Healthcare Resources

Healthcare Resources Index

Glossary of Terms
Frequently Asked Questions
Podcasts/Videos/Webinars
Traditional Medicare
Medicare Advantage
WA State Health Care Authority (HCA)/Public Employees Benefits Board (PEBB)
Dental Insurance
Links

Glossary of Terms

Glossary of Terms – a list of commonly used healthcare-related terms composed and maintained by the Healthcare Workgroup.

Frequently Asked Questions

Click on topic to expand for content.

Explanation of Benefits (EOB) – How to read it?

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Summary of Benefits – How to read it, what to look for?

Medical Deductible – What is it, what amount is it?

Prescription Drug Deductible – what it is, what amount is it, and the is the difference between medical and drug deductibles?

Medication Tiers – step therapy, how to file appeals

Formularies – they can change throughout the year

PPO, HMO and Managed Care Plans – what’s the difference

Managed care plans, including HMOs and PPOs, aim to control healthcare costs by using networks of providers, with HMOs offering lower premiums but more restrictions, and PPOs providing more flexibility but higher costs.

Here’s a breakdown of HMOs and PPOs:

Health Maintenance Organizations (HMOs):

Network Focus: HMOs primarily cover care within their network of doctors and hospitals.

Primary Care Physician (PCP): You usually need to choose a PCP who coordinates your care and makes referrals for specialists within the network.

Out-of-Network Care: Out-of-network care is typically not covered or covered at a significantly higher cost, except in emergencies.

Cost: HMOs generally have lower premiums and copays, but you have less flexibility in choosing providers.

Preferred Provider Organizations (PPOs):

Network Focus: PPOs also have a network of preferred providers, but you can see doctors and specialists outside the network.

Flexibility: You can see any doctor, including specialists, without needing a referral from a PCP.

Out-of-Network Coverage: PPOs offer some coverage for out-of-network care, but it’s usually at a higher cost than in-network care.

Cost: PPOs typically have higher premiums and copays than HMOs, but they offer more flexibility in choosing providers.

Point of Service (POS) Plans:

Hybrid Approach: POS plans combine features of both HMOs and PPOs.

Flexibility: You can choose to stay within the network or go outside of it, but out-of-network care usually comes with a higher cost.

Referrals: POS plans typically require a PCP and referrals for specialists, similar to HMOs.

Co-pay and Co-Insurance – what is the difference?

Decisions to make during Open Enrollment

Podcasts/Videos/Webinars

RPEC On Medicare Part 1: Getting Started in Medicare – Hosted by RPEC, featuring Matt Groshong, chair of the RPEC Healthcare Workgroup and Tim Smolen, Statewide Health Insurance Benefits Advisors (SHIBA) Program Manager. In part 1, we discuss getting ready for Medicare for those who are nearing retirement age. Tune in to learn about what you need to do, what your resources are, and why it’s so important to get everything right the first time. (Podcast/October 2024)

RPEC On Medicare Part 2: Medicare on the Commercial Market – Hosted by RPEC, featuring Matt Groshong, chair of the RPEC Healthcare Workgroup and Tim Smolen, Statewide Health Insurance Benefits Advisors (SHIBA) Program Manager. In part 2, we discuss Medicare options on the commercial market. (Podcast/October 2024)

Medicare Appeals 101 – An educational webinar hosted by the Center for Medicare Advocacy. View webinar video here. View slide presentation here. (Webinar/April 2025)

Universal Healthcare – An educational webinar hosted by RPEC featuring Rose Roach, the national coordinator of the Labor Campaign for Single Payer; Ross Valore, the Board and Commission Director at the Washington State Health Care Authority (HCA); and Mary Franzen, the Coverage Strategies Manager at the Washington State Health Care Authority (HCA). View webinar video here. View Rose Roach’s slides here. View HCA’s slides here. (Webinar/April 2025)

Traditional Medicare

The Medicare Open Enrollment Period runs from October 15th to December 7th each year.

Medicare Advantage

The Medicare Advantage Open Enrollment Period runs from January 1st to March 31st each year.

WA State Health Care Authority (HCA)/Public Employees Benefits Board (PEBB)

The open enrollment period is November 1 through 30.