Help for Understanding Health Insurance

Healthcare insurance includes words and abbreviations that can be confusing and hard to remember. This article describes a few key terms to demystify the health insurance world for Washington State families. Washington Healthplanfinder.org is a place to research insurance options statewide, with English and Spanish options.

Managed Care Organization (MCO)

A Managed Care Organization (MCO) is an agency that coordinates medical services and reimburses providers.

State medical insurance in Washington is called Apple Health. Apple Health pays a monthly premium to an MCO that an individual or family chooses to manage preventive, primary, specialty, and other health services. Apple Health also pays for some services directly, through Fee for Service (FFS).

The term “provider” describes any health care professional or facility that provides treatment. Doctors, nurses, mental health professionals, physician assistants, dentists, therapists, behavior specialists, and many other professionals are considered providers.

Clients enrolled in managed care must seek providers who are part of their plan’s network unless there is an emergency or prior authorization is arranged. Prior authorization means the insurance company agrees to pay for a service, treatment, prescription drug, medical equipment, or something else because it is determined to be medically necessary.

The Apple Health system includes five MCOs. Not all plans are available in all areas of Washington State. ​

  • Amerigroup (AMG)
  • Community Health Plan of Washington (CHPW)
  • Coordinated Care of Washington (CCW)
  • Molina Healthcare of Washington, Inc (MHW)
  • United Healthcare Community Plan (UHC)

For complicated circumstances, an MCO may recommend a case manager be assigned to support an individual’s care. Families also have the option to request case management, especially if locating providers is difficult to meet unique or substantial needs.

Health Maintenance Organization (HMO)

A Health Maintenance Organization (HMO) is a type of MCO.  An HMO is an independent system that requires enrollees to seek care within a specific network of hospitals and providers. An HMO plan is based on a network of providers who agree to coordinate care in return for a certain payment rate for their services. 

Preferred Provider Organization (PPO)

A Preferred Provider Organization (PPO) is another type of MCO. A PPO generally will allow individuals to choose their providers and does not limit reimbursement to providers in a specific network. Because of that, a PPO tends to be more expensive than an HMO.

What is the difference between Medicaid and Medicare?

Medicaid is income dependent, and Medicare is not. Both provide government-funded healthcare.

Medicaid is state-managed to provide free or low-cost medical coverage for individuals or families who qualify based on income. Washington’s Medicaid program is Apple Health.

Medicare is a federal health insurance program for individuals age 65 and older and for those with qualifying disabilities. Medicare is not dependent on income.

Copayments, Premiums, and Deductibles

When healthcare is not free, the cost to the family adds up through the copayments, premiums, and deductibles. Here’s what that means:

  • Copayment: a specific fee for a visit or procedure.
  • Premium: payment for the insurance. An individual might have premiums withheld from a paycheck, or an employer might agree to pay all or part of the premium.
  • Deductible: the amount of money an individual must pay each year before insurance payments “kick in.” After a deductible is met, the patient may still make copayments or pay a percentage of the cost, depending on the plan. Supplemental insurance through Medicare is sometimes an option to cover deductible expenses.

What is a Medicaid Waiver?

A Medicaid waiver allows the federal government to waive rules that usually apply to the Medicaid program. The intention is to reimburse for services that would not otherwise be covered by Medicaid. Waivers generally provide local, non-institutional solutions for individuals with disabilities. For example, in-home care paid for through a waiver might support someone to live in the community.

Medicaid.gov provides a Washington Waiver Fact Sheet that outlines waiver programs available in Washington State.

An Illustration of the insurance terms described in this document

Download the illustration as a PDF – Health Illustrative

Washington Health Plan Finder – Information You Need!

It’s that time of year again, November 1st through December 15th is open enrollment for Washington health benefit exchange. If you or a family member needs health insurance, especially if you qualify for Medicaid (Apple Health) it is imperative that you enroll by December 15th to avoid any penalties.

We know that the healthcare enrollment process can be complicated, especially if you or one of your family members have a special healthcare need or disability. Washington Health Benefit Exchange has some helpful articles and resources to walk you through the process. You can call Parenthelp123 at  1-800-322-2588  or go online at Parent help 123. They have a large knowledgeable staff of family navigators to help you understand the process, look at the plans and they can help you enroll right on the phone. If you have a child impacted by Autism, there is family support around enrollment and coverage at Washington Autism Alliance and Advocacy, they can be contacted at 425.894.7231 or by going online at Washington autism advocacy .

To begin the healthcare enrollment process head over to the Washington Health Benefits Exchange website.  If you are a new or current customer, the website will guide you through each step. Washington Health Benefit Exchange

If you think you may be eligible for Medicaid (Apple Health), Healthcare Services and Supports website guides you through the application process as well as the eligibility and income requirements.

If you are renewing your coverage, looking for new coverage, or want to compare healthcare plans. Renew your coverage

If you are looking for in-person support, 12 statewide locations will include in-person support, to include brokers and trained navigators who will be available to personally guide you in enrolling in health and dental coverage. They will help you determine whether you are eligible for Medicaid (Apple Health) or find the healthcare plan that is right for you based on your family’s healthcare needs. In-person assistance

The National Disability Navigator Resource Collaborative (NDNRC) mission is to ensure people with disabilities are receiving accurate information when selecting a healthcare plan The NDNRC website includes links that are disability specific, mental & behavioral health, and populations with special health care needs. National disability navigator

Are you having a baby? Did you lose your health coverage? Learn what the qualifying life events are that will allow you to enroll in healthcare outside of the enrollment period. Special enrollment

Learn about the required tax preparation, filing, and tax benefits when you enroll in a healthcare plan. The site includes frequently asked questions and videos to help you understand the filing process. Filing taxes

Enrolling in healthcare does not have to be complicated and confusing. There are many resources and professionals ready to help guide you through this process. Don’t wait. Enroll in a healthcare plan today!

Supplemental Security Income (SSI)

WHAT IS SSI?

SSI is a monthly financial benefit from the Social Security Administration to people with limited income and resources who are age 65 or older, blind or disabled.  Blind or disabled children, as well as adults, can get SSI.

In most states, SSI determination is required for Medicaid eligibility of children with disabilities.

ELIGIBILITY REQUIREMENTS:

  • Financial Determination
  • Parental income is deemed, counted then prorated among the family members
  • Exclusions
  • Income includes Earned and Unearned Income
  • Parental Resources are counted
  • Disability Determination

Specific requirements:

Marked and severe functional limitations as defined by the Social Security Administration the limitations must have lasted or are supposed to last for a continuous period of 12 months or longer

The decision is made by a State Agency, Disability Determination Service, specifically,  a team composed of a disability examiner and a medical or psychological consultant

What does the Social Security Administration Need?

  • Social Security Card for all children
  • Proof of Age—Birth Certificate for all children
  • Citizenship—Birth Certificate
  • Proof of Income—3 months LES
  • Earned-wages and special pays
  • Unearned Income-BAH/quarters and BAS

Proof of Resources:

  • Bank statements
  • Deed or tax appraisal
  • Insurance Policies
  • Certificates of Deposit, Stocks and Bonds

Proof of Living Arrangements:

  • Deed, tax bill, or lease receipt
  • Medical Assistance Cards
  • Information about household costs, (utilities)

Medical Sources of Information:

  • Medical Reports stating disability
  • Names, addresses and telephone numbers of doctors and other medical service providers
  • Names and Documentation on how disability affects the day-to-day activities.

How To Apply?

Go to local Social Security Office, ideally in the middle of month for faster service

Call the SSA office at 1-800-772-1213

While stationed overseas and you think your child may be eligible for SSI, you can apply by contacting the Federal Benefits Unit at the following Embassies or Consulates:

Germany Federal Benefits Unit
American Consulate General
Giessener Str. 30
60435 Frankfurt, Germany
Phone: 49-69-7535-2496
Fax:  49-69-749-352

England Federal Benefits Unit
American Embassy
24/31 Grosvenor Square
W1AW 2LQ London, England
Phone: 44-207-499-9000
Fax: 44-207-495-7200

Japan American Embassy
Federal Benefits Unit
1-10-5 Akasaka
Minato-ku, Tokyo
107-8420 Japan
Phone: 81-3-3224-5000
Fax: 81-3-3505-1862

Korea Social Security Division
Veterans Affairs
Regional Office
American Embassy
1131 Roxas Boulevard
0930 Manila, Philippines
Phone: 63-522-4716 or 63-2-526-5936
Fax:  632-522-1514

Things to Remember

  • It can take up to 180 days for approval.
  • Payments are retroactive to the date of application.  Your initial contact may be considered the date of contact.
  • 1 of every 5 applications are denied—APPEAL.*
  • When talking about the disability discuss the worst days, not the best.
  • It is necessary to complete both disability and financial determinations when assessing eligibility. This is because SSI eligibility determination may be used in other programs within your state.
  • Establishing the disability eligibility will enable your child to receive SSI when they turn 18 and the parent’s income is no longer considered, or if their economic situation changes.
  • *Tip: Appeals to decisions are common and a right for your child
  • Special Consideration for military families OCONUS
  • Continuation of SSI benefits for families who PCS CONUS to OCONUS who meet the following criteria:
  • Was eligible to receive SSI in the month before parent reported for duty overseas—payments will continue from the state you last were eligible

Report information regarding:

  • Moves of the child
  • People move into or out of the home
  • Changes of financial status
  • Leaving the Armed Forces and remaining overseas

For more information visit the SSI web page

“Working Together with Military Families of Individuals with DisAbilities!”