Washington LawHelp

Health Care Reform – Qualified Health Plans

Authored By: Northwest Justice Project LSC Funded
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5708EN - 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. Depending on your income, you may be able to get free insurance from Washington Apple Health (“WAH”).

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Introduction

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.  Depending on your income, you may be able to get free insurance from Washington Apple Health ("Apple Health"). Our publication called Health Care Reform – General Information has more information.

What is a Qualified Health Plan?

A Qualified Health Plan ("QHP") is a state-approved private health insurance plan that you can buy through Healthplanpinder (https://www.wahealthplanfinder.org.)

Am I eligible for a Qualified Health Plan?

Yes, if all these are true:

  • you are a U.S. citizen or have an eligible immigration status (see Health Care Reform – Immigrant Eligibility)

  • you live in Washington State

  • you are not in jail or prison

  • you do not have other minimum essential coverage

Can I get help paying for a Qualified Health Plan?

Yes, if all these are true:

  • you qualify to get coverage through a Qualified Health Plan (see above)

  • your job does not offer you affordable coverage at a certain level (see below)

  • you do not have other "minimum essential coverage"

  • your household's gross income is between 100% and 400% of the Federal Poverty Level (or, if you are a lawfully present immigrant who is not eligible for Apple Health , and your income is at or below 400% of the Federal Poverty Level)

  • you file taxes

  • if you are married, you file taxes jointly with your spouse

I can get health insurance through my job. Can I qualify to get help paying for a Qualified Health Plan?

A QHP might cost less than insurance available through your job if you qualify to get help paying for the QHP. You must use the insurance through your job if it is "minimum value" and "affordable." It is "minimum value" if it is similar in coverage to a Bronze level QHP (see below). It is "affordable" if the monthly cost to you (your share of the premium cost you pay monthly as opposed to the total cost of the premium paid by the employer) is 9.5% or less of your household income. Your household income is the income of the person filing taxes for your household and the income of their tax dependents. This does not include dependents who do not earn enough to have to file a tax return.

If you have minimum value, affordable health coverage for yourself from your job, you cannot buy a Qualified Health Plan. If you do not have minimum value, affordable health coverage for yourself from your job, you may qualify for help paying for a Qualified Health Plan.

How does insurance through my job affect my family?

If you have minimum value, affordable coverage through your job and you can also buy health insurance from your job for your spouse and dependents, the coverage is automatically considered "affordable" for them, too. This is true even if the cost for their insurance plus yours is more than 9.5% of your household income.

Your spouse and dependents can buy a Qualified Health Plan instead of the coverage through your job. They would not qualify for help paying for it.

I qualify to get help paying for a Qualified Health Plan. How does this help work?

There are two kinds of help to pay for a Qualified Health Plan:

  • subsidies

  • cost-sharing reductions

Subsidies (also called "health insurance premium tax credits") help you pay for your premium. Your premium is the amount you pay every month to have health insurance. You can get a subsidy if your household income is between 100% and 400% of the Federal Poverty Level (or, if you are a lawfully present immigrant who is not eligible for Apple Health and your income is at or below 400% of the Federal Poverty Level). You can receive the subsidy monthly so your premium costs less each month, or in a lump sum at the end of the year as a tax refund.

Cost-sharing reductions help you pay out-of-pocket expenses like co-payments and deductibles. You can get cost-sharing reductions if your household income is between 100% and 250% of the Federal Poverty Level and you choose a Silver plan (cost-sharing reductions are not available for Bronze, Gold, or Platinum plans). If you qualify for cost-sharing reductions, there will be a limit on the amount you pay out-of-pocket each year. Once you reach that amount, you will not have to pay any more co-pays or deductibles.

If you are a descendant or enrolled member of a federally recognized Indian Tribe or an Alaska Native who is a shareholder in an Alaska Native Corporation and your household income is at or below 300% of the Federal Poverty Level, you may qualify for a special subsidy that would reduce your cost sharing to zero. You would not pay any out-of-pocket costs after your monthly premium payment.

How do I apply for a Qualified Health Plan?

You can apply for a Qualified Health Plan and get subsidies through Healthplanfinder, an organization whose legal name is the Washington Health Benefit Exchange.

You can apply by

If you do not have internet access or you have trouble with the online application, call the number listed above, email customer support at customersupport@wahbexchange.org, or go to your local DSHS office for help. These places can help you find an In-Person Assister—someone in your community trained to help you. Visit http://www.dshs.wa.gov/esa/community-services-offices/community-services-office to find your local DSHS office online.

Can I apply anytime?

Generally, no, unless you might qualify for Apple Health or an exception applies to you. The exceptions, called "special enrollment periods," are on page 7.

Otherwise, Healthplanfinder will only take applications during a period called "open enrollment."  This year, open enrollment was from November 11, 2015, through January 31, 2016. The next open enrollment period is November 1, 2016, through January 31, 2017.  If you did not apply during open enrollment, you may not be able to get health care coverage until January 1st of next year unless a special enrollment period applies. (Page 7 has more on special enrollment.) 

I qualified for a QHP in the most recent open enrollment period. When did coverage start?

If you enrolled before December 23, 2015, coverage started on January 1, 2016. If you enrolled between December 23, 2014, and January 23, 2016, coverage started on February 1, 2016. If you enrolled between January 24, 2016 and January 31, 2016, coverage started on March 1, 2016. Open enrollment ended on January 31, 2016. The next Qualified Health Plan Open Enrollment is November 1, 2016, through January 31, 2017.

What if I started my application before January 31, 2016, but did not finish it because I had problems with the Website or contacting the call center?

Report your situation as soon as possible:

You could fit into a Special Enrollment Period. (Page 7 has more information.) You have 60 days to report problems with your application and request a special enrollment period.

You should call or email as soon as possible to ensure a timely review. Each situation will be reviewed on a case-by-case basis.

Will I get to choose the Qualified Health Plan I want?

Yes. After they approve you for a Qualified Health Plan, you have many options. Different companies will offer you coverage. Companies offer different "metal" levels of plans (called Bronze, Silver, Gold, or Platinum).

*It is important to think about which plan is right for your budget and health needs.

Bronze plans generally have the lowest monthly premiums but highest out-of-pocket expenses. Beware of the "Bronze Trap." You might choose this plan for the low monthly premiums, only to find your out-of-pocket costs are very high and you will not qualify for cost-sharing reductions. (See above.)

The Silver plan may be the better option.  Your out-of-pocket expenses will be lower. You can get tax credits and cost-sharing reductions. You could end up paying less overall with the Silver plan even though the monthly premiums are higher than the Bronze plan.

Gold plans will have higher monthly premiums but lower out-of-pocket expenses.

Platinum plans have the lowest out-of-pocket costs and highest monthly premiums. Platinum plans only make sense if your total medical spending will be more than your monthly premiums, or you need very specific treatments.
If you are under age 30, or do not have to get health coverage (see our publication called Health Care Reform – Requirement to Get Health Coverage), you can choose a fourth type of coverage: a catastrophic plan. These plans cost less, but offer very limited benefits.

What will my Qualified Health Plan cover?

It depends. All Qualified Health Plans must include basic coverage, called Essential Health Benefits. This includes:

  • Doctor visits

  • Emergency room care

  • Hospitalization

  • Prescription drugs

  • Maternity care

  • Mental health and substance use services

  • Rehabilitation and habilitation if you get injured or have a disability or chronic condition

  • Laboratory services (like X-rays)

  • Preventive care

  • Chronic disease management

*Basic coverage does NOT include adult dental care, adult vision care, most hearing care, or some types of long-term care.

Each Qualified Health Plan provider can also decide to cover more medical services. When you apply through Healthplanfinder, you can compare what each plan offers.

If I have a new Qualified Health Plan, can I keep my current doctors?

It depends. Once they approve you for a Qualified Health Plan, you can choose from several plans. On the Healthplanfinder website (www.wahealthplanfinder.org), you can search the plans to see if they include your doctor and pharmacy. You can also call a customer support representative at 1-855-923-4633 (1-855-WAFINDER) to ask if a certain Qualified Health Plan will allow you to see your current providers. You can ask your doctors which plans they accept.

How much will a Qualified Health Plan cost?

It depends on which one you choose. You may also qualify for help paying for your Qualified Health Plan (see page 2).

Do I need to report changes?

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

  • has a change in income

  • moves

  • gets married or divorced

  • gets pregnant or a pregnancy ends

  • gives birth or adopts a child

  • goes to or gets out of 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

These kinds of changes during the year can have serious consequences. You could lose your coverage. They can also affect how much your Qualified Health Plan will cost.

If you do not report changes and you should have been paying more for the Qualified Health Plan than you did, you will owe the IRS the difference.  If you do not report changes and you should have been paying less for the Qualified Health Plan than you did pay, you will get credit for the difference on your tax return. This process of adjusting your taxes at the end of the year to reflect premium and cost-sharing amounts is "reconciliation."

Report your changes by going to your account at www.wahealthplanfinder.org or calling a customer support representative at 1-855-923-4633 (1-855-WAFINDER).

How do I pay for my Qualified Health Plan?

You will make the premium payment directly to the Qualified Health Plan.

You will receive bills directly from your health and/or dental insurance company. Payment deadlines may vary. If your health and dental insurance is provided by two different companies, you must make a payment to each insurance company.

Contact your health or dental insurance company with any questions about billing, payment deadlines, or grace periods.

If you cannot make a payment, contact the Healthplanfinder to find an In-Person Assister in your area. These organizations in your community may be able to help you pay in a different way (cash or money order) or find a sponsor to pay the premium for you. You should also talk to a lawyer right away.

After your first payment, you can pay for your Qualified Health Plan in other ways, such as writing a personal check to the plan. You can also set up an automatic debit through your health and/or dental insurance company.

What if I miss a payment?

To keep your Qualified Health Plan and avoid an IRS penalty, you must make your monthly premium payment on time and in full every month. If you miss a payment and do not get subsidies, you might lose your health coverage after the first missed payment. If you do get subsidies, there is a three-month "grace period." If you do not pay the premiums by the end of the grace period, you will lose coverage. You may also be billed for medical services you use during those months. If your income has dropped since your premiums were calculated, you may qualify for a reduced payment.

*If you lose coverage, you will not be able to get coverage through a Qualified Health Plan again until the next annual open enrollment period (unless a special enrollment period applies). You may also have an IRS penalty.

If you are having trouble paying your premium due to a loss in income, tell the Healthplanfinder right away. The income change may mean you can start paying less for your Qualified Health Plan or you now qualify for free Washington Apple Health coverage.

What if I apply for a Qualified Health Plan and they deny my application?

You should appeal with the Healthplanfinder as soon as possible, 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.wahbexchange.org/appeals, calling a customer support representative at 1-855-923-4633 (1-855-WAFINDER), and other ways listed in the "Eligibility Decision" packet. You should also talk to a lawyer right away.

I have a Qualified Health Plan. What if I need a medical service that is not covered?

Contact your Qualified Health Plan provider to file a grievance or appeal right away. Contact your plan's customer service hotline to find out more about how to do this. If the plan does not resolve the situation, you have a right to a review by a neutral, independent organization. (See the publication called Office of Insurance Commissioner Guide to Appeals.) You should also talk to a lawyer right away.

Do I have to apply for a Qualified Health Plan every year?

Yes. You must renew your coverage during open enrollment each year. The next open enrollment period is November 1, 2016, through January 31, 2017. If you do not apply during open enrollment and you do not qualify to apply during a special enrollment period, you will not be able to get a Qualified Health Plan until the following year and you may owe the IRS for failing to get health insurance.

What is a "special enrollment" period?

Generally, you must apply through Healthplanfinder to purchase a Qualified Health Plan during open enrollment each year. If you do not, you will not usually be able to buy a Qualified Health Plan until the next open enrollment period. You will not have health coverage for the year. You may also owe the IRS.

"Special enrollment": There are certain special times outside open enrollment when you can apply for a Qualified Health Plan. Within 60 calendar days of a certain event, you can apply for a Qualified Health Plan. The events that allow you to apply during a special enrollment period include:

  • losing your job and the affordable health coverage you got through the job

  • a change in income that results in losing your Washington Apple Health coverage

  • a divorce that results in losing your health insurance coverage

  • gaining citizenship or lawfully present immigration status

  • gaining a new dependent (such as a new baby)

  • getting married

  • moving into Washington State from another state

  • being denied Medicaid

  • permanently moving to a new area that offers different health plan options

  • leaving jail or prison

  • there was an error in your enrollment process or other special circumstances or complex cases (see below)

*Becoming ill is NOT an event that allows you to apply for a Qualified Health Plan during a special enrollment period.

If you are an enrolled member of a federally-recognized Indian Tribe or an Alaska Native who is a shareholder in an Alaska Native Corporation, you can switch plans as often as once a month. The open and special enrollment periods do not apply to you.

If you missed open enrollment, talk to a lawyer right away. Find out if you can apply during a special enrollment period. You might qualify for Washington Apple Health, which allows you to apply any time during the year.
"Complex Cases Special Enrollment": These cases have exceptional circumstances. If you have a complex case, call 1-855-923-4633 (1-855-WAFINDER) or email customersupport@wahbexchange.org to report your special enrollment situation as soon as possible. (The deadline is generally 60 days from the event.) Your situation will be reviewed on a case-by-case basis. Complex cases include:

  • a natural disaster

  • unexpected hospitalization

  • misinformation, misrepresentation, or inaction by people or entities providing enrollment help

  • your insurance company did not get your information due to a technical issue

  • system errors related to immigration status

  • display errors on the Healthplanfinder website

  • error messages kept you from using Healthplanfinder to finish your application

  • unclear instructions about the necessary steps for 2016 enrollment

  • inability to submit an application because your income could not be verified

  • you are a survivor of domestic violence and you want to enroll in  a plan separate from your abuser

If you appeal an eligibility decision and the ruling goes in your favor, you will have the option of enrolling in or changing plans.

*Learn more: read the publication called Can I Still Enroll in Health Coverage.

What if I think I am being charged too much for the Qualified Health Plan or I am not getting the correct subsidy amount?

You should appeal with the Healthplanfinder as soon as possible, within 90 days of when you get your "Eligibility Decision" packet in the mail. You can ask for an appeal in many different ways, such as going online at www.wahbexchange.org/appeals , calling the Healthplanfinder at 1-855-923-4633 (1-855-WAFINDER), and other ways listed in the "Eligibility Decision" packet. You should also talk to 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 using a paper application from Healthplanfinder or your local DSHS office. If you go online, be sure to go the correct website (www.wahealthplanfinder.org). There are copycat scams at similar sites.

What if I need help applying or understanding my options?

Call an In-Person Assister or an insurance broker. There is a list of In-Person Assisters at WashingtonLawHelp.org, or go to www.wahealthplanfinder.org and click on the "customer support" link to search for a navigator or broker in your area.

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 9:15 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.

Deaf, hard of hearing or speech impaired callers can call CLEAR or 211 using the relay service of their choice.

211 and CLEAR will conference in interpreters when needed at no cost to callers. 

Free legal education publications, videos and self-help packets covering many legal issues are available at www.washingtonlawhelp.org.



5708EN

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 November 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.)

Last Review and Update: Nov 16, 2016
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