Washington Health Program. Mallory Lisk Community Development Manager February 24, 2012

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1 Washington Health Program Mallory Lisk Community Development Manager February 24, 2012

2 We Know Your Community Community Health Plan of Washington* (Est. 1992), a not-for-profit organization, is the only Washington State health plan founded by local community health centers. We invest and foster growth in the communities where you get your care. * Find out more about Community Health Plan of Washington at

3 What Is Washington Health Program (WHP)? Affordable health insurance Alternative to costly commercial insurance or employer sponsored coverage, including COBRA Covers preventive care and screenings Administered by the Washington State Health Care Authority (HCA) through an exclusive arrangement with Community Health Plan No state or federal subsidy for the program Peace of mind for individuals and families

4 Preventive Care Is Our Focus Mammograms Routine Physical Exams Well Baby Exams Prostate Screening Routine Pap Smears/Pelvic Exams Colorectal Screening Most Immunizations Covered in full at participating providers!

5 Your Medical Home A provider that coordinates your care. Primary Care Physician Specialists Prescription Drugs Hospitals Lab Services

6 Where Is Washington Health Program Available? All Washington Counties! Community Health Centers

7 Who Can Enroll? Washington State residents who: Are not eligible for free or purchased Medicare Do not get Basic Health or Medicaid benefits Are not confined to an institution Can provide proof of residency Complete and pass the Washington State Standard Health Questionnaire (SHQ) No citizenship requirement HCA decides who is eligible not Community Health Plan

8 Plan Choices Plan Options Health 75* or Health 100* Annual Benefit Maximum Annual Deductible Individual Family Annual Out-of-Pocket Maximum Individual Family $75,000 or $100,000 Participating Providers $500 $1,500 $3,000 $9,000 $75,000 or $100,000 Nonparticipating Providers $1,000 $3,000 $5,000 $15,000 * 98% of BH members never reach the $75,000-$100,000 annual maximum

9 Benefits and Services Plan Options Health 75 or Health 100 Participating Providers Nonparticipating Providers Benefits / Services Member Pays Member Pays After Deductible Preventive Care $0 (covered in full) 50% coinsurance Office Visits (Including Urgent Care) Emergency Room Pharmacy $10 for preferred participating; 30% coinsurance after deductible for participating $100 copay per visit for facility; deductible + coinsurance for other ER services $10 copay - Generic 50% coinsurance - Brand 50% coinsurance $100 copay per visit for facility; deductible + coinsurance for other ER services $20 copay Generic 50% coinsurance Brand Maternity Services* Deductible + 30% coinsurance Deductible + 50% coinsurance * If delivery is in first 6 months after you enroll, a separate $5,000 maternity deductible applies.

10 Benefits and Services continued Plan Options Health 75 or Health 100 Participating Providers Non-Participating Providers Benefits /Services Member Pays Member Pays after deductible Hospital Inpatient, outpatient Other professional services Radiology/labs Chiro/physical therapy (12 visits/year)* Skilled Nursing, Hospice, Home Health Durable Medical Equipment Dieticians (limited to services provided) Acupuncture (12 visit/year; no auth required. Add l visits may be covered with prior auth) Mental Health (10 inpatient days/year; 12 outpatient visits/year) Chemical Dependency ($5,000/2 years; $10,000 lifetime maximum) Deductible + 30% coinsurance Deductible + 30% coinsurance Deductible + 50% coinsurance Deductible + 50% coinsurance Organ Transplants (bone marrow, cornea, heart, heart/lung, liver, kidney, kidney/pancreas) Deductible + 30% coinsurance Deductible + 50% coinsurance Ambulance Deductible + 30% coinsurance Deductible + 30% coinsurance * Chiro/PT only when provided as post-operative treatment following reconstructive joint surgery. Visits must be within one year of surgery. No more than 6 of the 12 can be for chiro. Speech therapy is not covered.

11 Other Benefit Information Disenrollment and re-enrollment restarts the separate maternity deductible. There is no grace period. Out-of-pocket maximum applies to all services you get in each specific network preferred participating, participating, or nonparticipating. There is no crossover. ER copay is for the facility charge only. All other ER services are subject to coinsurance and deductibles. Washington Health Program benefits and deductibles apply only to Washington Health. There is no crossover with Basic Health. No dental or vision coverage. Your newborn is covered up to 21 days; then you must add the child to your plan through HCA. Certain conditions are covered only after a 9-month waiting period.

12 How Much Will It Cost? Average Premiums Health 75 ($75,000 maximum benefit coverage per year) Health 100 ($100,000 maximum benefit coverage per year) Premium calculator is online at

13 Where Do I Get Care? Community Health Plan s service network for State programs includes 19 networks of community health centers operating at 97 clinic sites, 263 affiliate providers operating at 499 sites, 596 primary care clinics and provider offices, 2,725 primary care providers, 14,350 specialists, over 100 hospitals and over 58,000 pharmacies nationwide. Provider lookup: Choose provider within Community Health Plan network or go outside network; cost differentials apply

14 Washington Health Program Provider Network Preferred-Participating Providers All community health center providers and all Washington Health Program Preferred providers listed on our web site Participating Providers All Washington Health Program Participating providers listed on our web site Nonparticipating Everyone else PCPs 824 Specialists PCPs 1,574 Specialists 13,231

15 Referrals You do not need a referral from your primary care provider (PCP). With a PCP referral you are assured the lowest out-of-pocket costs.

16 How Do I Enroll? Application is made to the Health Care Authority. Online resources available at include: Enrollment application The Standard Health Questionnaire An Application Guide Answers to frequently asked questions Premium Calculator There is no limit to how many people can enroll in the program. There is no wait list.

17 Standard Health Questionnaire (SHQ) Every applicant must complete a SHQ. Complete online or on paper. The SHQ is 26 pages long, available in English only. Completed and submitted SHQs are valid for 90 days. HCA scores SHQ not Community Health Plan. You may appeal scores via HCA. If HCA denies you coverage, you have 90 days from notice of rejection to apply for coverage with the Washington State Health Insurance Pool (WSHIP).

18 What Should I Expect Upon Enrollment? 1. HCA notifies you when you are accepted. 2. HCA tells you how much your premium will be and sends your first bill. 3. Community Health Plan sends you a welcome letter, ID card, and medical benefits summary.

19 Online Information Community Health Plan Online Program Info: Online Provider Directory: WHP help and information: or TTY at Health Care Authority Online Program Info: Online Materials: Customer Service: or TTY

20 Questions?