Group Health

Group Health Plans, Washington

Group Health of Washington, is a nonprofit health care system that provides both medical coverage and care and truly offers some terrific plans. Group Health and its subsidiary health carriers, Group Health Options, Inc. and KPS Health Plans, serve approximately 584,288 members in Washington and Idaho. More than 70 percent of members receive care in Group Health-owned medical facilities.

Group Health offers all the choices you need to pick the plan that’s right for you. Having one of these in your back pocket means that your care is easy to get and your coverage is there when you need it. It’s about letting go of the worry, so you can get on with living your life.

The Balance plans

If choice is first and foremost to you, the Balance plans from Group Health Options, Inc. are great because you can see any doctor you want for primary, specialty, and alternative care. These plans let you choose between the Alliant Plus in-network and out-of-network options, with different levels of coverage.

In-network care includes access to the more than 1,000* Group Health doctors and clinicians who are unavailable with any other health plan provider. In-network care also includes thousands of contracted community providers and the many doctors who practice at Virginia Mason and The Everett Clinic. Out-of-network care includes services from any other doctor, anywhere in the U.S., including discounted rates within the First Choice or Beech Street networks with no balance billing.

Structured like traditional copayment plans, you’ll pay a fee for your in- and out-of-network office visits. For some benefits (in- or out-of-network) your coinsurance won’t apply until after you pay your deductible. And, your deductible doesn’t apply to preventive care office visits, and to most in-network office visits, which is a whole lot of value.

The HealthPays® Health Savings Account

This plan from Group Health Options, Inc., qualifies you for a Health Savings Account (HSA), which means you can pair it with a separate bank account designated for pretax money used to pay eligible medical expenses. You choose your own financial institution, so you’re sure your money is safely where you want it. There are a few eligibility rules for this plan: You can’t be covered under any other plan, or enrolled in Medicare, and children under the age of 18 may enroll, but will not be eligible for an associated savings account. However, if you clear these exceptions, and if you want more choice to better manage your health care dollars, this plan puts you in the driver’s seat.

Additionally, HealthPays lets you choose between the Alliant Plus in-network and out-of-network options. In-network care includes more than 1,000* doctors and providers who practice at Group Health medical centers, thousands of community physicians with whom we contract, and many doctors who practice at Virginia Mason and The Everett Clinic. Out-of-network care means you can see any other doctor, anywhere in the U.S., including discounted rates within the First Choice and Beech Street networks with no balance billing.

*Source: OIC Provider List Form A

The Welcome plans

These three plans, offered by Group Health Cooperative, share a unique design. Your deductible and, in some cases, your coinsurance doesn’t kick in until after your fifth outpatient visit. That means those first five visits are covered with just a copayment or coinsurance, depending on the plan you pick. It’s our way of making sure you get the most from your health plan right from the get-go. These plans give you access to the Group Health network of doctors, who practice at more than two dozen medical centers statewide, plus nearly 6,500 contracted providers. Also, you can self-refer to most specialists at Group Health medical centers, which makes getting the care you need as easy as possible.

The Group Health Small Print

1. Acceptance of application: Group Health’s* acceptance of you and your dependents over the age of 19 for coverage is based upon your score(s) determined by the Washington State Health Insurance Pool (WSHIP) Standard Health Questionnaire unless an exemption under the law applies. In order to process your application for one of our individual and family plans, we must receive the application signed by you and your spouse/domestic partner, signed questionnaire(s) for each family member over the age of 18, and any Certificates of Creditable Coverage (if available).

2. Dependent children: When enrolling three or more eligible children (those under the age of 26), only the first two will be charged, except as noted in Section 3, below. Dependents aged 19 – 26 may be enrolled at any time of year. Dependents under the age of 19 must be enrolled between November 1 and December 15, unless they experience a qualifying event which makes them eligible for special enrollment. See Section 4, for a list of qualifying events. An eligible dependent who is totally incapable of self-sustaining employment because of a developmental or physical disability, and is chiefly dependent upon the Contract Holder for support and maintenance, may continue coverage for the duration of continuous total incapacity, regardless of age, provided enrollment does not terminate for any other reason. Medical proof of such a disability will be required at the time of application and periodically once enrolled.

3. Adults applying as a Guarantor (dependent-only coverage): Financial guarantors are only required for children under the age of 18. As a Guarantor, you hereby agree to accept the financial and contractual responsibilities for all dependents listed on the application. A Guarantor may enroll only dependent children who are under the age of 18 and dependents who are totally incapable of self-sustaining employment as described in Section 2, above. For dependent-only coverage, the oldest/only child (noted as Applicant/Subscriber on the application) is charged the lowest adult age rate, while the next two children are each charged the child rate. There is no charge for any additional children.

4. Special enrollment for individuals under age 19: All individuals under the age of 19 must apply for coverage during the open enrollment period from November 1 through December 15. If an individual under the age of 19 wishes to apply for coverage outside of the open enrollment period, either as a subscriber, a dependent-only, or as a dependent of a subscriber, they may do so only if they experience a qualifying event which makes them eligible for special enrollment. The four qualifying events are listed below:

a.) a loss of employer-sponsored coverage.

b.) a loss of eligibility under Medicaid or another public program providing health benefits.

c.) a loss of coverage as a result of the dissolution of a marriage.

d.) a change in residence and the health plan under which the individual was covered does not provide coverage in that service area.

5. Coverage effective date: The effective date of your application is based upon Group Health’s receipt of your completed application documents as noted in Section 1 above. All application documents must be received in Group Health’s Seattle Sales Department.

• For application documents received on or before the 20th of the month, coverage will begin on the first day of the following month. (Example: If your application is received on or before Oct. 20, then enrollment is effective Nov. 1.)

• For application documents received on the 21st through the end of the month, coverage will begin on the first of the month following the first full month after receipt. (Example: If your application is received Oct. 21–31, then your coverage begins Dec. 1.)

6. Premium payments: Premium payments are due on a calendar month basis on or before the first day of each month, subject to a grace period of 10 days. Payment can be set up through monthly billing, paid by check or money order, or as monthly automatic withdrawal from a checking or savings account. Premium amounts are subject to change upon 30-days written notice, which will be sent to the Contract Holder’s residential address unless there is a designated billing address provided on your application.

7. Revoking coverage: Failure to answer questions fully and correctly on your application documents may result in Group Health’s refusal to extend coverage, cancellation of coverage, or rescission of coverage for you and/or your family members.

8. Applicant’s financial liability: a) Pre-enrollment Services: If any hospital or medical service is rendered to you and/or your dependent(s) prior to your effective date of coverage, you will be responsible for paying for those services. These non-covered services will be billed to you at full schedule rates. Regardless of whether you and/or your dependents become a member, you will be responsible for payment of such charges; b) Prior Authorizations: Upon termination from any Group Health individual and family plan, all prior authorizations for health care coverage for the terminated individual(s) will no longer be valid, and you will be financially liable for any additional services obtained.

9. Pre-existing conditions: These plans include a nine-month pre-existing condition wait period that excludes coverage for any condition for which there has been any diagnosis, treatment (including prescribed drugs), or medical advice within the six-month period prior to the effective date of coverage. Section 6 of the application form for our individual and family plans will help us determine whether you have Creditable Coverage, which would allow Group Health to waive any pre-existing condition wait period(s) for you and/or your dependent(s). The pre-existing condition wait period does not apply to individuals who are under the age of 19, however, enrollment restrictions apply. Please see Section 4 for details.

10. Portability (Creditable Coverage): If you have been covered within the last 63 days by a plan with equivalent or greater overall benefits than the plan you purchase, we will waive pre-existing conditions or credit that coverage. If you had a 64-day-or-more break in coverage, no portability credit will be applied for pre-existing conditions.

11. Washington state residency & counties served: You must be a permanent resident of Washington state and reside in one of the counties in our service area in order to qualify for individual and family coverage from Group Health. The counties that are served by our individual and family plans are:

• Central/Eastern Washington: Benton, Columbia, Franklin, Kittitas, Walla Walla, Yakima, Spokane, and Whitman

• Western Washington: Grays Harbor (ZIP codes 98541, 98557, 98559, and 98568), Island, King, Kitsap, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Thurston, and Whatcom

12. Changing plans: Once you enroll in one of Group Health’s individual and family plans, you have the option to transition to any of our other open plans. When making any plan changes, you may be required to go through health screening again, so do not cancel your current coverage until you have been notified of your eligibility for enrollment into the plan for which you are applying.

Note: If you are changing from a Group Health Cooperative individual and family plan to a Group Health Options, Inc. plan, or vice-versa, in most cases, you and your dependents will be required to complete a new Standard Health Questionnaire.

13. Adding dependents: Subject to your plan’s terms, you may add eligible dependents over the age of 19 to your plan at a later date. Health screening may be required for these dependents prior to their enrollment, so please review the WSHIP Standard Health Questionnaire to determine whether or not the eligible dependents meet one of the exceptions. To add dependents under age 19, certain restrictions apply. Please see Section 4 for details.

* Coverage provided by Group Health Cooperative or Group Health Options, Inc.

NonCovered Procedures

• Chemical dependency (limited)

• Cosmetic services (limited)

• Dental services

• Experimental/investigational services

• Eyeglasses/contact lenses (specific plans)

• Hearing aids and related examinations

• Infertility

• Learning disorders

• Maternity (specific plans, as noted in Medical Coverage Agreement)

• Obesity/morbid obesity

• Orthognathic surgery

• Orthotics, except for treatment for diabetics (limited)

• Over-the-counter/nonprescription drugs

• Prescriptions (specific plans)

• Routine foot care (limited)

• Services or supplies not specifically listed as covered in the Medical Coverage Agreement

• Sexual dysfunction

• Sterilization reversal

• Temporomandibular joint disorder (TMJ) (limited)