Your Right to Obtain Health Insurance in Washington

Health insurance is almost entirely regulated by the states, and the rules and regulations governing it vary widely from one state to another, permitting or disallowing barriers to access.  It is important to understand how health insurance functions in your state in order to evaluate what types of reform are needed, both on the state and federal level, to make quality, affordable health insurance available to everyone.

Your rights to obtain health insurance in Washington vary depending on whether you purchase insurance as an individual, under a group plan, or as a small business owner.

Getting health insurance as an individual in the open market
If you are not insured through your employer, union, or some other type of group, you are currently not guaranteed the right to buy health insurance in Washington. Private insurers can refuse to sell you insurance because of your health status, or exclude a pre-existing condition from coverage, or charge you a higher premium based on your age. There are certain circumstances, however, when you must be allowed to buy individual health insurance.
Most insurers will require you to complete the Standard Health Questionnaire (SHQ). The questionnaire is used to determine your eligibility for an individual health insurance policy. Your health conditions will be assigned points depending on how costly they are.  If you accumulate more than 325 points on the SHQ, insurers can turn you down for individual health insurance.  If you accumulate less than that, the insurer can’t turn you down.

There are some situations when you do not have to take the SHQ and must be offered an individual health insurance policy regardless of your medical history. For information about the Standard Health Questionnaire, including how you are scored, how to appeal your score, and exceptions to the rules, visit the SHQ site.
Please note that insurers may impose pre-existing condition exclusion periods.  Insurers define pre-existing conditions as those for which you received medical advice in the past 6 months. Coverage for pre-existing conditions can be excluded for a maximum of 9 months. However, the amount of time you were covered under your previous insurer may be credited toward your pre-existing condition exclusion period if you have not had a break in coverage of 63 days or more.  This can cancel out or reduce the length of a pre-existing condition exclusion period.
If you are turned down for individual health insurance you may qualify for coverage from the Washington State Health Insurance Pool (WSHIP). Pre-existing condition exclusion periods under WSHIP plans cannot exceed 6 months. You must enroll within 90 days of receiving the denial notice from an insurer. Through WSHIP or any licensed insurance carrier, you may also be eligible to buy a HIPAA plan. HIPAA is a law that guarantees you access to insurance coverage if: 1) you had at least 18 months of continuous insurance coverage, the last day of which was under a group plan, 2) you have exhausted any COBRA coverage which was available to you, and 3) you are not eligible for any public or group health plans. No pre-existing condition exclusion periods can be imposed.

COBRA is a law that lets you keep the insurance you had through your job if your employer has 20 or more employees. COBRA coverage lasts up to 18 months (sometimes longer) after you’ve left or become ineligible for benefits. You will pay the full premium, i.e. both your share and the amount your employer or union was paying on your behalf. COBRA can be quite expensive, but may be cheaper than buying an individual policy on the open market.

In the case of an emergency, federal law protects you from being denied care in an emergency room, regardless of your insurance status or ability to pay. If you do not have health insurance and it’s not an emergency, hospitals are not required to treat you. However, some hospitals will anyway. In addition, some have charity care programs which set fees based on income for those who are uninsured.

Getting insurance through a group or small business
If you are insured through your employer, union, or some other type of group, you cannot be denied insurance because of your medical history. Insurers can however count as pre-existing conditions those for which you received medical advice in the 6 months prior to the start of your policy. If you had a break in insurance coverage of 90 days or more, you may face a pre-existing condition exclusion period. Coverage for pre-existing conditions can be excluded for a maximum of 9 months. You can get credit for prior coverage if you do not have a lapse in coverage of 90 days or more. This can cancel out or reduce the length of a pre-existing condition exclusion period.

For more information on getting and keeping health insurance, please visit www.ahirc.org.