When CAN I GET HEALTH INSURANCE FROM THE WSHIP?

• If you are denied coverage for individual health insurance because of your health, you can enroll in WSHIP. You must enroll within 90 days of receiving the denial notice from an insurer.
• You are also eligible for WSHIP if you live in a county where comprehensive health insurance is not available. If the only policy available to you is a catastrophic policy, you are eligible to buy health insurance from WSHIP.
• You may also eligible for WSHIP if you qualify for Medicare. To qualify, you must have been denied a Medicare supplemental policy for medical reasons, or offered a Medicare supplemental policy with restrictions, pre-existing condition exclusions, or higher-than-standard premiums.
• WSHIP also offers family coverage. Coverage for your spouse and/or dependant children (under 19 and unmarried) is available if you are eligible for and enrolled in WSHIP. Coverage can also be extended to dependent children over the age of 19 who are disabled.
• A variety of circumstances would make you ineligible for WSHIP.
• o You are not eligible for health insurance coverage from WSHIP if WSHIP has paid $2 million in benefits on your behalf. Benefits include spending on: hospital and professional services, prescription drugs, maternity care, and limited mental health and chemical dependency.
• o You are not eligible if you terminated your prior coverage in the pool within the last 12 months, unless you can show that you had other continuous coverage from the date that WSHIP terminated and which has been involuntarily terminated for any reason except non-payment of premiums.
• o You are not eligible for WSHIP if you are covered by another public program offering similar health benefits.
• o You are not eligible if you are an inmate of a public institution.

What will WSHIP cover?

• As of January 2008 WSHIP offers a choice of 5 non-Medicare options. These include a standard plan, a preferred provider plan, a HSA preferred provider plan and two “limited” preferred provider plans.
• Benefits vary depending on the type of plan you buy. Benefits are generally comprehensive and similar for the standard plan, the preferred provider plan and the HSA preferred provider plan. However, the two “limited” preferred provider plans have more limited covered benefits, including very minimal prescription drug coverage (capped at $2,000 or $3,000 per year, depending on the plan). In addition, these plans have more limitations on rehabilitative services, skilled nursing care, medical supplies and equipment and spinal manipulation, among others. The limited preferred provider plan B doesn’t cover maternity benefits. All plans have a lifetime maximum of $2 million.
• Cost-sharing varies depending on the type of plan you buy. The annual deductible options under the standard plan are $500, $1,000, or $1,500. Under the preferred provider plans, you can choose an annual deductible of $500, $1,000, $2,500 or $5,000. Under the two “limited” plans, only a $1,500 deductible option is offered. Finally the HSA-qualified Preferred Provider Plan has a $3,000 deductible.
• The amount of cost sharing you will face after you have met the deductible also varies.  With the standard plan, you can go to any provider and the plan covers 80 percent of allowed charges for most benefits.  The preferred provider plans pay 80 percent of covered charges when you receive services from a provider participating in the plan’s network, but only 60 percent of covered charges for out-of-network care.   Depending on the plan option you select, prescription drugs are subject to co-pays or co-insurance.
• All plan options have an annual out-of-pocket maximum on cost sharing.  These maximums vary by plan option and range from $1,000 to $10,000 for in-network care.  Prescription drugs have separate annual-out-of-pocket maximums.  Non-network medical care may be subject to higher maximums.  Once you have reached the out-of-pocket maximum, the plan will pay 100% of allowed charges for covered services for the remainder of the year. 

For a full description of covered benefits, contact WSHIP directly at 1-800-877-5187 or visit them on the web for a summary description of each plan at https://www.wship.org

What about coverage for my pre-existing condition?

• WSHIP can impose a pre-existing condition exclusion period. Pre-existing condition exclusion periods cannot exceed 6 months.

WSHIP can count as pre-existing any condition for which you received - or, in WSHIP’s judgment, for which you should have sought - medical care, treatment, diagnosis or advice in the 6-month period prior to enrollment.  This is called the prudent person rule.

• In some circumstances, you will get credit for prior continuous coverage against the imposition of a pre-existing condition exclusion period. You will get credit only if you had prior benefits under a previous group plan or individual health insurance policy. You will not be given credit for prior coverage if your prior plan was a catastrophic plan. To receive credit, your coverage must be continuous with no more than a 63-day lapse between your old coverage and new WSHIP plan.
• You will not face a pre-existing condition exclusion if you are HIPAA eligible.

What can I be charged for WSHIP coverage?

• Premiums depend on the plan you select and your age. For example, if you select standard plan option with a $500 deductible, the monthly premium is $343.00 for a 24-year-old but $1, 533.69 for a 64-year-old. Generally the preferred provider plans are less expensive compared to the standard plan but the cost sharing requirements are greater and the benefits may be more limited.
• You may be eligible for a premium discount depending on the WSHIP plan you select, your income and your history of health insurance coverage. Premium discounts and low-income rates are available for the standard plan only. Enrollees with incomes up to 300 percentage of the federal poverty level are eligible for modest premium discounts of approximately 15-25 percent. In addition, regardless of income, modest premium discounts (ranging from 5 to 20 percent) are available for new enrollees who had at least 18 months of prior continuous coverage before joining WSHIP, and for any WSHIP enrollee who has been covered under the program for at least 36 months.
• For a full description of premiums and premium discounts, contact WSHIP directly at 1-800-877-5187 or visit them on the web for at https://www.wship.org.

How long does WSHIP coverage last?

• Your coverage cannot be canceled because you get sick or have high medical claims. This is called guaranteed renewability. You have this protection provided that you pay the premiums and do not defraud the WSHIP.