Monday, October 28, 2013

"The insurance company came out and looked at my car. Doesn't that commit them to paying the claim?"

No. Insurers are required to investigate claims, but the fact that they start an investigation doesn't obligate them to pay a claim that they wouldn't otherwise pay. Once the facts are gathered and reviewed, the insurer can then make a coverage decision.

That said, if you feel your claim has been wrongly denied, is delayed, isn't fair, etc., our consumer advocacy staff may be able to help you. (We're the state agency that regulates insurance in Washington state.) Email us at or call us at 1-800-562-6900.

Not in Washington state? Here's a handy map to help you contact your own state's insurance regulator.

Tuesday, October 22, 2013

Why does my insurer ask such tough questions about my claim?

We get this question a lot. The insurance industry experiences millions of dollars of claims regularly, year after year. Many of the claims are legitimate, but unfortunately, many involve fraud.
Whether or not a claim is legitimate or fraudulent, it is important that insurance companies perform complete investigations and gather all supportive documentation to be able to evaluate a claim.
Of course, the claim process is not a fun thing to experience, but it is necessary that you cooperate with the insurer to help facilitate your claim. Expect them to want supporting documentation and to ask questions - it may take a bit of time. But, after you've answered their questions and provided the necessary information, you should expect a timely decision and a clear explanation of their decision. If you don't that you've been treated fairly, call us at 1-800-562-6900 or file a complaint. Maybe we can help!

Monday, October 21, 2013

Having trouble reaching the Exchange's call center?

We know Washington's Exchange, is still experiencing high call volumes at most times of the day. If you need help getting started, consider calling a navigator or an insurance broker. You can find both in your area by entering your zip code. Here's the info. for finding a navigator and the broker information.

"I've invented a new medical treatment. How can I get insurers to cover this?"

Our consumer hotline gets this question periodically. Someone will have come up with a new way of treating some ailment, only to find that insurance companies don't want to cover it.

Insurance companies are far more likely to cover a treatment is it's "evidence-based. Typically, a treatment is deemed evidence-based after extensive clinical trials, for which the inventor (or inventor's company, actually) usually pays. In the scientific community, evidence-based treatments are considered more reliable, and therefor a better value for insurance companies' money -- and more likely to lead to success for the patient.

That said, insurance companies can pay for any treatment, so there's nothing stopping them from covering a treatment that's not evidence-based. However, with many health conditions, there are already numerous treatments available.

If you're a patient, and your insurer is refusing to pay for a particular treatment that you think would be effective, see our "How to appeal a health insurance denial" guide. You can win an appeal, but it takes some work.

Also, here in Washington state, the health plans we regulate -- which are about 37 percent of them -- must, by law, must include access to every type of licensed medical provider. Meaning that if you want to see a naturopathic physician, chiropractor, physician, acupuncturist, etc. for treatment, the choice is yours, so long as the treatment is within the scope of their practice. The law doesn't change what health conditions are covered by your plan, but it gives you more choice in who -- i.e. which kind of provider -- will treat you.

Thursday, October 17, 2013

Medicare open enrollment started this week and ends Dec. 7

Medicare's open enrollment period for prescription drug plans (Part D) and Medicare Advantage plans is Oct. 15 - Dec. 7. This is the time when you can enroll in a new plan or sign up for coverage.

If you need assistance understanding your options, we have trained volunteers in your community. Our Statewide Health Insurance Benefits Advisors (SHIBA) program offers free help to people with Medicare questions and can help you search for plans online. We even have free Medicare workshops across the state.

Remember, if you want to enroll in  new plan, you must contact Medicare. You cannot sign up through the state's new health benefit exchange,

If you have limited income and need help paying prescription drugs, check out Medicare's "Extra Help" program. To see if you qualify, contact the Social Security Administration at 1-800-772-1213 or go to

For more help, contact a local SHIBA office in your area.

Wednesday, October 16, 2013

Job seekers - We're looking for a legislative liaison and a policy/rules manager

Two jobs at the Insurance Commissioner's office just posted this week - a Legislative Liaison and a Policy and Rules Manager. Both positions are exempt, open until filled and salary depends on experience.

The Legislative Liaison is responsible for developing and managing our legislative and policy strategy, including developing our legislative agenda, legislative testimony, bill analysis, and stakeholder management. They're also the principal policy advisor to the executive management team on legislative and budget proposals impacting the agency.

The Policy and Rules Manager supervises staff in our Policy and Legislative Affairs division, prepares position briefs, decision memos, reports, coordinates rule-making for the agency, and drafts and adopts rules on behalf of the agency.

If you're interested or know someone who might be, encourage them to apply soon!


See most recent earthquakes in our area - are you ready for the big one?

We're getting ready for tomorrow's Great ShakeOut Earthquake Drill by cleaning out all the stuff under our desk - how about you? It's been a long time since the Nisqually Quake, but if you lived in Washington state then, you probably remember where you were and what it felt like. 
Some of us here in Olympia - only miles from the epicenter - heard what sounded like a freight train. Others saw the ground move like water. Are you ready for the next one? 
Check out the earthquake tracker on KIRO's It'll show you the most recent quake, how big it was and where it occurred.  

And don't forget about earthquake insurance - here's what you need to know.

Monday, October 14, 2013

How to report insurance fraud in Washington state

Our agency -- Washington state's insurance regulator -- handles a wide variety of complaints about insurance fraud by individuals and by businesses.

To report insurance fraud or scams, please see our online reporting form.

We also offer tips to avoid insurance scams, starting with the old-but-true advice that if it sounds too good to be true, it probably is.

We also have some tips on how to identify and report Medicare fraud and abuse, such as being billed for services you didn't receive.

Wednesday, October 9, 2013

I know the new health subsidies are based on your household income, but how do they define 'household'?

“Household” only includes you, your spouse, and anyone you can legally claim as a dependent on your tax return.

 It generally wouldn’t include a non-marital relationship (such as a boyfriend or girlfriend), except under very limited circumstances.

To get more details, see page 16 of the IRS instructions for filling out Form 1040 or call the IRS (after the government shutdown ends) at 1-800-829-1040.

Tuesday, October 8, 2013

When your insurance renews, remember to look at the statement

When you get a new insurance policy or your current policy renews, be sure to review the statement. You need to be sure that you're getting the type and level of coverage you asked for. 

Most people simply file away the information -- or toss it. But take a few minutes to look it over first. You really don't want to find out after the fact that a) you were paying for coverage you didn't want or need, or b) worse, that you didn't have coverage for something important.

If you see something that doesn't look correct, contact your agent or insurer immediately, before a loss occurs. If you wait until afterward, you'll likely be stuck with whatever coverage was in force at the time of the loss.

It's also a good idea to periodically review your coverage with your agent or insurer. You may want to add or eliminate coverage as changes occur in your life situation.

Friday, October 4, 2013

Hole-in-one insurer pleads guilty to three felonies

Kevin Kolenda, a Connecticut businessman who insurers golf tournament hole-in-one prizes but has a history of not paying, pleaded guilty today in King County Superior Court to two counts of selling insurance without a license and one count of first-degree theft.

Kolenda started Golf Marketing in 1995 and sold hole-in-one insurance coverage to charity golf tournaments across the country including in Washington state. He repeatedly failed to pay winning golfers, leaving charities to come up with the prize money. To skirt prosecution, he also changed the name of his business several times.

Other states where Kolenda sold bogus insurance including: Montana, Ohio, Georgia, California, New York, Hawaii, Alabama, Massachusetts, Florida, Connecticut and North Carolina.

Kolenda paid $10,000 in restitution today. He will pay another $5,000 in four months, when he returns to Seattle for sentencing.

Thursday, October 3, 2013

What to do if your Medicare Advantage plan is going away

Medicare open enrollment starts Oct. 15. Some people may have already received a notice saying their Medicare Advantage plan is going away. If you or someone you know has received a notice, here's some steps to take:

  • Check with your medical providers and find out what Medicare Advantage plans they accept in 2014.
  • Read about your rights
  • Avoid a gap in coverage by selecting a new plan before Dec. 31
  • If you can't decide between a Medicare Advantage plan or returning to Original Medicare, see page 59 of the Medicare and You 2014 booklet for help

Need more help? Contact our free Statewide Health Insurance Benefits Advisors (SHIBA), They can  help your evaluate and compare plans. 

Wednesday, October 2, 2013

WAhealthplanfinder will be down tonight for system improvements

Washington's Exchange - the - is up and running, but some people are still experiencing slow loading times and difficulty submitting their applications. The Exchange is taking the website down tonight starting at 10 p.m. until 6 a.m. tomorrow morning to work on system improvements. Want an update on their progress? Check often.

I hear new health plans must meet 'actuarial value' standards - what's that mean?

All individual and small employer health plans sold inside and outside the new Health Benefit Exchange - - must have an actuarial value of at least 60 percent.

This means the plan must pay for least 60 percent of your medical costs for essential health benefits. Sixty percent is the standard for the new 'bronze level' plans. You also can choose from a silver level or gold metal level plan. Silver plans pay for 70 percent of your costs and gold pay for 80 percent.

Here's answers to additional questions about how the new 'actuarial value' works:

If my plan has an actuarial value of 70 percent  does that mean I will not have to pay more than 30 percent of my entire insurance costs?
No, the actuarial value is only based on the level of coverage the plan provides for essential health benefits.  If your plan has an actuarial value of 60 percent, for example, that means that the plan will pay 60 percent of your covered expenses for essential health benefits and you pay 40 percent of the covered expenses for essential health benefits. 
Although the actuarial value of your covered expenses for essential health benefits will be covered, you may have other costs such as deductibles, copays and coinsurance, as well as costs for services that are excluded or are not covered benefits.

Make sure you read your policy to see what services are excluded services.  Benefits that are not covered would be subject to the terms of your insurance policy, so it is important to read your policy before getting the service or treatment. 
What are essential health benefits? As of Jan. 1, 2014, all individual and small employer health plans must cover these 10 benefits:

  1. ambulatory patient services
  2. emergency services
  3. hospitalization
  4. maternity and newborn car
  5. mental health and substance use disorder services including behavioral health treatment
  6. prescription drugs
  7. rehabilitative and habilitative services and devices
  8. laboratory services
  9. preventive and wellness services, chronic disease management
  10. pediatric services ‐ including oral and vision care


Tuesday, October 1, 2013

Washington's Healthplanfinder now up and running

After a few hours of technical difficulties earlier today, is now up and running. There may be a few more glitches as additional issues are fixed, so if you're filling out an application, be sure to save your information. Also, the website will be down temporarily tonight at 8 p.m.

Eight health insurers have been approved to sell 46 different plans inside the Exchange. Remember, the Exchange is the only place you can go to receive federal tax subsidies to help lower your monthly premium - and there's only one official Exchange for our state -

If you earn more than the cut-off for a subsidy (about $46,000 for an individual and $94,200 for a family of four), you also can shop for insurance outside the Exchange. To see all of the plans available in your county - both inside and outside the new Exchange - check out this map.