Health Care Reform - General Information
Authored By: Northwest Justice Project
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5707EN - If you do not have health insurance or your health insurance does not cover the care you need, you may have new options under the Affordable Care Act, the federal health reform law.
- What is the Affordable Care Act?
- What does the Affordable Care Act do?
- What coverage can I get in Washington State?
- What is Washington Apple Health?
- What is a Qualified Health Plan?
- Can I get coverage under Washington Apple Health or a Qualified Health Plan?
- How can I apply for health coverage under the Affordable Care Act?
- When does coverage begin for Apple Health and Qualified Health Plans?
- Can I apply for coverage anytime?
- Do I have to get health insurance coverage?
- What if my income changes during the year?
- How can I apply for coverage?
- What if I need help applying?
- What if I need legal help?
If you do not have health insurance OR your health insurance does not cover the care you need, you may have options under the Affordable Care Act, the federal health reform law.
You may have heard people refer to the Affordable Care Act (ACA) as "Obamacare" or the "health reform law." Its full name is the Patient Protection and Affordable Care Act. This federal law:
changes how health insurance companies operate
expands the ways people can get and afford health insurance
takes steps toward lowering health care costs for our country and many people (some will pay more)
Congress passed the law in 2010. It is being phased in over time. Many important parts of the law started in 2014.
The law affects different groups of people differently. Many who already had insurance (such as through a job or Medicare) have not had many changes. For others (such as those who do not have insurance), the ACA may help get health coverage.
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 others
only covering medical expenses up to a certain dollar amount each year or in a person's lifetime
making unlimited profits
The ACA also:
introduces new ways to get and afford health coverage
requires most people to have health insurance (our publication called Health Care Reform – Requirement to Get Health Coverage has more information)
allows young adults to stay on their parents' insurance to age 26
closes the Medicare Part D "donut hole" by 2020, making prescription drugs more affordable
*You can learn more about the law at www.healthcare.gov.
There are two coverage options available in Washington State:
An expansion of Medicaid (part of "Washington Apple Health") for some adults aged 19-64. Medicaid is a type of health insurance coverage for lower-income people. If you qualify, this coverage is free.
State-approved "Qualified Health Plans" offering better benefits and higher standards than past commercial insurance options. If you qualify, there are subsidies to make these plans more affordable and cost-sharing reductions to reduce your out-of-pocket costs.
It is our state's Medicaid program. Medicaid is free health insurance for low-income people. In the past, even if you were low-income, you had to meet other requirements to get Medicaid (such as being disabled, being under age 19, or having kids in the home). The Affordable Care Act expands Medicaid coverage for adults who do not meet these criteria. In Washington, we call Medicaid Expansion and other types of Medicaid "Washington Apple Health."
*Our publication called Health Care Reform – Medicaid Expansion has more information.
It is a state-approved private health insurance plan offering better benefits and higher standards than past commercial insurance options. Only Healthplanfinder, an online marketplace for comparing and buying health insurance, sells Qualified Health Plans.
Maybe. Most Medicaid in Washington is now called "Washington Apple Health" or "Apple Health." You can get coverage through Apple Health if all these are true:
you are between the ages of 19 and 64
you are a U.S. citizen or have an eligible immigration status (see our publication called Health Care Reform – Immigrant Eligibility)
you live in Washington State
you are not in jail or prison
you are not on Medicare
your household's income is at or below 138% of the Federal Poverty Level (children and pregnant women are eligible at higher income levels)
You can get coverage through a Qualified Health Plan in Washington if all these are true:
you are a U.S. citizen or have an eligible immigration status (see our publication called Health Care Reform – Immigrant Eligibility) AND
you live in Washington State
you are not in jail or prison
you do not have other minimum essential coverage (see Health Care Reform – Qualified Health Plans)
*Our publication called Health Care Reform – Qualified Health Plans has more information.
You can apply for all the health coverage options (including Apple Health and Qualified Health Plans) by going to www.wahealthplanfinder.org or calling 1-855-923-4633 (1-855-WAFINDER). You can also get a paper application at your local DSHS office. See below for how to get help applying.
When you apply for health coverage through Healthplanfinder, it will screen you for many health care programs, including Apple Health and Qualified Health Plans. If you are eligible for Apple Health, they will enroll you in that program (which is free).
Some Apple Health programs are only available to people with disabilities. If you financially qualify for these services, DSHS will determine if you meet the disability standard.
If you do not qualify for Apple Health, you can compare Qualified Health Plans and choose the best coverage for you. You can also see if you are eligible for subsidies to make these plans more affordable or for cost-sharing reductions to reduce your out-of-pocket costs for deductibles, coinsurance, and copayments. Our publication called Health Care Reform – Qualified Health Plans has more information.
Qualified Health Plans: you must apply and enroll before the 23rd of the month for coverage to start on the first of the next month.
Apple Health: your coverage can start immediately. In some cases, it can start up to three months before they approved your application.
Washington Apple Health: You can apply any time of the year.
Qualified Health Plans: You can usually apply only during a period called open enrollment. This open enrollment period is different from the open enrollment period for Medicare. This year, open enrollment for Qualified Health Plans was from November 1, 2015, through January 31, 2016. The next open enrollment period is November 1, 2016, through January 31, 2017. If you do not apply during open enrollment, you may not be able to get health care coverage until the next year.
Special Enrollment: You may be able to apply outside open enrollment if you have a qualifying event or special circumstances. Examples are losing your job-based health insurance; marriage; you are a domestic violence survivor; computer errors in your application; divorce; having a baby; and some income changes. The publications called Health Care Reform – Qualified Health Plans and Can I Still Enroll in Health Coverage have more information.
For most people, the answer is yes. The Affordable Care Act includes a requirement that most people either have coverage or pay the Internal Revenue Service (IRS) a penalty. This requirement exists because the costs of insurance go up for everyone if people wait until they get sick to get health coverage.
If you already buy insurance for yourself, get insurance through your job or a public program like Medicare, or get a coverage option like Apple Health or a Qualified Health Plan, you will not have to pay the penalty. There are some other exceptions to the penalty. Our publication called Health Care Reform – Requirement to Get Health Coverage has more information.
You must report changes in income and other changes in your household (like becoming pregnant or someone moving out of the house). You can report these changes to Healthplanfinder online in your account or by calling a customer service representative at 1-855-923-4633 (1-855-WAFINDER). If you do not report a change that would raise your premium or reduce the subsidy (tax credit) you get, you may have to pay back the difference.
You can apply for coverage through Healthplanfinder online at www.wahealthplanfinder.org, by phone at 1-855-923-4633 (1-855-WAFINDER), or by using a paper application from Healthplanfinder or your local DSHS office. If you go online, make sure you go to the correct website (www.wahealthplanfinder.org). There are copycat scams at similar sites.
Call an In-Person Assister or an insurance broker. You can find a list of In-Person Assisters at WashingtonLawHelp.org, or go to www.wahealthplanfinder.org and click on the "customer support" link in the upper right-hand corner to search for a navigator or broker in your area.
Apply online with CLEAR*Online - https://nwjustice.org/get-legal-help
- Call CLEAR at 1-888-201-1014
CLEAR is Washington's toll-free, centralized intake, advice and referral service for low-income people seeking free legal assistance with civil legal problems.
Outside King County: Call 1-888-201-1014 weekdays from 9:15 a.m. until 12:15 p.m.
King County: Call 211 for information and referral to an appropriate legal services provider Monday through Friday from 8:00 am – 6:00 pm. You may also call (206) 461-3200, or the toll-free number, 1-877-211-WASH (9274). You can also get information on legal service providers in King County through 211's website at www.resourcehouse.com/win211/.
Persons 60 and Over: Persons 60 or over may call CLEAR*Sr at 1-888-387-7111, regardless of income.
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 April 2016.
© 2016 Northwest Justice Project — 1-888-201-1014
(Permission for copying and distribution granted to the Alliance for Equal Justice and to individuals for non-commercial use only.)