Individual Health Insurance in Washington State
What is the process for obtaining coverage?
What is the Washington State Health Insurance Pool (WSHIP)?
What is a Health Savings Account (HSA)?
Washington state residents can get health insurance through commercial insurance companies or the Washington State Health Insurance Pool (WSHIP). If you do not have insurance through your employer or a public program, or you wish to consider an alternative coverage, here are your options.
Commercial Insurance Companies
That Offer Health Plans in Washington:
- Regence BlueShield
- Group Health Cooperative
- Premera Blue Cross
- Lifewise
- KPS Health Plan
- Asuris Northwest Health
Things to Consider when Selecting a Health Plan:
Which plans do business in my county?
Individual health plans by county are listed in a publication of the Washington Insurance Commissioner’s office, “Shopping for Individual Health Care Coverage,” page 7.
Eligibility
- Commercial insurance is available to anyone who does not score too high on the Standard Health Questionnaire (described below) and can afford to pay for the insurance.
- Those who score too high on the Standard Health Questionnaire can get insurance through the Washington State Health Insurance Pool (WSHIP).
Benefits
HMO v. PPOs
One thing to consider is whether you want a health maintenance organization (HMO) plan or a preferred provider network (PPO) plan
- A HMO plan requires you only see doctors on a list of providers, except in some emergency situations, and that if you see a specialist or go to the hospital you get a referral from your primary care doctor.
- A preferred provider network encourages you to only see doctors in the network – you pay less if you obtain care from those in-network (those who are contracted with your plan). You can see doctors who are out-of-network but you will have to pay more.
Costs
Premiums
- Monthly premiums for individual commercial insurance depend on the plan you choose, your age, where you live, if you are a smoker or a nonsmoker, the age of your children/dependents, and other factors.
- Complete pricing information is available directly from each insurance carrier or insurance agents/brokers.
Cost-sharing
- All commercial plans involve some cost-sharing: the covered individual pays 20% - 50% of the cost of service.
Deductibles
- Commercial plans generally have calendar year deductibles between $500 and $10,000.
Out-of-pocket maximums
- Most commercial plans limit how much you must pay out-of-pocket for the services you receive. After you reach the maximum, the insurance company will cover all remaining costs for the year.
Pre-existing Conditions Waiting Periods
All commercial plans in Washington have a 9-month pre-existing conditions waiting period
- You may have to wait 9 months for coverage for a health condition that you were treated for, or received advice about, in the 6 months before you join the plan
- This waiting period applies to those transferring from a “catastrophic plan” and those who have had a gap in coverage of more than 63 days.
- A “catastrophic plan” is one that has a calendar year deductible of at least $1,500 and an annual out-of-pocket expense maximum for covered benefits of at least $3,000 (this does not include premium payments).
Credits
- If you had comparable or better insurance prior to enrolling in a new health plan, the new plan must credit the time you were enrolled in the old plan toward your waiting period. (E.g., if you were enrolled for 6 months, you will be credited 6 months toward the 9 month waiting period.)
Other ways you might overcome the waiting period:
- If you had 18 months of comparable coverage with another health insurance company immediately prior to your enrollment with the new health plan, the 9-month pre-existing conditions waiting period may be waived.
- If you are deemed an “eligible individual” under federal law: www4.law.cornell.edu
What is the process for obtaining coverage?
Contact the carrier or an insurance agent/broker
- Complete an application, often the Standard Health Questionnaire, in which you disclose your medical history.
- To access a Standard Health Questionnaire and scoring tools, go to www.wship.org. Websites for insurance carriers generally provide this information as well.
- You will not have to complete a Standard Health Questionnaire if you are coming off COBRA or in certain other situations. See www.insurance.wa.gov for more information, and check when applying for insurance whether you must complete the questionnaire.
- The insurance carrier must notify you of acceptance or rejection within 15 business days of receiving your application.
- If you are rejected you will be referred to WSHIP.
- If you disagree with the carrier’s scoring decision, you may go through an appeals process.
What is the Washington State Health Insurance Pool (WSHIP)?
WSHIP offers comprehensive coverage at higher prices to those individuals who are not eligible for commercial health insurance plans based on their responses to the Standard Health Questionnaire.
- Premiums generally are higher for WSHIP plans than for commercial health plans. Premium rates charged by WSHIP may be found at www.wship.org.
- WSHIP does offer some lower premium plans that have high deductibles.
If I already receive health insurance through WSHIP can I transfer to individual commercial insurance?
- WSHIP enrollees may apply for commercial insurance at any time.
- You will need to complete the Standard Health Questionnaire. If you score low enough on the questionnaire, you must be offered commercial insurance coverage.
- If you were on a WSHIP plan for at least nine months that had a deductible of less than $1,500, you should not be required to serve a pre-existing condition waiting period for commercial insurance.
- If you believe you are erroneously serving a pre-existing condition waiting period, you may contact Mary Childers, Compliance Officer, OIC, at (360) 725-7095 or (800) 562-6900.
What is a Health Savings Account (HSA)?
A Health Savings Account (HSA) is an account in which you and your employer can contribute tax-deductible money to cover your health care expenses. The amount you can deposit is limited. You choose what you pay for with the funds in your account, including health care costs not covered by your insurance.
For more information on HSAs go to For more information on HSAs go to www.insurance.wa.gov.