the first day of the waiting period. See also Pre-existing Condition Exclusion Period.
Washington Basic Health (WBH). The system created and administered by the state of Washington to enable low income individuals, families to purchase basic health care services through participating managed health care plans. WBHPP is administered by the Health Care Authority, available to Washington residents who meet income guidelines, are not eligible for Medicare, and are not institutionalized at the time of enrollment. Premiums are based on age and income.
Washington Basic Health Plus (WBHP). A Medicaid Program administered by the Department of Social and Health Services and the Health Care Authority for children from low income families. There are no premiums or co payments.
Washington State Health Insurance Pool (WSHIP). A state high risk pool for federally eligible individuals and individuals with health problems who do not qualify for private individual health insurance.
Wellness Activity Discount. A discount in the price of your individual or group health plan premium that may be applied if you participate in an explicit program of activity consistent with department of health guidelines, such as smoking cessation, injury and accident prevention, reduction of alcohol misuse, appropriate weight reduction, exercise, automobile and motorcycle safety, blood cholesterol reduction and nutrition education, for the purpose of improving enrollee health status and reducing health service costs. The discount may be as much as 20%. See also Tenure Discount, Adjusted Community Rating.
