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LifeWise HealthPlans of
Washington: FAQ
Eligibility
Q. If I live out of the state for part of the
year can I still be covered?
A. Yes, so long as you are a permanent resident of
Washington state. Keep in mind that only emergency
or urgent care outside of the state will be covered
at the higher benefit level. All non-urgent and non-emergency
care outside of the state will be covered at a constant
50% benefit level.
Q: Can state residents age 65 or older enroll
on a LifeWise individual product?
A: Only non Medicare-eligible residents who are 65
years of age or older when their coverage will begin
may enroll on one of these individual plans. Please
note that people already on an individual plan when
they reach age 65 may continue their individual coverage.
Q: Are single employee groups eligible?
A: Yes. Single employee groups are eligible for LifeWise
Individual plans.
Q. Are children covered by medical child support
orders required to be Washington state residents?
A. No. The residency requirement does not apply nor
must they complete the Standard Health Questionnaire.
And, the nine-month pre-existing condition waiting
period will be waived. Please note that these children
would receive out-of-area benefits for all services,
with the exception of medical emergencies and accidental
injuries.
Effective Date of Coverage
Q: Do you accept applications for effective dates
more than one month in the future?
A: Yes. Applicants may designate a first-of-the-month
effective date of up to three months from the date
of application.
Applying for coverage
Q: How do I apply for coverage?
A: You will find product information and forms on
this Web site (see the left side of the screen). Once
you have selected the plan and rates you want, fill
out the enrollment application and the Standard Health
Questionnaire (if needed). Be sure to include the
documentation requested on the application checklist.
Q: If I choose a $10,000 deductible plan, can
I later change to a $500 deductible plan with the
same benefits?
A: Yes, but you would have to complete the Standard
Health Questionnaire, and acceptance to the new plan
will depend on the results of that questionnaire.
In addition, the pre-existing condition waiting period
will apply because you are moving to a plan offering
greater overall benefits and, as with all newly effective
contracts, you will have a 12-month waiting period
for organ and bone marrow transplant benefits. In
all cases deductibles and benefit maximums will start
over.
Q: If a member currently enrolled in a LifeWise
Individual plan applies for a new plan and is not
accepted, may he or she retain the existing coverage?
A: Yes.
Q: The tobacco use section on the application
asks whether any tobacco products have been used in
the past 12 months. Are nicotine patches considered
tobacco products?
A: No. We are asking about tobacco products such
as cigarettes, cigars, chewing tobacco and other like
products.
Standard Health Questionnaire
Q: When does an applicant not need to fill out
a Standard Health Questionnaire?
A: You don't need to fill one out if you are:
- Applying for coverage due to relocating within
Washington state to an area where your prior health
plan isn't offered.
- Applying for coverage because your health care
provider (whom you have seen in the past 12 months)
has cancelled from his or her prior insurance, and
is contracting with us.
- Applying for coverage after exhausting COBRA continuation
coverage.
- A newborn child or newly adopted child of an existing
LifeWise individual enrollee.
You must apply for coverage within 90 days of relocation,
provider cancellation or exhaustion of COBRA in order
to have the Standard Health Questionnaire requirement
waived.
Q: Do current LifeWise enrollees have to fill
out the Standard Health Questionnaire if they want
to switch to another Individual plan?
A: Yes.
Q: If I have exhausted my state continuation of
coverage, must I fill out the Standard Health Questionnaire?
A: Yes. However, in some cases the nine-month pre-existing
condition waiting period may be waived.
Q. Who reviews the Standard Health Questionnaire
sent to LifeWise?
A. LifeWise reviews each questionnaire. The questionnaire
was developed by the Washington State Health Insurance
Pool Board, which sets the rules and procedures to
score and evaluate it.
Q. Would a different health plan score the Standard
Health Questionnaire differently?
A. All health plans must score the questionnaire
using instructions from the board of the Washington
State Health Insurance Pool.
Q: Do all the family members have to show proof
of residency or just the subscriber?
A: We require proof of residency from the primary
applicant.
Q: I haven't received a certificate of creditable
coverage yet from my former carrier. How does this
affect me?
A: A carrier must provide a certificate of creditable
coverage within 30 days of termination of policy and
at no charge to you. If your coverage starts before
we have a copy of your proof of coverage, pre-existing
conditions will apply. However, once we receive the
document from you, we will apply the proof of coverage
retroactively to your coverage start date.
Q: What is considered acceptable proof of prior
coverage for someone who has just moved from a foreign
country?
A: We will evaluate each situation separately. A
health card, plan identification card or certificate
issued by the national health plan is acceptable proof.
Rates
Q: When determining an enrollee's age for rate
purposes, what is age based on-last birthday (current
age) or nearest birthday?
A: Current age.
Q: Can a separate policy be written for the other
family members if one adult smokes?
A: Yes.
Enrollment denials
Q: If an applicant is denied enrollment, is he
or she told why?
A: Yes, if an applicant is determined to be eligible
for coverage through the Washington State Health Insurance
Pool. LifeWise mails a copy of the questionnaire to
the applicant with a letter listing each condition
marked and the scores it received within 15 business
days of our receiving the complete application.
Q: If someone is denied coverage by LifeWise and
obtains coverage from the WSHIP plan, can he or she
ever return to private market coverage?
A: Yes. An enrollee on the WSHIP plan may apply for
private insurance coverage at any time. However, the
person must complete the Standard Health Questionnaire,
which determines eligibility for coverage on private
plans.
Q: If a parent with children applies for coverage
and the parent is not eligible based on the answers
to the Standard Health Questionnaire, what happens
to the eligible children?
A: The children may be covered, as long as the parent
marked "yes" on the application when answering the
question "If one or more family members is not accepted
for coverage, I authorize LifeWise to enroll those
who are eligible in the program I have selected."
The children would automatically become subscribers
under separate contracts at the lowest subscriber
rate (assuming all children are under 25 years of
age).
Eligibility for WSHIP
Q: Who can apply directly to WSHIP?
A: Only those people who live in counties where no
individual insurance is offered may apply directly
to WSHIP, or those who have been denied coverage from
a private insurer (denial letter from a carrier required)
Pre-existing conditions
Q: Is there a pre-existing condition waiting period
on the LifeWise Individual plans?
A: Yes. The pre-existing condition waiting period
is nine months. However, under certain circumstances
the waiting period may be reduced or waived completely.
For details, please contact us at 1-888-836-6135.
Q: Does an adopted child new to the contract have
to fulfill the nine-month pre-existing condition waiting
period?
A: The adopted child must enroll within 60 days of
the adoption to avoid the nine-month pre-existing
condition waiting period. The newly adopted child
will not need to complete the Standard Health Questionnaire.
However, if the 60-day period for enrollment is not
met, the child may qualify for a waiver under other
criteria.
Q: What is the difference between a 63-day break-in-coverage
as it applies to pre-existing conditions and the 90-day
rule in which you don't have to complete the Standard
Health Questionnaire?
A: If you have a 63-day break-in-coverage, you must
complete the Standard Health Questionnaire and your
previous coverage will not be credited to the waiting
period. If, within the last 90 days, you 1) exhausted
COBRA, 2) your provider has left your current plan,
or 3) you've moved to an area in Washington where
your current coverage is not available, you do not
have to fill out the Standard Health Questionnaire.
But, if the time lapse is between 64 and 90 days,
the prior coverage will not be credited toward your
pre-existing condition waiting period.
Benefits
Q: Do LifeWise's Individual plans include maternity
benefits?
A: All but the catastrophic Individual plans include
maternity benefits.
Q. Is pregnancy considered a pre-existing condition?
A. Yes. However, prenatal care (maternity-related
services received before, but not including, labor
and delivery) is not subject to the nine-month pre-existing
condition waiting period. Delivery and post-partum
care for the mother are subject to the waiting period.
Q: Do the plans include pharmacy benefits?
A: All of our Individual plans include limited pharmacy
benefits.
Q: Diabetic supplies and organ transplant anti-rejection
drugs are not limited by the $2,000 maximum in the
prescription plan. Do they count toward the $2,000
maximum?
A: No.
Q: Do enrollees have coverage outside of the country?
A: Yes. Benefits for services received outside the
U.S. are provided at a constant 50% level, except
for medical emergencies or accidental injuries. Benefits
are not provided for treatment or drugs considered
experimental or investigational by U.S. medical standards.
Q. How are mammograms covered?
A. Mammograms are covered under the diagnostic imaging
benefit, and are subject to the calendar year deductible
and coinsurance. They are not covered as part of preventive
care benefits.
Q. When is the organ and bone marrow transplant
12-month waiting period waived?
A. All new enrollees must satisfy the 12-month waiting
period for organ and bone marrow transplants. LifeWise
does not credit time for prior coverage, even if the
coverage was with another Premera program.The exceptions:
(1) an enrollee needs a transplant due to an accidental
injury occurring on or after the effective date of
coverage on the plan; or (2) the transplant is required
due to a congenital disease or congenital anomaly
of a child who has been covered with us since the
date of birth or date of adoption.
Q. Will LifeWise reimburse enrollees for drugs
purchased in Canada?
A. Yes, benefits are based on LifeWise's allowable
charge for drugs purchased in Canada or anywhere else
outside the U. S. if the medications are approved
by the U.S. Food and Drug Administration and meet
the contract's definition of "prescription drug";
and, the drug and the condition being treated are
not excluded by the enrollee's contract.
Q. Does a newborn automatically have coverage
and at what point does the parent have to fill out
an application for the newborn?
A. On plans that cover maternity care, newborn care
is provided automatically for a period of 21 days
following birth if the mother is enrolled and receiving
obstetrical care benefits. Because the automatic coverage
is tied to whether the mother is receiving maternity
benefits, coverage is not automatic on the catastrophic
plans (which provide no obstetrical coverage). If
you wish to provide coverage for the newborn beyond
the 21-day period, you must submit an enrollment application
within 60 days of birth. If you apply after the baby
is 60 days old, the newborn may be eligible to enroll
but you must complete the Standard Health Questionnaire
for the babywho will also be subject to the nine-month
pre-existing-condition waiting period.
Q. Do the LifeWise plans include 24-hour coverage
for employers?
A. The plans are not specifically 24-hour coverage
plans, although benefits will be provided for work-related
conditions in situations where the enrollee is not
entitled to receive Worker's Compensation or similar
occupational benefits.LifeWise Individual plans are
not substitutes for any federal- or state-mandated
occupational coverage that employers are required
to provide for their employees.
Q. Are the prescription drug and medical deductibles
separate?
A. Yes, they are separate, and amounts credited toward
one deductible cannot be used to satisfy the other
deductible.
Provider networks
Q. How can I find out if my doctor is in LifeWise's
network?
A. A provider directory (LINK) is available on this
Web site. Or, call us for a printed provider directory
at 1-888-836-6135.
WSHIP
Q: What is the Washington State Health Insurance
Pool (WSHIP)?
A: The Washington State Health Insurance Pool (WSHIP)
was created by the Washington State Legislature. It
provides health coverage to Washington residents who
cannot find adequate commercial health coverage due
to their health conditions, or because they reside
in a county where commercial individual coverage is
not offered.
Q: Is WSHIP the high risk pool?
A: WSHIP is sometimes referred to as "the high risk
pool," but that label is not correct. WSHIP was created
by the Washington State Legislature. It provides health
coverage to Washington residents who cannot purchase
commercial health coverage due to their health conditions,
or because they reside in a county where commercial
individual coverage is not offered.
Q: How do I contact WSHIP?
A:
Washington State Health Insurance Pool (WSHIP)
P.O. Box 33727
Indianapolis, IN 46203-0727
Phone: 1-800-877-5187
Fax: 317-614-2096
(8:00 am - 5:00 pm PST)
www.onlinehealthplan.com/oasys/wship
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