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Health Care Reform - General Information

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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 options under the Affordable Care Act, the federal health reform law. #5707EN


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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 federal Health Care Reform law (also known as the Affordable Care Act or ACA).

What is the federal Health Care Reform?

You may have heard people refer to it as 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 you 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. This law is still in effect. The new presidential administration has made some changes to it.

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. It may help others, such as those who do not have insurance, get health coverage.

You may have heard of a court decision in Texas that held the ACA unconstitutional throughout the country. The judge in that case has “stayed” his decision (delayed implementation of it) while it is appealed. This means the court decision does not affect 2019 enrollment or coverage under the ACA.

What does the federal Health Care Reform do?

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 other people.

  • Only covering medical expenses up to a certain dollar amount each year or in your lifetime.

  • Making unlimited profits.

It also:

  • Introduces new ways to get and afford coverage. 

  • Requires most people to have insurance. Read Requirement to Get Health Coverage.

  • Allows young adults to stay on their parents’ insurance up to age 26.

  • Closes the Medicare Part D “donut hole” by 2020. This makes prescription drugs cheaper.

*Learn more at www.healthcare.gov.

What coverage can I get in Washington State?

Your options are:

  • An expansion of Medicaid (part of “Washington Apple Health”) for some adults ages 19-64. Medicaid is a type of free health insurance coverage for lower-income people who qualify.

  • State-approved “Qualified Health Plans” offering better coverage than past commercial options. If you qualify, subsidies can make these plans more affordable, and cost-sharing reductions can lower your out-of-pocket costs.

What is Washington Apple Health?

It is Washington state’s Medicaid program. Medicaid is free health insurance for lower-income people. In the past, you also had to meet other requirements to get Medicaid, such as having a disability, being under age 19, or having kids in the home. The ACA extended Medicaid to adults who do not meet these other criteria. In Washington, we call all types of Medicaid “Washington Apple Health.”

What is a Qualified Health Plan?

It is a state-approved private health insurance plan offering better coverage than past options. Only Healthplanfinder, an online marketplace for health insurance, sells Qualified Health Plans.   

Can I get coverage under Washington Apple Health?

Yes, if all these are true:

  • You are age 19 - 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 or prison.

  • You are not on Medicare.

  • Your household income is at or below 138% of the Federal Poverty Level.  Children and pregnant women are eligible at higher income levels.

Can I get coverage through a Qualified Health Plan in Washington?

Yes, if all these are true:

*Qualified Health Plans has more info.

How do I apply for insurance under the federal Health Care Reform?

You can apply for all options, including Apple Health and Qualified Health Plans, by going to www.wahealthplanfinder.org or calling 1-855-923-4633. You can also get a paper application at your local DSHS office. See below for how to get help applying.
Healthplanfinder will screen you for many health care programs. If you are eligible for Apple Health, they will enroll you in that free program.

Some Apple Health programs are only for people with disabilities. If you financially qualify, DSHS determines if you meet the disability standard.

If you do not qualify for Apple Health, you can compare Qualified Health Plans and choose the best one for you. You can also see if you qualify for subsidies to make these plans more affordable, or cost-sharing reductions to lower out-of-pocket costs. Read Qualified Health Plans.

When does coverage start for Apple Health and Qualified Health Plans?

Qualified Health Plans: you must apply and enroll before the15th of the month for coverage to start on the first of the next month.  If you apply during the open enrollment period (see below), you must apply by December 15 for coverage to start January 1.   

Apple Health: your coverage can start immediately. In some cases, it can start up to three months before they approved your application.

Can I apply for coverage anytime?

Washington Apple Health: Yes. You can apply any time of the year.

Qualified Health Plans: No. You can usually apply only during a period called open enrollment. This is different from the Medicare open enrollment period. This year, open enrollment for Qualified Health Plans was November 1, 2018, - December 15, 2018. The next open enrollment period is expected to be November 1, 2019, through December 15, 2019. You must apply by December 15, 2019 for coverage starting on January 1, 2020.  If you do not apply during open enrollment, you may not be able to get coverage until the next year.

Special Enrollment: You may be able to apply for a Qualified Health Plan outside open enrollment if you have a qualifying event or special circumstances. Examples are losing your job-based health insurance, marriage, domestic violence, computer errors in your application, divorce, having a baby, and some income changes.  Read Qualified Health Plans and Can I Still Enroll in Health Coverage.

Do I have to get health insurance coverage?

By law, the answer is yes. However, starting in 2019, you will not pay a penalty for failing to have health insurance.

The ACA established the individual mandate. It requires people to have health insurance for themselves and their dependents.  If you wait until you get sick to get health coverage, the costs of insurance go up for everyone.

A tax penalty on your federal income taxes enforced the mandate to have health insurance. However, in 2017, Congress made the penalty zero. Congress did not get rid of the requirement to have health insurance.

The requirement to have health insurance is still in the ACA, but you will not pay a penalty for failing to have health insurance from 2019 on, unless Congress changes the law again. You may still have to pay a penalty if you did not have health insurance in 2018 and earlier.

If you already buy insurance for yourself, get it through your job or a public program like Medicare, or get an option like Apple Health or a Qualified Health Plan, you likely already meet the ACA’s requirement to have health insurance. There are other exceptions. Read Requirement to Get Health Coverage.

Starting in 2019, there will be no tax penalties for failing to have health insurance. If you do not have insurance in 2019, you will not face a penalty. If you do not have health insurance in 2017 or 2018, you could still have a tax penalty.

What if my income changes during the year?

You must report changes in income and other household changes, like becoming pregnant or someone moving out of the house. You report changes to Healthplanfinder online in your account or by calling a customer service representative at 1-855-923-4633. If you do not report a change that would raise your premium or lower your subsidy (tax credit), you may have to pay back the difference.

How can I apply for coverage?

  • Online at www.wahealthplanfinder.org.
  • By phone at 1-855-923-4633.
  • Using a paper application from Healthplanfinder or your local DSHS office.

Make sure you go to www.wahealthplanfinder.org. Similar sites may be copycat scams.

Can I get help applying?

Yes. Call an In-Person Assister (Navigator) or an insurance broker. You can search for In-Person Assisters at washingtonlawhelp.org, or go to www.wahealthplanfinder.org and click on the link in the customer support section to look for a navigator or broker in your area.


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 January 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.)


Last Review and Update: Jan 11, 2019