Bookmark & ShareSome benefits described here are based on state laws. We have attempted to describe them accurately, but if there are differences, the laws will govern.
NOTE: Be sure to read about exclusions and waiting periods (in the Washington Health Member Handbook), including the waiting period for pre-existing conditions, for information about what is NOT covered by Washington Health.
Peace of mind (We've got you covered)
| Covered Benefit | In-Network Community Health Plan Clinic and Affiliates | Out-of-Network | Description |
|---|---|---|---|
| Medical Plan (Per Calendar Year) | |||
| Annual Benefit Limit | Health 75-$75,000 Health 100-$100,000 |
Health 75-$75,000 Health 100-$100,000 |
Total maximum amount the plan will pay per person in any calendar year |
| Annual Deductible | $500 per member/$1,500 per family | $1,000 per member/$3,000 per family | The amount you pay every year before the plan pays for covered services |
| Coinsurance | 30% | 50% | Percentage of allowed charges you pay after you meet the deductible |
| Annual Out-of-Pocket Maximum (Deductible does not apply) | $3,000 per member/$9,000 per family | $5,000 per member/$15,000 per family | The set limit after which your plan pays 100% of the allowable charge |
| Covered Services (Annual Benefit Limit of $75,000 or $100,000) | |||
| Preventive Care* | Covered in full | Deductible, then 50% | Includes preventative immunizations, medical exams, sports physicals, women's health, well baby exams |
| Preventive Screenings* | Covered in full | Deductible, then 50% | PAP smear, PSA testing, colorectal cancer screening, cholesterol screening, bone density testing |
| Ambulance Transportation | Deductible, then 30% | Administered as In-Network | Includes transport to the nearest facility equipped to provide appropriate care |
| Chemical Dependency** | Deductible, then 30% | Deductible, then 50% | Diagnostic evaluation and education, organized individual and group counseling |
| Diagnostic Imaging and Laboratory Services | Deductible, then 30% | Deductible, then 50% | Includes x‐rays, ultrasounds, CAT scans, MRIs, lab tests, and interpretations |
| Durable Medical Equipment | Deductible, then 30% | Deductible, then 50% | Includes orthotics, prosthetics, and related supplies |
| Emergency Room*** | $100 copay/visit | $100 copay/visit | Includes the services of the facility and supplies |
| Home Health Care, Hospice | Deductible, then 30% | Deductible, then 50% | Specialized care services administered inpatient and outpatient |
| Hospital Care | Deductible, then 30% | Deductible, then 50% | Hospital room and board, surgery, anesthesia, intensive and coronary care, laboratory tests, radiology services, drugs while in hospital |
| Mammograms | Covered in full | Deductible, then 50% | Radiological procedure and explanation of results once every 12 months |
| Maternity Services++ | $5,000 Deductible, and 30% coinsurance | $5,000 Deductible, and 50% coinsurance | Delivery and associated hospital care |
| Mental Health++ | Deductible, then 30% | Deductible, then 50% | Individual and family counseling |
| Office Visits (Including Urgent Care) | Clinic-$10 copay Affiliate-Deductible, then 30% |
Deductible, then 50% | Includes examination, consultation, evaluation, and treatment plan |
| Organ Transplants+++ | Deductible, then 30% | Deductible, then 50% | Professional and facility fees, diagnostic tests and exams, surgery, and follow-up care |
| Prescription Drugs | Tier 1 (generic): $10
Tier 2 (brand name and non-formulary): 50% |
Tier 1 (generic): $20 Tier 2 (brand name and non-formulary): 50% |
Drugs and medicine requiring a prescription including injectibles, contraceptive drugs, devices, and supplies |
| Rehabilitation^ | Deductible, then 30% | Deductible, then 50% | Includes physical, occupational, and chiropractic services |
| Skilled Nursing Facility | Deductible, then 30% | Deductible, then 50% | Includes room and board, ancillaries, and professional fees |
* Benefits provided at 100% allowable charges, not subject to deductible or coinsurance (except for out-of-network, non-contracted provider)
** Benefits limited to $5,000 every 24 months or $10,000 lifetime maximum
*** Entire Emergency Room Visit subject to deductibles and coinsurance, copay waived if admitted to the hospital
+ Deliveries occurring within the first six months of initial enrollment or re-enrollment are subject to $5,000 deductible and coinsurance, otherwise subject to deductible and coinsurance
++ Limited to 10 inpatient visits per year and 12 outpatient visits per year (office visits to manage medication do not count toward 12 visit maximum)
+++ 12 month waiting period applies, except for newborns or for a condition that is not pre-existing
^ Up to a combined maximum of 12 visits per year (of those no more than 6 can be for chiropractic care). Allowed only when used as post-operative treatment following reconstructive surgery (within one year after date of surgery).
