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Health Care Reform - Medicaid Expansion

Authored By: Northwest Justice Project LSC Funded
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5180EN - 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.

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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. Our publication called Health Care Reform – General Information Has more information.

What is Medicaid?

Medicaid is a type of free health insurance for low-income people. In the past, even if you were low-income, you would have to meet other eligibility criteria (such as being disabled, being under age 19 or having kids in the home) to get Medicaid. The Affordable Care Act expands Medicaid coverage for adults who do not have these special circumstances. We call this new coverage Medicaid Expansion. In Washington, we will call Medicaid Expansion and all other types of Medicaid "Washington Apple Health."

Am I eligible for Medicaid Expansion?

You are eligible for Medicaid Expansion in Washington if:

  • you are between the ages of 19 and 64 AND

  • 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 AND

  • you are not in jail AND

  • you do not qualify for Medicare AND

  • your household's income is at or below 138% of the Federal Poverty Level (higher income levels apply to children and pregnant women)

Other types of Medicaid require that you be disabled and have few resources or have kids in the home. To get Medicaid Expansion, these additional criteria do not apply.

How do I apply for Medicaid Expansion?

Online: You can apply at www.wahealthplanfinder.org through Healthplanfinder, a new organization sometimes known by its legal name, the Washington Health Benefit Exchange.
Phone or other ways: If you do not have internet access or if you have trouble with the online application, go to your local DSHS office or call the hotline and ask for help. The phone number is 1-855-923-4633 (1-855-WAFINDER). These places can help you find an In-Person Assister—someone in your community trained to help you with the application process free.

Can I apply anytime?

Yes. You can apply for Medicaid Expansion and other Medicaid programs anytime.

If I qualify for Medicaid Expansion, when will coverage begin?

Coverage will start January 1, 2014, if you apply before then. If you apply after January 1, 2014, coverage will start as soon as they process your application.

What will Medicaid Expansion cover?

It will cover 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

Medicaid Expansion does not cover every health service. Like most insurance coverage, it has limitations and exclusions. You can find out more in the plan booklet you will get soon after signing up for coverage. If you do not know if a medical service is covered, talk to your doctor. If Medicaid Expansion does not cover a service you need, you have the right to ask for an exception or to appeal the denial, but act fast. There are time limits.

If I have Medicaid Expansion, can I keep my current doctors?

It depends. When they approve you for Medicaid Expansion, you will be assigned to a managed care plan (also called a "Healthy Options" plan). You will learn about your managed care plan through a letter that will come in the mail after you enroll. An In-Person Assister can also help you select your plan when you enroll.

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

When they approve you for Medicaid Expansion, talk with your doctor and pharmacy. See if they are signed up with a Healthy Options managed care plan. If so, ask the Health Care Authority to switch you to that managed care plan. You can call the Health Care Authority at 1-800-562-3022 to ask them to switch you to a different managed care plan. You can switch managed care plans as often as every month.

If your doctor or pharmacy is not signed up with a Healthy Options managed care plan, you might be able to get a special exception to keep seeing that doctor or pharmacist.

How much will Medicaid Expansion cost?

Nothing. Services you get through your Medicaid Expansion coverage are free as long as they are covered services. If you do not know if Medicaid Expansions covers a medical service, talk to your doctor.

Do I need to report changes?

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 jail or prison, 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 your changes by going to www.wahealthplanfinder.org or calling 1-855-923-4633 (1-855-WAFINDER). There can be serious consequences if you do not report changes. You could lose your coverage.

Do I need to reapply each year?

It depends. Each year, you will get a letter in the mail asking if there have been any changes in your household or income. If there have been no changes, your Medicaid Expansion coverage will automatically renew for another year. If there have been changes, you will need to send information about these changes to Healthplanfinder.

What if I apply for Medicaid Expansion and the application is denied?

If they deny your application for Medicaid Expansion, Healthplanfinder will tell you about any other coverage options available to you, such as Qualified Health Plans with subsidies to help with the costs of coverage.

Even if you can get one of these other coverage options, you have the right to appeal the denial of Medicaid Expansion. If you think that you are eligible for Medicaid Expansion, you should appeal. Coverage through Medicaid is free and offers benefits you cannot get through a Qualified Health Plan (like dental care).

To appeal your Medicaid Expansion denial, 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 www.wahealthplanfinder.org, calling the Healthplanfinder at 1-855-923-4633 (1-855-WAFINDER), and other ways listed in the "Eligibility Decision" packet. You should also talk with a lawyer right away.

What if I have Medicaid Expansion and I need a medical service that is not covered?

Contact your managed care plan to file a grievance or appeal right away. Contact your plan's customer service hotline to find out how to do this. If the plan does not resolve the situation, you have a right to a fair hearing in front of a neutral judge. You should also talk with a lawyer right away.

How can I apply for coverage?

You can apply for coverage through Healthplanfinder online at www.wahealthplanfinder.org, by phone at 1-855-923-4633 (1-855-WAFINDER), or by requesting a paper application from Healthplanfinder or from your local DSHS office. If you go online, be sure to go the correct website (www.wahealthplanfinder.org).

What if I need help applying or understanding my options?

If you need help applying for coverage, you should call an In-Person Assister to get free help. You can find a list of In-Person Assisters at WashingtonLawHelp.org.

What if I need legal help?

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 9:10 a.m. until 12:25 p.m. CLEAR works with a language line to provide free interpreters as needed to callers. If you are deaf or hard of hearing, call 1-888-201-1014 using your preferred TTY or Video relay service.

  • 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). 211 works with a language line to provide free interpreters as needed to callers. Deaf and hearing-impaired callers can call 1-800-833-6384 or 711 to get a free relay operator. They will then connect you with 211. 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 October 2013.

© 2013 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.)

Last Review and Update: Oct 24, 2013