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Health Care Reform - Medicaid Expansion

Authored By: Northwest Justice Project
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If you do not have health insurance, or your insurance does not cover the care you need, you may have options under the Affordable Care Act, the federal health reform law. #5180EN

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Intro

If you do not have health insurance, or your insurance does not cover the care you need, you may have options under the Affordable Care Act, the federal health reform law.  Read Health Care Reform – General Information.

What is Medicaid?

It is a type of free health insurance for people with low incomes. In the past, you would also have to meet other criteria (such as having a disability, being under age 19, or having kids in the home) to get Medicaid.  The Affordable Care Act expanded Medicaid coverage for adults who do not have these special circumstances. We call this Medicaid Expansion. In Washington, we call Medicaid Expansion and all other types of Medicaid “Washington Apple Health.”

Am I eligible for Medicaid Expansion?

Yes, if all these are true:

  • you are between ages 19 and 64

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

  • you live in Washington State

  • you are not in jail

  • you do not qualify for Medicare

  • 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 have a disability and have few resources or have kids in the home. To get Medicaid Expansion, these criteria do not apply.

How can I apply for coverage?

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

What if I need help applying or understanding my options?

You can call an In-Person Assister to get free help. You can find a list of In-Person Assisters at WashingtonLawHelp.org.

Can I apply anytime?

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

Do I need to reapply every year?

It depends. Each year, you will get a letter in the mail asking if there have been changes in your household or income. If there have not, your Medicaid Expansion coverage automatically renews for another year. If there have, you must send info about these changes to Healthplanfinder.

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

As soon as they process your application.

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.

What does Medicaid Expansion cover?

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

Medicaid Expansion does not cover every health service. Like most insurance coverage, it has limitations and exclusions.  The plan booklet you get after signing up for coverage has more info.  

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 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.

I am getting Medicaid Expansion. Can I keep my current doctors?

It depends.  When they approve you for Medicaid Expansion, they will assign you to a managed care plan (an “Apple Health” plan).

You learn about that plan through a letter that comes in the mail after you enroll.  Or an In-Person Assister can help you select your plan when you enroll.

Each managed care plan has contracts with different doctors and pharmacies. Each 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 an Apple Health managed care plan. If so, call the Health Care Authority (HCA) at 1-800-562-3022.  Ask the HCA to switch you to that managed care plan.  You can switch plans as often as every month.

If your doctor or pharmacy is not signed up with an Apple Health managed care plan, 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.

I have Medicaid Expansion. What if I need a medical service the plan does not cover?

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.  Contact 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.

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 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.  

What happens if I do not report changes?

You could lose your coverage.

What if I apply for Medicaid Expansion and they deny my application?

Healthplanfinder will tell you about any other coverage options available, such as Qualified Health Plans with subsidies to help with the costs of coverage.  Read Qualified Health Plans.

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

How do I appeal my 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 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.

 

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 May 2019.

© 2019 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.)

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Last Review and Update: May 23, 2019
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