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WashingtonLawHelp.orgWashington LawHelp

Washington's Apple Health for Kids Medical Programs

Authored By: Northwest Health Law Advocates
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Medical programs in Washington provide full medical and dental coverage for children whose families have incomes up to 300% of the Federal Poverty Level (FPL). Read this publication to find out who qualifies.Publication #5312EN

Contents

Read Online

*Read this only if you live in the state of Washington.

*Some eligibility rules and procedures are more flexible during the COVID-19 Public Health Emergency. Visit https://nohla.org/index.php/covid-19-resources/ to learn more.

 

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 under age 19:

  • who live with parents, relatives or friends

  • in foster care

  • who are homeless and living on their own

Apple Health for Kids coverage is comprehensive. It includes preventive care and check-ups.

 

What does it cost?

It depends.

Families below 215% of the Federal Poverty Level (FPL) have no costs - no deductibles, no premiums and no co-payments.

Families between 215% and 265% FPL pay monthly premiums of $20 per month for one child, up to $40 per month total..

Families between 265% and 317% FPL pay premiums of $30 per month for one child, up to $60 per month total.

 

What are the eligibility guidelines 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 through March 31, 2021):

 


Family Size

Monthly Income
215% FPL

Monthly Income
265% FPL

Monthly Income
317% FPL

1

$2,287

   $2,818

$3,371

2

3,089

3,808

4,555

3

3,892

4,797

5,738

4

4,695

5,786

6,922

5

5,497

6,776

8,105

6

6,300

7,765

9,289

7

7,103

8,754

   10,472

8

7,905

9,744

   11,656

 

Whose income counts in deciding if we are eligible for Apple Health for Kids?

The income of parents and stepparents in the home counts. A child’s income may not count when it is below a certain amount or is from Social Security. Some other kinds of income to household members also do not count. Even if your family’s income is more than the levels in the section above, you should still apply.

 

What if the child has other insurance?

It depends on family income level.

If family income is less than 215% FPL, a child can have other health insurance in addition to Apple Health for Kids. In this situation, Apple Health for Kids provides “wraparound” coverage. It pays premiums, deductibles, and cost sharing required by the other insurance. It also covers services the other insurance does not cover.

 

*Apple Health also may reimburse the parent for the cost of this other insurance. This is the Premium Payment Program. Read more at www.hca.wa.gov/health-care-services-supports/program-administration/premium-payment-program.

 

If family income is above 215% FPL, a child gets Apple Health for Kids with Premiums instead. A child in this situation who has access to other health insurance may not be eligible for this Apple Health program.

  • Children who have other “creditable” health insurance do not qualify for Apple Health for Kids with Premiums. Call HCA at 1-800-562-3022 about your specific insurance.

  • Children are not eligible for Apple Health for Kids with Premiums if a parent works at a public agency, even if the parent declines (decides not to get) the health coverage. Losing eligibility for Apple Health with Premiums creates a special open enrollment for the child to get Public Employees Benefits Board (PEBB) or School Employees Benefits Board (SEBB) program coverage. The special open enrollment is short. The parent employee can contact the employer’s personnel or benefits office for info.   

 

What is the new program for former foster youth?

A child who was in foster care in Washington and getting Apple Health at age 18 or on the date he aged out of foster care (up to 21 years old) will be eligible for Apple Health coverage until age 26. Former foster youth have no income limit to qualify for Apple Health. They do not need to reapply. Read Health Coverage for Former Foster Youth.

 

How do I apply for Apple Health for Kids?

A child can 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 customer support line at 1-855-923-4633.

  • By mail: Print the “Application for health care coverage” (form 18-001P) from the Health Care Authority website: www.hca.wa.gov/medicaid/forms/pages/index.aspx (links to forms in other languages). Type “18-001P” in the Search bar near the top of the webpage. Send to the address on the form. Keep a copy of the application for your records. Mailed applications take longer to process.

  • Contact a “navigator” to help: A trained navigator usually can meet with you in person. During the COVID-19 pandemic, this free help is through phone or sometimes online. To find one, go to the Healthplanfinder website: www.wahealthplanfinder.org. Click on “Customer Support” in the upper right corner. That page has a section called “Get virtual help enrolling.” Under that, select “Search for a NavigatororContact an Organization.” For questions about whether you qualify for Apple Health (Medicaid), call 1-800-562-3022 (the Health Care Authority).

Read more at www.hca.wa.gov/applehealth/Pages/default.aspx.   

 

Can children apply separately from their parents?

It depends. A child under age 19 can apply separately from their parents if they are not living with the parents and the parents do not claim the child as a tax dependent. In this situation, the parents’ income does not count.

A child applying separately from their parents cannot apply online. For help applying, call HCA’s special contact person for this issue:  

  • HCA CONTACT: Jessica Cottom (days and times available vary during the pandemic)

  • EMAIL: jessica.cottom@hca.wa.gov (use email to schedule a phone call)   

  • PHONE: (360) 725-2050    

  • FAX: 360-725-1158, attention: Jessica   

 

I am turning 19. What will happen to my Apple Health for Kids coverage?

At age 19, Apple Health for Kids ends. You might qualify for Apple Health for Adults (it has a lower income limit) or another Apple Health program.

Renewal might happen automatically. You might need to take some steps to make it happen. HCA will send you a notice about this.

If you are turning age 19:

  • You can apply or renew through a primary applicant who claims you as a dependent on their tax return. HCA will do an automatic renewal without you having to file a separate application.

  • You can apply separately even if someone claimed you as a tax dependent. Then you can manage your own account and choose a different health plan, if you want.

  • You must apply separately if you are not the primary applicant’s spouse or tax dependent. This applies even if you do not file taxes.

 

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

If a child who was or is receiving Apple Health for Kids becomes ineligible, HCA must consider if the child is eligible for other Apple Health programs before ending Apple Health for Kids.

 

My child is not eligible for any Apple Health program. Are there other options?

The child may be eligible for Qualified Health Plan (QHP) coverage. A QHP is a private insurance plan. It is available through the Healthplanfinder. It comes with tax credits to help pay your premiums if your household income is below 400% of the federal poverty level. If your income is lower, you may qualify for discounts on cost sharing to reduce out-of-pocket expenses. Read Qualified Health Plans. It is available at www.WashingtonLawHelp.org.  

 

They ended my Apple Health for Kids coverage. I disagree with that decision. Now what?

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

 

When do I appeal?   

You generally have 90 days to appeal. But you must appeal earlier than that if you want your coverage to continue (“continued benefits”) during your appeal.  

To get continued benefits, you must appeal either within ten days from the notice date or before your coverage ends, whichever is later. You should start your appeal and ask for continued benefits right away by phone to make sure you are on time. Follow up in writing..  

 

How do I appeal?

You can appeal by:

  • Phone: Call 1-855-WAFINDER (1-855-923-4633) or the Health Care Authority at 1-800-562-3022. Or call the Office of Administrative Hearings at 1-800-583-8271. Keep notes of the date and number you called, and the staff person’s name.

  • Writing: Fill out any form that came with your denial or termination letter, or download the Appeal Request Form here: www.wahbexchange.org/news-resources/appeals/ and fill it out. Attach a copy of the letter denying or terminating (ending) Apple Health coverage. Call 1-855-923-4633 for help with the form. Make a copy of the form before sending, to keep for your records. Then do one of these:

    • Mail to Health Care Authority P.O. Box 45504 Olympia, WA 98504-5504. If possible, use certified mail return receipt, or call later to confirm HCA received it.  

    • Fax to 1-360-586-9080 (Health Care Authority). Call to make sure HCA got the fax. Keep notes about your call to confirm.

    • Online: Log in to your Healthplanfinder account at http://wahealthplanfinder.org and submit an appeal.

 

What should my appeal request say?

It should include:  

  • The name and birth date of the person appealing

  • The application ID

  • The date of the decision you are appealing

  • Contact info for the person asking for the hearing

  • Why you are appealing

  • If you want to keep your benefits during your appeal (called “continued benefits”).

  • Any help or accommodations you need to understand, communicate, or take part in the hearing process

 

I am appealing a decision. What if English is not my preferred language?

The agency will provide a sign language or spoken language interpreter and written translations of hearing materials free of charge.  

 

Tell me more about getting health coverage during an appeal.

You may be able to keep getting your Apple Health program while you appeal. But this requires making your appeal right away. (See “How Do I Appeal” above.)

If you miss the short deadline to get continued benefits while appealing, you can still appeal, but your coverage will stop during your appeal. If you get “continued benefits” but lose your appeal, you may be asked to pay something back for the Apple Health for Kids coverage you had during the appeal.

You also can enroll in QHP coverage while your appeal is being decided. Losing your Apple Health gives you a “Special Enrollment Period” to enroll in a QHP. Act fast. This special enrollment period lasts only 60 days from your loss of Apple Health.

It can be complicated to decide if you should 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. Contact CLEAR for help figuring this out. (See Get Legal Help below.)

 

What if I decide not to appeal?

Enroll in a QHP right away if you do not have other health insurance.

 

How do I enroll in QHP coverage?

Go online to www.wahealthplanfinder.org, or call 1-855-923-4633.

To make sure you have no gaps in health coverage, you must do both of these:

  • Select a plan by the 15th of the month before the month you want the coverage to start.

  • Pay the premium by the due date.

The due date the plan sets in the bill should be no earlier than the coverage start date and at least 15 days after the bill. Check with the health plan to find out how and when to send the payment. Read more about paying plans at www.wahbexchange.org/current-customers/insurance-company-payment-options/.

 

I appealed. What happens at the hearing?

An administrative law judge will decide if the denial or termination was legally

 

Get Legal Help

Visit Northwest Justice Project to find out how to get legal help. 

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Last Review and Update: Jul 06, 2020
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