How to get health insurance if you missed open enrollment

If you missed open enrollment and didn't sign up for health insurance by Jan. 31, 2016, you may have to wait until next year's open enrollment period, unless you have a life event that makes you eligible for a special enrollment or you qualify for Apple Health (Medicaid).

Such events include, but are not limited to:

• Losing health insurance, including an employer plan or individual health plan
• Losing Apple Health (Medicaid) because you no longer qualify
• Giving birth to or adopting a child
• Permanently moving to a new area where your current plan doesn't provide coverage
• Your employer not paying your COBRA premiums on time
• Your COBRA coverage ending or reaching the lifetime limit
• Your dependent turning age 26 and losing their coverage on your employer plan
• Getting married or entering into a domestic partnership
• Getting divorced or ending a domestic partnership
• Cancelling your Washington State Health Insurance Pool (WSHIP) coverage
• Your health plan no longer being offered for sale in Washington state

Most special enrollment periods are limited to 60 days from the qualifying event. Keep in mind that you won't qualify for special enrollment if you voluntarily cancel your health insurance or if your insurer cancels you because you didn't pay your premium.

If you don't qualify for special enrollment, here's some resources that may help you afford medical care.

Next year's open enrollment for individual and family coverage starts Nov. 1, 2016.

Who determines how much my totaled car is worth?

We hear from many consumers who are trying to resolve their auto total loss claims with their own insurer or another insurer. A total loss is when a vehicle is in a collision and the insurance company determines it would cost more than the vehicle is worth to repair it, so they “total” it.

Once an insurer declares a vehicle a total loss, they owe you the retail market value of your car, plus sales tax. But how do you know if the amount the insurer offers you is a reasonable estimate of the retail market value? Many consumers don’t know they have the right to, and should, ask the insurance company for a total loss valuation report, which shows the comparable auto data the insurer used to calculate your vehicle’s value. Most insurance companies don’t automatically provide the report to consumers and there’s no requirement that they provide it without being asked.

Insurers can either give you cash for your vehicle’s retail value or offer to replace your vehicle with a comparable vehicle in your area.

Read more about auto total loss on our website. Questions? You can contact our consumer advocates online or at 1-800-562-6900.

Not sure if we can help you with an insurance problem? Ask us anyway

Recently, a Washington consumer posted a story on Facebook about her brother, who was on the waiting list for a heart transplant but was being put on hold because of “paperwork” issues with the insurance company. She asked her Facebook friends to file a complaint with the Insurance Commissioner, resulting in more than 40 complaints to our office.

One of our consumer advocates looked into the complaint and determined that the insurance provider was Apple Health, our state’s Medicaid program that is overseen by the Washington state Health Care Authority. In other words, we have no authority over the plan. But that didn’t deter our consumer advocate from trying to help.

First, we reached out to the Facebook user and asked her to let people know that they should contact the Health Care Authority with complaints about Apple Health. Then our consumer advocates reached out to the Health Care Authority to make sure this complaint was received and addressed as a high priority. The next day, we got an email from the concerned sister that said, “Thank you so much for your response and directing my complaint to the proper department. Today (my brother) got his insurance straightened out and is back at A1 status. Thanks again!”

We want people to be aware of this for two reasons: First, helping consumers access insurance is one of our missions, even if it’s not something we regulate. So even if you’re not sure if we can help you, reach out to us anyway. If we can’t help, chances are that we know someone who can. Second, social media is a powerful tool and is a way to quickly escalate a consumer problem. We have a robust social media presence, so don’t be afraid to reach out to us on Facebook or Twitter. We will make sure to get you to the right person.

Here’s how you can reach us:

• Talk to an insurance expert: http://bit.ly/consumerhelp or call 1-800-562-6900
• Connect with us on social media: http://bit.ly/OICsocial

Insurers should be current on emerging treatments for consumers

A growing concern for consumers and health insurers is the cost of prescription drugs and specifically, treatment for debilitating and life-threatening diseases.

Hepatitis C is a good example. New drugs are now used to cure this life-threatening liver ailment with proven success. But the pills are costly, ranging from $55,000 to almost $95,000 per patient for a standard 12-week treatment period.

Two nationwide organizations, the American Association for the Study of Liver Diseases and the Infectious Disease Society of America, now recommend that most patients receive treatment even if they are in the early stage of the disease versus waiting until it has progressed.

Last November, the federal government encouraged states to ensure that health coverage policies are “informed” by the treatment guidelines noted above. Unfortunately we do not have the authority to mandate that insurance companies abide by the guidelines. However, we do expect insurers to be current on all appropriate guidelines that best serve consumers. That is true for all types of treatments.

We recently asked health insurers in Washington if they were aware of the new guidelines and if they were making any changes to how they were treating patients with this disease. The responses were varied, but there were common themes:

• No company excludes treatment.
• All allow testing to detect the disease.
• All recommend that patients consult their doctors on the best course of action.

What’s also evident is that insurers are trying to manage their claims costs. That’s not unexpected. Future prescription drugs for ailments such as multiple sclerosis and high cholesterol are expected to cost even more than the hepatitis C treatment.

The emphasis for insurers, though, should be on ready access to appropriate treatment that leads to a healthier state and nation overall.

If you believe you’ve not getting access to prescription drugs or other necessary treatment, we can help you understand your rights to appeal and even contact your insurer on your behalf.

My insurance premium went up. How can I find out the reason for the increase?

Consumers frequently ask us this question. Your agent or insurer should be able to provide you with an explanation other than “there was a general rate increase.” We recommend that you obtain a policy-specific premium breakdown directly from your agent, and that you ask for a rate worksheet comparison between your old premium and your new premium. 

Every policy is priced differently, depending upon the type of coverage you want and what are called underwriting factors.

Underwriting factors for auto insurance may include:

• Household/family driver records.
• Driver(s) age(s).
• Type of vehicle(s).
• The number of miles you drive per year.
• Where you live and/or drive your car.
• Level of coverage being purchased
• There may be surcharges or discounts unique to your situation.

Underwriting factors for homeowner’s insurance may include:

• The age of your home.
• The materials used to build your home.
• Your home’s value, as based upon its size and features.
• Your home’s location.
• Prior claims or losses for the home.

Read more about understanding auto insurance and understanding home insurance.

Questions? You can contact our consumer advocates online or at 1-800-562-6900.

If you find yourself the subject of an insurance fraud investigation, the best thing to do is cooperate

Our consumer advocates respond to thousands of inquiries from Washington consumers each year. Sometimes, we hear from people who are the subject of an insurance company fraud investigation.

Most consumers we talk to are surprised to find out that insurers have the right and responsibility to investigate potentially fraudulent insurance claims. If an insurance company flags a claim as high risk for fraud, consumers are contacted by the company’s special investigations unit (SIU).

Being the subject of a fraud investigation can be unnerving, and many consumers are bewildered and angered by SIU actions of their insurers. Consumers who contact us generally feel the company is infringing on their rights; however, that is not the case. We advise consumers to cooperate with the company’s investigation; most policies state that consumers are required to cooperate with any investigations, or they forfeit their rights outlined in the insurance policy.

Insurance fraud is a crime in Washington state, so if you are being investigated, it’s best to cooperate and provide any documentation you can to support the facts in your claim.

If an insurance company’s SIU finds evidence that a crime occurred, they forward the case to Commissioner Kreidler’s SIU, which conducts an investigation and works with the state Attorney General’s Office and local law enforcement to prosecute people who are suspected of committing insurance fraud.

In 2015, Kreidler’s SIU received nearly 1,700 fraud referrals and obtained 22 felony guilty pleas or convictions. Approximately 10 cents of every dollar consumers pay toward insurance premiums pays for a fraudulent insurance claim.

Read more about Kreidler’s SIU. 

Questions? You can contact our consumer advocates online or at 1-800-562-6900.

Medicare offers weight loss program

A new year has started and many of us have set weight loss as a goal. You may be thinking of looking into one of the many weight-loss programs available to consumers. However, if you’re on Medicare, did you know that it pays for obesity screening in some cases as a preventive service?

For people who qualify for the obesity screening, Medicare pays for up to 22 face-to-face intensive counseling sessions during a 12-month period with a primary care doctor who accepts Medicare. Qualifying clients have a body mass index (BMI) of 30 or higher. 

The Columbian newspaper in Vancouver recently featured a medical clinic that provides this service for Medicare recipients.

If you are interested in this service, first you should contact your primary care doctor to see if he or she offers this type of program. You can read more about the coverage on Medicare’s website.

There’s still time to get a health plan for 2016

Consumers have until Jan. 31 to sign up for a health plan for 2016 coverage. People who do not have a health plan for 2016 face a penalty on their taxes of 2.5 percent of their income or $695 per person, whichever is higher. Read more about the tax penalty.

If you are still looking for a health plan, you check our state’s health insurance exchange, Washington Healthplanfinder to find out if you qualify for financial help, including tax credits that may lower the cost of coverage. 

If you do not qualify for help with your health insurance, you can contact an insurance agent or broker directly to find out what your plan options are. You can look at the 2016 individual plans and rates on our website.

Read some tips from us about things you should consider when shopping for a health plan.

After Jan. 31, you’ll have to qualify for a special enrollment period to sign up or make a change to your plan, or wait until the 2017 open enrollment period.

Questions? You can contact our consumer advocates online or at 1-800-562-6900.

Wednesday is the deadline to get a health plan for Jan. 1

Consumers have until Dec. 23 to sign up for a health plan through Washington Health Benefit Exchange for coverage that begins on Jan. 1. The last day to get health insurance for 2016 is Jan. 31. People who do not have a health plan for 2016 face a penalty on their taxes of 2.5 percent of their income or $695 per person, whichever is higher. Read more about the tax penalty.

If you are still looking for a health plan, you can look for one at our state’s health insurance exchange, Washington Healthplanfinder and find out if you qualify for financial help, including tax credits that may lower the cost of coverage. If you do not qualify for help with your health insurance, you can contact an insurance agent or broker to find out what your plan options are.

Read some tips from our office about things you should consider when shopping for a health plan.

Questions? You can contact our consumer advocates online or at 1-800-562-6900.

Is there a drone on your shopping list? You might want to talk to your agent or broker

The Federal Aviation Administration (FAA) estimates more than one million drones will be sold this holiday season. Everyone from photographers and farmers to law enforcement and hobbyists are using drones.  Whether for personal or commercial use, there are a number of insurance issues to consider ranging from personal injury and property damage to privacy concerns.

Drones present a significant risk to property and life on the ground in the event of an accident. Drones can crash due to faulty and inappropriate operation, mechanical defects and component failure. Losses and damages could involve bodily injury to humans and animals as well as buildings and structures.

Using a private drone as a hobby is generally covered under a homeowner’s insurance policy—and subject to a deductible--which typically covers radio-controlled model aircraft. This also applies to a renter's insurance policy. Look at the contents section of your policy, or talk to your agent to see if your drone will be covered if it is lost, stolen or damaged. If your drone falls onto your car, damage to your car may be covered if you have a comprehensive coverage auto policy.

A larger concern is liability for an accident caused by your drone. If your drone crashes into someone else's vehicle or a person. If you have a homeowner’s or renter's policy, generally the policy will cover liability for an accident caused by your drone if it is determined that you were negligent and at fault. Check with your agent or insurer to verify your policy contains this important coverage. You can also read a story about drone insurance that was recently posted on the Insurance Journal’s website.

Drones are defined as remotely piloted aircraft systems and the FAA says pilots of unmanned aircraft have the same responsibility to fly safely as manned aircraft pilots. In addition to FAA regulations, state and municipalities may have their own laws regarding drone use.  The FAA has issued these guidelines for drone hobbyists:

• Don't fly higher than 400 feet and stay clear of surrounding obstacles.
• Keep the aircraft in sight at all times.
• Stay away from manned aircraft operations.
• Don't fly within five miles of an airport unless you contact the airport and control tower before flying.
• Avoid flying near people or stadiums.
• Don't fly an aircraft that weighs more than 55 pounds.
• Use caution when flying your unmanned aircraft.
• With some drones weighing up to 55 pounds, a fall from the sky can cause significant damage to property or bystanders.

Recently, federal regulators announced that recreational drone operators will soon need to register their aircraft. This will allow authorities to trace a drone back to the owner, which means it's vital that you're in compliance with laws and regulations and have the appropriate insurance coverage.

No health insurance for 2015 or 2016? You may be facing a tax penalty

If you can afford health insurance but you choose to not enroll in coverage for 2016, you may be required to pay a fee when you file your 2016 federal income taxes. The fee is also called a penalty, fine, or the individual mandate.

A few facts about the individual mandate:

• The fee is calculated one of two ways. The fee for not having health insurance if you can afford it is $695 per person in your household who doesn’t have health insurance or 2.5 percent of your income – whichever is higher. HealthCare.gov has a guide to estimate the fee you’ll have to pay if you don’t have health insurance. 

• The fee for 2015 is lower than for 2016. For 2015, the fee for not having health insurance if affordable insurance is available to you is $325 per person or 2 percent of your annual household income – whichever is higher. The fee is calculated based on the number of months you, your spouse, or your tax dependents went without qualifying coverage, such as an employer-sponsored health plan, Medicare, Medicaid or coverage through Washington Healthplanfinder.
  
  In some cases, the fee may be higher than buying health insurance through Washington Healthplanfinder. You can look at plans and find out if you qualify for help at www.wahealthplanfinder.org. 

• For some people, exemptions from the fee are available. People with very low incomes and individuals who meet other specific conditions can receive an exemption from the requirement to have health insurance and will not have to pay the fee. Additional information about exemptions and a tool that helps you determine if you qualify for an exemption is available on HealthCare.gov. 

If you need health coverage and want to avoid the fee for 2016, the deadline to enroll in a plan is Jan. 31. If you don’t enroll by then, you could have to wait another year to get coverage and may have to pay the fee when you file your 2016 income taxes. If you want coverage that starts on Jan. 1, you need to enroll by Dec. 23.

More information about the individual mandate on the Internal Revenue Service's (IRS) website.