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Eligibility

Medicare Plans - Eligibility Requirements


                                                  
Important


Effective January 1, 2014 WSHIP is only accepting applications for its Medicare-eligible plan (Basic Plan). The Basic Plan provides secondary coverage for qualified individuals enrolled in Medicare Parts A and Part B who live in a county without a reasonable choice of Medicare Advantage Plans. Click Here to learn more about eligibility requirements for the Basic Plan.


Individuals not eligible for Medicare may purchase coverage from the Washington Healthplanfinder at www.wahealthplanfinder.org or buy directly from an insurance company during defined open enrollment periods. You can’t be turned down for pre-existing conditions. Click Here to learn about Washington Healthplanfinder.


 

General Eligibility Requirements

  • You must be a resident of Washington state;
  • You must be enrolled in Medicare Part A and Part B;
  • You must provide evidence of rejection for medical reasons, a requirement of restrictive riders, an up-rated premium, or a pre-existing conditions limitation on a Medicare supplemental insurance policy, or not have comprehensive Medicare Supplement coverage available to you; and
  • You must not have access to a reasonable choice of Medicare Advantage Plans
    (Part C).

Determining if You Have Reasonable Choice of Medicare Advantage Plans (Part C)

Under Washington law effective August 1, 2009, to be eligible for coverage under WSHIP’s Medicare-eligible Basic Plan you must live in a Washington county where you do not have reasonable choice of comprehensive Medicare Advantage Plans (Part C).

Definition of Reasonable Choice

Reasonable choice of Medicare Advantage Plans means:
  1. You have a choice of health maintenance organization (HMO) or preferred provider organization (PPO) Medicare Advantage Plans offered by at least three different carriers that have had provider networks in your county of residence for at least five years.
  2. The benefit plan options include coverage at least as comprehensive as Plan F Medicare supplement plan combined with Medicare Parts A and B.
  3. The benefit plan options also provide access to adequate and stable provider networks that make up-to-date provider directories easily accessible on the carrier website, and will provide a hard copy, if requested.
  4. The health care provider with whom you have an established care relationship and from whom you have received treatment within the past twelve months is not a member of the available HMO or PPO Medicare Advantage Plan carrier networks.

Counties with Reasonable Choice

The Washington counties below have been determined by WSHIP to have reasonable choice of Medicare Advantage Plans. If you live in one of these counties you are not eligible for WSHIP unless your health care provider is not included as a member of at least one of the HMO or PPO benefit plans available to you.

Counties with reasonable choice of Medicare Advantage Plans in 2014:

Clark, King, Pierce, Spokane, Thurston

Dependent Eligibility

Coverage for your dependent children is available provided that you are eligible for and are enrolled in WSHIP. Dependent children must be unmarried and under the age of 26. Coverage can be extended for dependent children over age 26 who are disabled. Children can be added to Basic Plan if they qualify for Medicare Parts A and B. If they do not qualify for Medicare Parts A and B, they may enroll in a WSHIP non-Medicare plan.

You are Not Eligible for WSHIP Coverage if One of the Following Applies to You:

  • You have terminated coverage in WSHIP within the last 12 months, unless you can show that you had continuous other coverage from the date WSHIP coverage terminated, which has been involuntarily terminated for any reason other than non-payment of premiums.

  • You are an inmate of a public institution.

  • You have coverage under a public program that duplicates WSHIP benefits.

  • You do not reside in Washington state (except qualified resident dependent children temporarily living outside of Washington state).

  • You are not enrolled in Medicare Parts A and B.

  • You have a reasonable choice of Medicare Advantage Plans (Part C).

Note:

Involuntary termination of other coverage and / or currently disabled with no coverage other than Medicare, by themselves, do not necessarily make you eligible for WSHIP.