Alphabet Soup: A Brief Guide to Washington State's Insurance Options

Medicare or Medicaid? EIP, EIIP, EHIP? COBRA? WSHIP? EOB's? CNP, MNP, QMB?

This flyer is meant to be a relatively short cheat-sheet to help keep these programs straight. We will not give all the details, but will summarize them and provide contact information for you to access any additional information you might need.

Medicare

Medicare is an insurance program run by the federal government. It is for people who receive (or would qualify for) some sort of Social Security benefits including Social Security Retirement Benefits (SSA) or Social Security Disability Insurance (SSDI). The card is red, white, and blue, and your identification number is your Social Security number plus a letter. Medicare is the primary payer for any claims. That means that your doctor will send bills to Medicare before asking anyone else to pay. Medicare comes in two parts:

• Part A: Pays for expenses related to a hospital or nursing facility and is free.
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• Part B: Pays for doctor visits and related tests and has a monthly premium (for 2004 the premium amount is $66.60/month).

Medicare is a national plan, but can be a little different from place to place. Some areas require that you enter a Medicare HMO. These HMO Medicare plans usually have better coverage, but limit your ability to see certain doctors or to travel. Medicare will be phasing in some changes in the next two years. In June of this year, Medicare approved drug discount cards become available. Then in 2006, Medicare will offer prescription drug coverage. (Washington's Governors Advisory Council on HIV/AIDS (GACHA) will be holding a forum on the new Medicare drug bill, and all of its problems, on the morning of May 11, 2004, in the Seattle area. Contact STEP for more information.)

Who to Call

To find out if you are covered: 1-800-772-1213.

For general questions: 1-800-MEDICARE (633-4227).

For specific questions in Washington: 1-800-444-4606.

Medicaid

Medicaid is insurance that comes from the state and is run by the Department of Social and Health Services (DSHS). Medicaid is limited to low-income individuals who are either children, expectant mothers, or disabled individuals. Medicaid participation is not allowed for undocumented aliens. Medicaid will pay for most doctor visits, some dental needs, some vision services, and most prescriptions. Medicaid can also pay for the Medicare Part B premiums (the $66.60 from above). Medicaid has three basic sections. These letters will appear on your green Medicaid coupon:

• CNP: This stands for the "Categorically Needy Program." The CNP coupon is for anyone receiving an income equal or lower than the present amount of Supplemental Security Income. Individuals with a CNP coupon do not need to pay any amount before the Medicaid is active.

• MNP: This is the "Medically Needy Program." The MNP coupon is what is often called "spenddown medical." The term spenddown refers roughly to the amount your income exceeds the present amount of Supplemental Security Income ($564/month for 2004). The state has determined that Medicaid will not pay for any services until the spenddown has been paid ... by you. Once the spenddown is paid, the insurance is almost identical to the CNP coverage. See the Early Intervention Program for spenddown assistance.

• QMB: This program is the "Qualified Medicare Beneficiary" program. If you are eligible for this program, Medicaid will pay the Medicare Part B premium needed to keep your Medicare Part B. This program has several variations including: SLMB, ESLMB, QI-1, QDWI, and QI-2. They are all variations on the same program, but will change how much of the Medicare Part B premium Medicaid will actually pay.

Who to Call

DSHS has several offices, and you will need to contact the appropriate office for your area. To learn where you should go, call: 1-800-562-3022.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

COBRA is a law requiring employers that have more than 20 employees to offer employees the option of paying for their own insurance premiums after the employee quits, is laid-off, or gets fired. The employee must pay the monthly insurance premiums (usually between $200 and $600 each month), but there is no change in the coverage. Individuals who accept COBRA can stay on that insurance program for 18 months as long as regular payments are made. If an employee leaves work due to disability, he or she can apply for an extension of 11 additional months on COBRA.

Who to Call

Your Human Resources contact through work.

Washington State Health Insurance Pool (WSHIP)

The Washington State Health Insurance Pool (WSHIP) "is designed to provide health insurance to Washington residents who are unable to find adequate health insurance coverage in the private market due to their mental or physical condition" (from the WSHIP mission statement). Insurance companies can legally reject applications for individual insurance coverage based on a person's medical status. WSHIP is the alternative for people who get rejected. If you are eligible for insurance through employment or you are eligible for Medicaid (note that this says Medicaid, the DSHS program, not Medicare, the SSA program), you cannot receive WSHIP. Applying for WSHIP involves applying for an individual insurance plan and getting rejected. It may be a good idea to consult with a case manager before starting this process. WSHIP does not have dental or vision coverage.

Who to Call

For WSHIP information: 1-800-877-5187.

Early Intervention Insurance Program (EIIP)

The Early Intervention Insurance Program (EIIP) is a state program funded by the Department of Health. The program will pay the monthly insurance premiums for low-income individuals with an HIV-positive diagnosis, but not an AIDS diagnosis. The Early Intervention Insurance Program will pay for COBRA plans, WSHIP, and some individual insurance plans. EIIP will not pay for dental insurance premiums.

Who to Call

EIIP: 284-9277.

Evergreen Health Insurance Program (EHIP)

The Evergreen Health Insurance Program (EHIP) is a state program currently funded by the Department of Social and Health Services. The Evergreen Health Insurance Program will pay the monthly insurance premiums for low-income individuals with an AIDS diagnosis. The Evergreen Health Insurance program will pay for COBRA plans, WSHIP (there is a waitlist for WSHIP coverage), other individual insurance plans, and Medicare B premiums. EHIP will not pay for dental insurance premiums.

Who to Call

EHIP: 323-2834 or 1-800-945-4256.

Early Intervention Program (EIP)

The Early Intervention Program (EIP) is Washington State's version of the federal AIDS Prescription Drug Program (APDP) or AIDS Drug Assistance Program (ADAP). All of these names refer to a single pot of money that is given to the states to help low-income HIV-positive individuals access medications. In Washington, state money is added to this federal money to create the Early Intervention Program (EIP). Effective April 2004, a monthly cost-share for prescriptions has been added based on your income and whether or not you have other insurance coverage. Individuals under 100% Federal Poverty Level are exempt from this cost share, but must apply for Medicaid coverage. Only individuals earning less than 300% of federal poverty level (around $2,000 per month) are eligible for enrollment in EIP.

The Early Intervention Program will do one of three things:

• Complete Coverage: If you do not have insurance, the Early Intervention Program will pay for all doctor visits, labs, and prescriptions that are connected to monitoring and treating HIV. This will not pay for unrelated illnesses or injuries, dental care, vision services, or hospitalization.

• Prescription Assistance: For individuals with primary insurance, the Early Intervention Program will pay for the co-pays on medication related to the treatment of HIV.

• Spenddown Coverage: For individuals on Medicaid, EIP will pay $900 a month toward a person's spenddown.

Who to Call

EIP, either: 360-236-3426 or 1-800-272-2437 option 2.

Other Terms

• Explanation of Benefits (EOB): These are statements from your insurance company showing what your doctor billed to the insurance company, and what the insurance company paid. While they may show that the "patient" owes some amount of money, they are not bills. It is a good idea to keep these statements.

• Deductible: This is the amount of money an insurance company expects you to pay before they will start their coverage. Common amounts are $500 or $1000 each year.

• Pre-Existing Condition Wait Period: Insurance companies can refuse to pay for certain services related to a condition you may have had before starting new insurance. This is only true of individual plans, not group plans. These wait-periods are usually 3, 6, or 12 months long.

• Premium: This is how much insurance costs each month. Premiums usually cost between $200 and $600 each month.

• Co-Pay: This is how much you have to pay for services like doctor visits and labs, or for prescriptions. Co-pays are usually either set at $10 to $20, or are a set percentage of the total cost of the service.

• Certificate of Creditable Coverage: This is a letter from a previous insurance company verifying how long you had coverage with them, and when that coverage ended. This letter may be needed to avoid a pre-existing condition wait period when you start a new insurance plan.