Washington

Washington's Apple Health for Kids Medical Programs

Authored By: Northwest Health Law Advocates
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What is Apple Health for Kids?

Apple Health for Kids (also known as Medicaid) provides full medical and dental coverage for children whose families have incomes up to 317% of the Federal Poverty Level (FPL). This coverage is available for:

  • Kids who live with parents, relatives or friends

  • Kids in foster care

  • Homeless kids and kids living on their own

Apple Health for Kids coverage is complete including preventive care and check-ups. There are no deductibles, no premiums and no co-payments for families below 215% of the Federal Poverty Level (FPL). Families between 215% and 265% FPL pay monthly premiums of $20 per child per month, but no more than $40 per month. Families between 265% and 317% FPL pay premiums of $30 per child per month, but no more than $60 per month.

What are the eligibility guidelines for Apple Health for Kids?

To be eligible for Apple Health for Kids, a child must be under nineteen years old, live in Washington, and have countable family income under 317% of the Federal Poverty Level as set out below (current 4/1/14 through 3/31/15

Family Size

Monthly Income
215% FPL

Monthly Income
265% FPL

Monthly Income
317% FPL

1

$2,091

$2,577

$3,083

2

2,818

3,474

4,155

3

3,546

4,370

5,228

4

4,273

5,267

6,300

5

5,001

6,163

7,373

6

5,728

7,060

8,445

7

6,455

7,957

9,518

8

7,183

8,853

10,590

The income of parents and stepparents in the home is counted. A child's income does not count if the child is not required to file a tax return. Some other kinds of income also do not count. Even if income exceeds the above levels, families should be encouraged to apply.

Are there limitations if the child has other insurance?

There are no limitations for a child with other health insurance when family income is less than 215% FPL. For these children, Apple Health for Kids provides "wraparound" coverage: it pays premiums, deductibles, and cost-sharing required by the other insurance. It also covers services not covered by the other insurance.

For children in families with income above 215% FPL who have access to other health insurance, there are limitations on eligibility for Apple Health for Kids. Children with other insurance may not qualify for Apple Health for Kids, depending on the type of insurance. 

What is the new program for former foster youth?

If a child was in foster care in Washington and receiving Apple Health (Medicaid) at age 18 or on the date he aged out of foster care (up to 21 years old), the child will be eligible for Apple Health coverage until he is 26. There is no income requirement for former foster youth to qualify for Apple Health. They do not need to reapply. For more details, see the publication Health Coverage for Former Foster Youth.  

How do I apply for Apple Health for Kids?

A child may apply for Apple Health for Kids online, by phone or mail, or by contacting a navigator. 

  • Online: At the Healthplanfinder website: www.wahealthplanfinder.org.

  • By phone: Call the Healthplanfinder's customer support line at 1-855-923-4633.

  • By mail: Print the application from Health Care Authority's website: http://www.hca.wa.gov/medicaid/forms/pages/index.aspx (also includes links to forms in other languages).  Send to the address on the form. Keep a copy of the application for your records.

  • In person:  Contact a navigator. To find a navigator in your area go to the Healthplanfinder website: www.wahealthplanfinder.org, and click on "customer support" in the upper right hand corner. You can also contact a lead organization in your area.

  • If you need help with your application, call 1-855-623-9357.

More information is available at http://www.hca.wa.gov/applehealth/Pages/default.aspx.   

Can children apply separately from their parents?

If a child is under 19 years old, he can apply separately from his parents if he is not living with them and is not claimed by them as a tax dependent. If this is the situation, the parents' income will not be counted. If a child is applying separately from his parents, he cannot apply online. HCA has a special contact person to assist in the processing of the application:

  • HCA CONTACT: Jessica Cottom (only available during regular HCA office hours of Monday – Friday from 8:00am – 5:00pm)
  • PHONE: (360) 725-2050
  • EMAIL: jessica.cottom@hca.wa.gov
  • FAX: (360) 664-2186

What if a child's medical is denied or terminated?

If a child was or is receiving Apple Health for Kids but becomes ineligible, HCA is required to look at whether the child is eligible for other Apple Health programs before terminating Apple Health for Kids. If not, the child may also be eligible for Qualified Health Plan (QHP) coverage. A QHP is a private plan available through the Healthplanfinder. People who get QHP coverage can get tax credits to help pay their premiums if their household income is below 400% of the federal poverty level. In some cases, you may qualify for discounts on cost-sharing to reduce your out-of-pocket expenses. For more information about QHP coverage, see http://www.washingtonlawhelp.org/resource/health-care-reform-general-information?ref=HjJYD.

If you disagree with the decision, how do you appeal?

If Apple Health coverage is denied or terminated, you have the right to appeal and request an administrative hearing.   

You generally have 90 days to appeal (ten days if you want coverage until the hearing – see below). You can appeal by:

  • Calling Washington Healthplanfinder at 1-855-923-4633 or calling the Health Care Authority at 1-855-623-9357.

  • Emailing Washington Healthplanfinder at appeals@wahbexchange.org.  Make sure to include the name and birth date of person appealing, the application ID, the date of the eligibility determination being appealed, and the reason for the appeal. Print a copy of your appeal and keep for your records.

  • Completing the Appeal/Hearing Request Form, attaching a copy of the letter denying or terminating Apple Health coverage, and mailing to: Health Care Authority P.O. Box 45504 Olympia, WA 98504-5504. Download the appeal form here: http://www.wahbexchange.org/news-resources/appeals/ Make a copy of the form before you send it and keep it for your records.  

  • Completing the Appeal/Hearing Request Form and faxing it along with to 1-866-720-2892. Keep a copy of the form for your records.

Continued coverage pending an appeal:

You can receive continued Apple Health for Kids coverage if you appeal within 10 days of receiving written notice of the decision. If you lose your appeal, you may be asked to pay something back for the Apple Health for Kids coverage you had during the appeal. You can also enroll in QHP coverage while your appeal is being decided. Making a decision about whether to pay for QHP coverage and ask for tax credits during your appeal, or risk having to pay for continued Apple Health for Kids coverage if you lose your appeal, can be complicated. You may want to contact CLEAR to help you figure this out (see information below).

If you decide not to appeal, do not delay enrolling in a QHP. To ensure there are no gaps in coverage you must select a plan and pay your first monthly premium by the 23rd of the month before you want coverage to start.

At the Hearing:

An impartial administrative law judge will decide whether the denial or termination was legally correct.  If you need help or advice regarding the hearing, your legal services office may be able to assist or advise you.  Or, you may call CLEAR at 211, if you live in King County, or at 1-888-201-1014 if you live outside of King County.  For tips on representing yourself, you may ask for the publication Representing Yourself at an Administrative Hearing.

 

 

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This publication provides general information concerning your rights and responsibilities.  It is not intended as a substitute for specific legal advice. 
This information is current as of December 2014.