Understanding Health Insurance

Navigating health insurance can be confusing, making it hard to determine which services are

covered and what your potential out-of-pocket costs might be. In this guide, we clarify the

different types of insurance and the coverage they offer.

Employer-Sponsored Insurance (ESI)

Health insurance provided by an employer, known as Employer Sponsored Insurance (ESI), is categorized as commercial insurance and is typically offered at little to no cost to the employee. These plans are often products of large insurance companies such as Premera or Kaiser Permanente. The monthly payment for your commercial insurance is referred to as the premium, and may be shared between you and your employer. Additionally, employer-sponsored commercial plans can be:

Fully funded: Purchased from an insurance company

Self-funded: Sourced from a trust (e.g., Teamsters)

Self-funded plans may have different coverage for services compared to fully funded plans, as

determined by the trust. If you opt for family coverage, commercial insurance plans allow dependents to remain on a parent or guardian's plan until the age of 26. Generally, commercial

plans cover a wide range of services and are accepted by most health care facilities, but they can also be the most costly.

Purchasing Insurance from the Marketplace

If your employer does not provide insurance or if you are self-employed, you have the option to purchase health insurance from the Washington Health Plan Finder. These individual plans, offered by insurance companies, tend to have lower costs (lower monthly premiums) but may provide limited coverage for specialists. However, they usually cover traditional healthcare expenses effectively. Be aware that some specialist services might not be included, and not all providers may accept these plans.

State-Funded Insurance: Apple Health

If your monthly or annual income falls below a certain threshold, you may qualify for state-

funded insurance known as Apple Health (also referred to as Medicaid or state insurance) in

Washington State. You can check your eligibility here. This insurance is free for those who qualifyand is designed to help cover healthcare costs for individuals in need. Therefore, if you cannot afford the monthly healthcare premium and are eligible for Apple Health, you will receive care at no cost to you. Keep in mind that these plans may cover limited services and not all providers or specialists may accept them.

Medicare

Medicare is a federally funded health insurance program for individuals aged 65 and older in the

United States and consists of 4 parts. Medicare Part A covers inpatient hospital expenses, while

Part B covers many outpatient costs, including doctor visits and necessary tests. Many Medicare beneficiaries opt for additional coverage through Medicare Supplements or Medicare Advantage plans, which enhance or replace Part A and function similarly to traditional commercial insurance. Most Medicare participants also have a Part D plan for prescription coverage.

Military Health Insurance

Military health insurance called Tricare is accessible to active-duty personnel, their families, and retired service members. In the United States, the Defense Health Agency provides these plans, which encompass a wide range of services and often come at little to no cost for members. Keep in mind, not all providers accept Tricare and services may be limited to military facilities.

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How Insurance Plans Work

Now, let’s explore how most insurance plans operate. We have already covered the premium, which is the cost of the health insurance plan. Most plans also feature a deductible, which is the amount you are required to pay out-of-pocket for certain healthcare services before the insurance coverage begins. For instance, if your commercial plan has a $500 deductible, you must pay that amount before the insurance starts covering expenses. Some plans may “waive the deductible” for preventive services, such as annual check-ups or screenings for chronic diseases. The deductible resets each year.

Once you have met the deductible, the plan will cover the services you receive based on the plan details. Additionally, some plans may include a copay or coinsurance that you must pay to the provider upon receiving services. These payments are referred to as “cost sharing,” meaning your insurance plan shares the cost with you. For example, if you have a $25 copay per visit, that is your out-of-pocket expense for the service, and the insurance will cover the remainder. If your plan includes coinsurance, this is a percentage of the covered charge. For instance, with an 80/20 coinsurance arrangement, the insurance covers 80% of the allowable charge, leaving you to pay the remaining 20%.

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Coverage in Washington State

In Washington State, approximately 92% of residents are estimated to have health care coverage as of this writing. Considering the significant expenses tied to healthcare and medical emergencies, it is essential to be aware of your current coverage and services you may be eligible to receive.

At Michelle Weinbender Nutrition, we contract with many insurance companies and our intention is to bill insurance for the services you receive. We do our best to check your insurance benefits for nutrition counseling to ensure you have a clear understanding of what to expect for coverage and your financial responsibility.

References

1.“Eligibility Overview”, Washington State Health Care Authority, hca.wa.gov

“Washington at a Glance”, State Health Access Data Assistance Center,

shadac.org/washington#