7429 East Heather Way, Everett, WA  98203-5424

Washington State Health Insurance Plans

Washington State health insurance plans are not all created equal, and sometimes the quickest way to lose your shirt in the market is by making a poor choice for your coverage. Here at Benefits NW, Inc., we offer our clients better tools to conduct their own decision-making process, starting with major goals and ending with a shortlist of viable plans. There's no better way on the Web to research and finalize this essential investment.

Many employers are unaware of the variety of choices this state affords for coverage, including basic health plans, EPOs, HSAs and more. When you factor in how much your employees want to pay out of pocket, what effect pre-tax premiums will have on their paychecks and the total cost of healthcare in a given area, the options can quickly become overwhelming. At Benefits NW, Inc., we believe there is a better way.

The good news is that there are indeed people who can guide you through the fine print, and here you'll find some of the most knowledgeable experts in the state. We can lay out various plans and crunch all the numbers on future scenarios so you experience no surprises down the road. Whether you anticipate poor health for a member's family or a general bump in prescription rates, we can give you a clear projection and sound advice.

There's no more comprehensive approach to healthcare, and at Benefits NW, Inc. we're proud of our commitment to client care. If you want to learn more, please feel free to contact us anytime. We're available by phone at (877) 455-7591 or by email at marketing@benefitsnw.com.

Washington Health insurance is a form of individual or group insurance . where individuals pay premiums in order to help protect themselves from unexpected catastrophic healthcare expenses. Health insurance works by estimating the overall "risk" of healthcare expenses and developing a regular monthly financial arrangment (such as a monthly premium or annual premium ) that will ensure that money is available to pay for the healthcare benefits specified in the insurance contract between the insurance sponsor and the member. The healthcare benefit is administered by a central organization, which is most often a private insurance company, a third party administrator or a government entity.
Market-based health care plans such as that in the United States rely heavily on private (many are publicly held companies listed on national stock exchanges) and not-for-profit health insurance carriers (Such as many Blue Cross and Blue Shield organizations).

A Washington Health insurance policy is a contract between an insurance company and an employer or an individual/family. The contract can be renewable annually or monthly. The type and amount of health care costs that will be covered by the health plan are specified in advance, in the contract or Evidence of Coverage booklet. The individual policy-holder's payment obligations may take several forms

 * Premium: The amount the policy-holder pays to the health plan each month to purchase health coverage. For an employer, the premium may change monthly as the number of employees and their dependents covered varies

 * Deductible: The amount that the policy-holder must pay out-of-pocket before the health plan pays its stated share. For example, a policy-holder might have to pay a $500 deductible per year, before any of their health care is covered by the health plan. It may take several doctor's visits or prescription refills before the policy-holder reaches the deductible and the health plan starts to pay for care.
Many policies allow for prescriptions, office visits and other outpatient benefits to be paid with a copay and are not subject to the deductible.

 * Copayment: The amount that the policy-holder must pay out of pocket before the health plan pays for a particular visit or service. For example, a policy-holder might pay a $25 copayment for a doctor's visit, or $10 to obtain a prescription. In most instances, the copay for generic drugs are lower than the copay for brand named drugs. A copay must be paid each time a particular service is obtained.. Usually the copay does not offer credit toward the coinsurance maximum or the out -of-pocket maximum.

 * Coinsurance: Instead of paying a fixed amount up front (a copayment), the policy-holder must pay a percentage of the total cost. For example, the member might have to pay 20% of the cost of a surgery, while the health plan pays the other 80%. . Usually there is an upper limit on coinsurance especially if the plan is a preferred provider organization (PPO) type of plan. The incentive to stay within the preferred provider organization is set by reducing the coinsurance percentage(therefore increasing the percentage that the insurance company pays) and by having a coinsurance maximum value for in network benefits only.

 * Exclusions: Not all services are covered. The policy-holder is generally expected to pay the full cost of non-covered services out of their own pocket. Examples of exclusions include surgeries to reverse sterilization, cosmetic surgeries for esthetic purposes only, sex change operations, drugs to enhance sexual performance and hair growing drugs

 * Coverage limits: Some health plans only pay for health care up to a certain dollar amount overall -- this is usually called the "lifetime maximum benefit". Usually, if this maximum is reached, the policy will restore benefits by a certain dollar amount each year ( for example $50,000 per year restoration)

Also the policy-holder may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. An example of this is for preventive care. I have seen some policies have anywhere from a $200 to $500 annual maximum for these expenses.

 * Out-of-pocket maximums: Not in the same league as coverage limits, here, the member's payment obligation ends when they reach the out-of-pocket maximum, and the health plan pays all further covered costs for that calendar year. Usually the out-of-pocket maximum for a family is a multiple of 2 or 3 times the individual out-of-pocket maximum.

Prescription drug plans are a form of insurance offered through many Washington Health Insurance plans in the U.S., where the patient pays a copayment and the prescription drug insurance pays the rest. Again, usually the generic drugs are covered by a signficantly lower copay than the brand named drugs. Many of the individual plans in llieu of a copay for prescriptions, will include a discount rx plan . These discounts maybe anywhere from 20-40% discounts

Some health care providers will agree to bill the insurance company if patients are willing to sign an agreement that they will be responsible for the amount that the insurance company doesn't pay, as the insurance company pays according to "reasonable" or "customary" charges, which may be less than the provider's usual fee.

Health insurance companies also often have a network of providers who agree to accept the reasonable and customary fee and waive the remainder. It will generally cost the patient less to use an in-network provider.

Washngton Health Insurance companies are now offering Health Incentive accounts (HIA)[5], to reward users for living healthy and making healthy choices, like stop smoking and/or losing weight. They may get you funds added into your Health IncentiveAccount, which may lower your out of pocket costs. The health incentive accounts also carry over from year to year but once you leave the program you lose those benefits in the HIA.

Idaho, Oregon, & Washington Health Insurance History and evolution
The concept of health insurance was proposed in 1694 by Hugh Chamberlen from the Peter Chamberlen family. In the late 19th century, "accident insurance" began to be available, which operated much like modern disability insurance..
Later, in the United States, the first insurance plans began during the War between the States "Civil War" during the years 1861-1865.
The earliest health insurance coverage only offered coverage against accidents only as they were related to rail or steamboat travel.
These accident plans were the predecessors to the more comprehensive health plans that we know fo today. The first group policy giving comprehensive medical benefits was offered by Massachusetts Health Insurance of Boston in 1847. Insurance companies issued the first individual health insurance policies in about 1890.
In 1929, the first modern group health insurance plan was formed. A group of teachers in Dallas, Texas, contracted with Baylor Hospital for room, board, and medical services in exchange for a monthly fee. Several large life insurance companies entered the health insurance field in the 1930's and 1940's as the popularity of health insurance increased. In 1932 nonprofit organizations called Blue Cross or Blue Shield first offered group health plans. Blue Cross and Blue Shield Plans were successful because they involved discounted contracts negotiated with doctors and hospitals. In return for promises of increased volume and prompt payment, providers gave discounts to the Blue Cross and Blue Shield plans.
All forms of employee benefit plans began to be popular starting after the end of World War II as the GI's came back home and went to work in the factories and offices.
Union leaders collectively bargained for for better benefit packages, including tax-free, employer-sponsored health insurance.
Government programs to cover health care costs began to expand during the 1950s and 1960s as the federal govenment was called to offer more programs and therefore had to charge higher taxes.
Disability benefits were included in social security coverage for the first time in 1954. When the government created Medicare and Medicaid programs in 1965, private sources still paid 75 percent of all of the health care costs. By 1995, individuals and companies only paid for about half of the health care with the government responsible for the other half.
During the 1980's and 1990's, the cost of health care rose rapidly and the majority of employer-sponsored group insurance plans switched from "fee-for-service" plans to the cheaper "managed care plans." As a result, most Americans with health insurance were enrolled in managed care plans by the mid-1990s

Health Maintenance Organizations (HMO"s) became popular among employers as they were structured to keep costs under control by requiring patients to see a primary care provider before seeing specialists. More expensive procedures required prior approval from health plans,
The result was that many employee members felt restricted in their access to healthcare. There was a backlash to these restrictions and as more people became dissatisfied with these plans, more flexible Preferred Provider Organzations became popular and the people moved away from the HMO model. .
In 1993 President Bill Clinton presented to the U.S. Congress a single payer health care reform plan that would have guaranteed health insurance for all Americans paid for by increased taxes. Congressional leaders opposed the plan as it was too expensive and excessively regulated. Many people also didn't want the quality or the cost of their health care to be determined by the federal government as compared to the private free market. When was the last time you knew that the federal government provided the best quality or the best efficiency in anything? What people were afraid of was that this would have increased the inflation rate on the cost of medical care and reduced the quality of that care.
In 1994, members of Congress introduced a series of alternative proposals, but no compromise was ever reached. In 1996 Congress passed the Mental Health Parity Act, to require some employers to offer health plans with psychiatric benefits. Congress also passed the Health Insurance Portability and Accountability Act in 1996. This protected individuals from losing their health insurance when they moved from one job to another or became self-employed.

The Bush administration and Congress have pledged to reform health care but even the proposals have been delayed by more urgent financial concerns and issues related to Iraq. It is unlikely that the Federal Government will change the foundation of the current system anytime soon. It would be wise for all people to check their insurance benefits, make sure that their policies serve their needs, and simultaneously shop for the best plans as they also try to select the best doctors. As in many areas of commerce, and life, the more regulations and laws and bureaucracies there are, the greater the costs, inefficiencies and reduced quality are the results.
This payment model continued until the start of the 20th century in some jurisdictions, where all laws regulating health insurance actually referred to disability insurance. Patients were expected to pay all other health care costs out of their own pockets, under what is known as the fee-for-service business model. During the middle to late 20th century, traditional disability insurance evolved into modern health insurance programs. Today, most comprehensive private health insurance programs cover the cost of routine, preventive, and emergency health care procedures, and also most prescription drugs, but this was not always the case.

How Idaho, Oregon & Washington Health Insurance works
An Idaho, Oregon or Washington health insurance policy is a contract between an insurance company and the insured. The insured may be an Idaho, Oregon, or Washington individual, family, or an employer such as a corporation or other organization. . The contract can be renewable annually or monthly. The type and amount of health care costs that will be covered by the health plan are specified in advance, in the member contract or Evidence of Coverage booklet. The individual policy-holder's payment obligations may take several forms:
Premium: The amount the policy-holder pays to the health plan each month to purchase health coverage.
Deductible: The amount that the policy-holder must pay out-of-pocket first and before the health plan pays its share. For example, a policy-holder might have to pay a $500 deductible per year, before any of their health care is covered by the health plan. It may take a trip to the emergency room or a few sets of diagnostics and labs and xrays before the policy-holder reaches the deductible and the health plan starts to pay for care.
Copayment: The amount that the policy-holder must pay out of pocket before the health plan pays for a particular visit or service. For example, a policy-holder might pay a $45 copayment for a doctor's visit, or to obtain a prescription. A copayment must be paid each time a particular service is obtained. In many cases, the copayment would pay for the doctor's visit or prescription even if the deductible is not paid out yet. .
Coinsurance: Instead of paying a fixed amount up front (a copayment), the policy-holder must pay a percentage of the total cost. For example, the member might have to pay 20% of the cost of a surgery, while the health plan pays the other 80%. It is important to have a coinsurance maximum written in the contract because the coinsurance can be a catastrophic amount even at 20% of costs.
Exclusions: Not all services are covered. The policy-holder is generally expected to pay the full cost of non-covered services out of their own pocket. Examples include cosmetic surgery, sex change operations, reversal of
Coverage limits: Some health plans only pay for health care up to a certain dollar amount. The policy-holder may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some plans have annual or

lifetime coverage maximums. In these cases, the health plan will stop payment when they reach the benefit maximum, and the policy-holder must pay all remaining costs.
Out-of-pocket maximums: Similar to coverage limits, except that in this case, the member's payment obligation ends when they reach the out-of-pocket maximum, and the health plan pays all further covered costs. Out-of-pocket maximums can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.
Prescription drug plans are a form of insurance offered through many employer benefit plans in the U.S., where the patient pays a copayment or coinsurance and the prescription drug insurance pays the rest. In increasing frequency, the drug plan will have a separate deductible as well.
Some health care providers will agree to bill the insurance company if patients are willing to sign an agreement that they will be responsible for the amount that the insurance company doesn't pay, as the insurance company pays according to "reasonable" or "customary" charges, which may be less than the provider's usual fee.
Health insurance companies also often have a network of providers who agree to accept the reasonable and customary fee and waive the remainder. It will generally cost the patient less to use an in-network provider.
Health Insurance companies are now offering Health Incentive accounts (HIA)[7], to reward users for living healthy and making healthy choices, like stop smoking and/or losing weight, may get you funds added into your Health Incentive Account, which may lower your out of pocket costs. The health incentive accounts also carry over from year to year but once you leave the program you lose those benefits in the HIA.

Inherent problems with private Idaho, Oregon & Washington Health Medical insurance
Any private insurance system will face two inherent challenges: adverse selection and ex-post moral hazard.

Adverse selection
Idaho, Oregon & Washington Insurance companies use the term "adverse selection" to describe the tendency for only those who will benefit from insurance to buy it. Specifically when talking about health insurance, unhealthy people are more likely to purchase health insurance because they anticipate large medical bills. On the other side, people who consider themselves to be reasonably healthy may decide that medical insurance is an unnecessary expense. For example, ; if a healthy person sees the doctor on average once a year and it costs $250, that's much better than making monthly insurance payments of $300 .
The fundamental concept of health insurance is that it balances medical claims across a large, sample of randomly chosen individuals For instance, an Idaho, Oregon or Washington medical insurance company has a pool of 1000 randomly selected member-subscribers, each paying $150 per month for a total pool of $150,000 per month. . One member becomes very sick while the others stay relatively healthy, allowing the insurance company to use most of the money paid by the healthy member-subscribers to pay for the treatment costs of the sick member.. Adverse selection upsets this balance between healthy and sick member-subscribers by leaving an insurance company with a higher percentage of sick subscribers and not enough revenues to balance out the cost of their medical expenses with a large enough number of healthy subscribers.
Because of adverse selection, medical insurance companies use a patient's medical history to screen out persons with pre-existing medical conditions. Before buying health insurance, a person typically fills out a comprehensive medical history form that asks whether the person smokes, how much the person weighs, whether the person has been treated for any of a long list of diseases and so on. In general, those who present a large financial burdens are denied coverage or charged high premiums to compensate. One large U.S. industry survey found that roughly 13 percent of applicants for comprehensive, individually purchased health insurance that go through the medical underwriting process were denied coverage. Declination rates increased significantly with age, rising from 5 percent for individuals 18 and under to just under a third for individuals aged 60 to 64. On the other side, applicants can get discounts if they do not smoke and are healthy.
 

In Washington State,for individual & family health insurance up to age 65, there is a"Standard Health Questionnaire for Washington State." This health questionnaire needs to be to completed in most instances. Approximately 92% of applicants pass this screen. The other 8% are offered the Washington State Health Insurance Pool Plan which offers alternative plans at significantly higher rates.