Health care coverage options in Washington State

Yes, you should read this if you live in Washington State and you do not have health insurance, or your insurance does not cover the care you need.

You will learn options you might have for health care coverage under the federal Affordable Care Act (ACA).

Its full name is the Patient Protection and Affordable Care Act. This federal law gives you more ways to get and afford health insurance.

Among other things, it stops health insurance companies from:

• Refusing to offer health insurance to people with health problems (pre-existing conditions).
• Charging people with health problems higher premiums than other people.

It also:

• Introduces new ways for you to get and afford coverage. 
• Lets young adults stay on their parents’ insurance up to age 26.
• Closes the Medicare Part D “donut hole” by 2020. This makes prescription drugs cheaper.

Yes, but in 2017, a new federal law repealed (canceled) the penalty if you do not have a minimum level of health insurance.

You can apply at wahealthplanfinder.org or by calling 1-855-923-4633. You can also get a paper application at your local DSHS office, if it is open to walk-ins. If you want help applying, see “can I get help applying” paragraph below.

Healthplanfinder will screen you for many health care programs. If you are eligible to get Apple Health, they enroll you in that free program.

Some Apple Health programs are only for people with disabilities. If you financially qualify, DSHS checks if you meet the disability standard.

If you do not qualify to get Apple Health, you can compare Qualified Health Plans and choose the best one for you. You can also see if you can get help to make these plans or out-of-pocket costs more affordable. Read Qualified Health Plans to learn more.

It is Washington State’s main Medicaid program. Medicaid is free health insurance for people with lower incomes. In the past, you also had to meet other requirements to get it. These included having a disability, being under age 19, or having kids in the home. Under the ACA, adults who do not meet these other requirements may still be eligible to get Washington Apple Health for other reasons.  

Yes, if all these are true:

• You are age 19 to 64.
• You are a U.S. citizen or have an eligible immigration status. Read Health Care Reform – Immigrant Eligibility to learn more.
• You live in the state of Washington.
• You are not in jail or prison.
• You are not on Medicare.
• Your household income is at or below 138% of the Federal Poverty Level. Children and pregnant people are eligible at higher income levels. Learn more about the Federal Poverty Guidelines.

Yes. You can apply any time of the year.

Your coverage can start immediately. In some cases, it can start up to three months before they approved your application.

It depends. Each year, you will get a letter or email asking if there have been changes in your household or income. If there have not, your Apple Health coverage automatically renews for another year. If there have, you must send information about these changes to Healthplanfinder.

There may be a premium for the coverage itself. Services you get through this coverage are free as long as they are covered services. If you do not know if Apple Health covers a medical service, talk to your doctor.

It covers health services, including:

• Doctor visits
• Emergency room care
• Hospitalization
• Prescription drugs
• Maternity care
• Mental health and substance use services
• Rehabilitation and habilitation
• Laboratory services (like X-rays)
• Preventive care
• Chronic disease management
• Dental care

Apple Health does not cover every health service. Read the plan booklet you get after signing up for coverage to learn more.  

If you do not know if a medical service is covered, talk to your doctor. If Apple Health does not cover a service you need, you can ask for an exception or appeal. Act fast. There are time limits. Read Apple Health Grievances and Appeals: If You Disagree with your Apple Health Managed Care Plan or Have a Complaint.

It depends. Each managed care plan has contracts with different doctors and pharmacies. Each plan also covers different prescriptions.

When you are approved for Apple Health, you can select a managed care plan (an “Apple Health” plan) for yourself. Use the Smart Planfinder option in Washington Healthplanfinder to search for plans that cover your current doctors and prescriptions. Watch a short video to learn more about the Smart Planfinder.

You might be able to get a special exception to keep seeing that doctor or pharmacist. Read Apple Health Managed Care and Your Rights: Medicaid in Washington State to learn more.

If you don’t select one for yourself for whatever reason, you will be assigned to a plan.

Yes. HCA has health care navigators who can, among other things, help you apply and select a plan. You do not have to pay for a navigator’s help. Visit the Navigators page on Washington Healthplanfinder to learn more.

You should file a grievance or appeal with your managed care plan right away. Read Apple Health Grievances and Appeals: If You Disagree with your Apple Health Managed Care Plan or Have a Complaint. Call your plan’s customer service hotline to find out how. If the plan does not resolve the situation, you can have a fair hearing in front of a judge. You should also talk to a lawyer right away.

You can switch plans as often as every month. Call the Health Care Authority (HCA) at 1-800-562-3022.

Yes. You should report changes immediately if you or someone in your household:

• has a change in income by over $150 for two months
• moves
• gets married or divorced
• gets pregnant or a pregnancy ends
• gives birth or adopts a child
• goes to or is released from jail or prison
• enters a nursing home
• has a change in immigration or citizenship status
• has a change in health care coverage
• has a change in tax filing situation

You can report changes by going to wahealthplanfinder.org or calling 1-855-923-4633.  

You could lose your coverage.

If you are not eligible for Apple Health, Healthplanfinder will tell you about any other coverage options available, such as Qualified Health Plans with subsidies to help with the costs of coverage. See below Read Qualified Health Plans for more information.

Even if you can get one of these other coverage options, you can appeal the denial of Apple Health. If you think you should be getting Apple Health, you should appeal. Coverage through Apple Health is free. It offers benefits you cannot get through a Qualified Health Plan, like dental care.

You must ask for an appeal within 90 days of when you get your “Eligibility Decision” packet in the mail from Healthplanfinder. You can ask for an appeal in many different ways, such as going online at wahealthplanfinder.org, calling the Healthplanfinder at 1-855-923-4633, and other ways listed in the “Eligibility Decision” packet. You should also talk with a lawyer right away. Read Apple Health Grievances and Appeals: If You Disagree with your Apple Health Managed Care Plan or Have a Complaint.

It is a state-approved private health insurance plan. It offers better coverage than past options. Only Healthplanfinder, an online marketplace for health insurance, sells Qualified Health Plans.

Yes, if all these are true:

• You are a U.S. citizen or have an eligible immigration status. Read Health Care Reform – Immigrant Eligibility to learn more.
• You live in the state of Washington.
• You are not in jail or prison.
• You do not have other minimum essential coverage.

Read Qualified Health Plans to learn more.

No. You can usually apply only during a period called open enrollment. This is different from the Medicare open enrollment period.

For coverage to start Feb. 1, 2022, you must buy a plan from December 16, 2021 through January 15, 2022. If you do not apply during open enrollment, you may not be able to get coverage until the next year.

You must apply and enroll before the15th of the month for coverage to start on the first of the next month.

Yes. You might be able to apply for a Qualified Health Plan outside open enrollment if you have a qualifying event or special circumstances. Examples are losing your job-based health insurance, marriage, domestic violence, computer errors in your application, divorce, having a baby, and some income changes. Read Qualified Health Plans to learn more.

You must report changes in income and other household changes, like getting pregnant or someone moving out of the house.

You can report any changes to Healthplanfinder online in your account. You can also call a customer service representative at 1-855-923-4633. If you do not report a change that would raise your premium or lower your subsidy (tax credit), you may have to pay back the difference.

Yes. Talk to a health care navigator. Visit the Navigators page on Washington Healthplanfinder to learn more.