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Qualified Health Plans

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

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What is a Qualified Health Plan?

It is a state-approved private health insurance plan you can buy through Healthplanfinder.

*If you do not have health insurance or your insurance does not cover care you need, you may have options. Depending on your income, you may be able to get free insurance: Washington Apple Health ("Apple Health"). Health Care Reform – General Info has more info.

Can I get a QHP?

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/prison.

  • You do not have other "minimum essential coverage." See below.

Can I get help paying for a QHP?

Yes, if all these are true:

  • You qualify to get coverage through a QHP. See above.

  • Your job does not offer you affordable coverage at a certain level. See below.

  • Your household's gross income is between 100% - 400% of the Federal Poverty Level (OR 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.

  • You are married and file taxes jointly with your spouse.

I can get health insurance through my job. Can I get help paying for a QHP?

If the insurance through your job is not minimum value, affordable health coverage, you may qualify to get help paying for a QHP. If you get help paying for it, a QHP might cost less than the insurance through your job.

"Minimum value" means the coverage is like a Bronze level QHP. (See below.) "Affordable" means your share of the monthly premium is 9.5% or less of your household income. Your household income is the incomes of the person filing taxes for your household and their tax dependents. It does not include dependents who do not earn enough to file a tax return.

How does insurance through my job affect my family?

If you have minimum value, affordable coverage through your job AND you can buy health insurance from your job for your spouse/dependents, the law says the coverage is "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/dependents can buy a QHP instead, but they cannot get help paying for it.

I qualify to get help paying for a QHP. How does this work?

There are two kinds of help:

  • Subsidies.

  • Cost-sharing reductions.

Subsidies ("health insurance premium tax credits") help pay for your premium. Your premium is what you pay every month to have health insurance.

You can get a subsidy if your household income is between 100% - 400% of the Federal Poverty Level OR you are a lawfully present immigrant, ineligible for Apple Health, with income at/below 400% of the Federal Poverty Level. You can get the subsidy monthly so your premium costs less each month OR in a lump sum tax refund at the end of the year.

Cost-sharing reductions help you pay out-of-pocket expenses like co-payments and deductibles. You can get these if your household income is between 100% - 250% of the Federal Poverty Level and you choose a Silver plan. You cannot get cost-sharing reductions for the other plans.

If you get cost-sharing reductions, there is a limit on your out-of-pocket payments each year. After you reach that limit, you will not have to pay any more co-pays or deductibles.

Enrolled members of federally recognized Indian Tribes or Alaska Natives who are shareholders in an Alaska Native Corporation with household income at/below 300% of the Federal Poverty Level qualify for a special subsidy. You would pay no out-of-pocket costs after your monthly premium payment.

How do I apply for a QHP?

You can apply and get subsidies through Healthplanfinder. Their legal name is the Washington Health Benefit Exchange.

  • Go online at www.wahealthplanfinder.org.

  • Call 1-855-923-4633 (1-855-WAFINDER).

  • Get a paper application from DSHS or Healthplanfinder.

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

Can I apply anytime?

Generally, no, unless you might qualify for Apple Health OR an exception ("special enrollment period") applies. See below.
Otherwise, Healthplanfinder only takes applications during an "open enrollment" period.  This year, open enrollment was from November 1, 2016, - January 31, 2017. The next open enrollment period is November 1, 2017, - January 15, 2018. 

When does coverage start?

If you enrolled before December 23, 2016, coverage started on January 1, 2017. If you enrolled between December 23, 2016, and January 23, 2017, coverage started on February 1, 2017. If you enrolled between January 24, 2017 and January 31, 2017, coverage started on March 1, 2017. Open enrollment ended on January 31, 2017. The next Qualified Health Plan Open Enrollment is November 1, 2017, through January 31, 2018.

What if I did not finish my application before January 31, 2017 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. (See below.) You have 60 days to report problems with your application and ask for a special enrollment period.

Can I choose my QHP?

Yes. Different companies will offer different "metal" levels of plans (Bronze, Silver, Gold, or Platinum). You must decide 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 it for the low monthly premiums, but find your out-of-pocket costs very high and you do not qualify for cost-sharing reductions. (See above.)

The Silver plan may be better for you.  The out-of-pocket expenses are lower. You can get tax credits and cost-sharing reductions. The monthly premiums are higher than the Bronze plan, but you could end up paying less overall.

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

Platinum plans have the lowest out-of-pocket costs and highest monthly premiums. These 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 Requirement to Get Health Coverage), you can get a catastrophic plan. These cost less, but offer very limited benefits.

What will my QHP cover?

It must include these Essential Health Benefits:

  • Doctor visits.

  • Emergency room care.

  • Hospitalization.

  • Prescription drugs.

  • Maternity care.

  • Mental health and substance use services.

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

  • Lab services (like X-rays).

  • Preventive care.

  • Chronic disease management.

It does NOT include

  • Adult dental/vision care.

  • Most hearing care.

  • Some long-term care.

A QHP provider can decide to cover more medical services. When you apply through Healthplanfinder, you can compare what each plan offers.

Are there dental plans?

Yes. Anyone who enrolls in a QHP can enroll in a dental plan.

You can search for and enroll in dental plans on Healthplanfinder. They cover

  • Just adults.

  • Adults and children.

  • Children only.

Households can only sign up for one dental plan. Any tax credits you are eligible for apply to only the health plan, not the dental plan.

Can I keep my current doctors?

Maybe. You can check

  • When searching plans at www.wahealthplanfinder.org.

  • By asking a customer support representative at 1-855-923-4633 (1-855-WAFINDER).

  • By asking your doctors which plans they accept.

How much will a QHP cost?

It depends on which one you choose. You may also qualify for help paying for your Qualified Health Plan.

Do I need to report changes?

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

  • Has a change in income.

  • Moves.

  • Gets married/divorced.

  • Gets pregnant or a pregnancy ends.

  • Gives birth or adopts a child.

  • Goes to/gets out of jail/prison.

  • Enters a nursing home.

  • Has a change in immigration/citizenship status.

  • Has a change in health care coverage.

  • Has a change in tax filing situation.

These changes during the year can have serious consequences. You could lose your coverage. They can change the cost of your QHP.

If you do not report changes and you should have been paying more for the QHP than you did, you will owe the IRS the difference. If you should have been paying less, you will get credit for the difference on your tax return.

How do I report changes?

Go to your account at www.wahealthplanfinder.org or call a customer support representative at 1-855-923-4633 (1-855-WAFINDER).

How do I pay for my QHP?

You will get bills directly from your health/dental insurance company. You pay the premium directly to the QHP. Payment deadlines vary. If two different companies provide your health and dental insurance, you must make payment to each.

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

What if I cannot make a payment?

Contact the Healthplanfinder to find an In-Person Assister in your area. They may be able to help you pay in a different way (cash/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 QHP in other ways, such as writing a personal check or setting up an automatic debit.

What if I miss a payment?

To keep your QHP and avoid an IRS penalty, you must make your full monthly premium payment on time every month. If you do not get subsidies, you might lose your health coverage after the first missed payment. If you get subsidies, you have a three-month "grace period." If you do not pay the premiums by the end of the grace period, you lose coverage. They may also bill you directly for medical services you used during those months. If your income has dropped since they calculated your premiums, you may qualify for a lower payment.

*If you lose coverage, you cannot get a QHP again until the next annual open enrollment period (unless a special enrollment period applies). You may also have an IRS penalty.

What if I have lost my job?

Tell Healthplanfinder right away. You may be able to start paying less for your QHP, OR you may now qualify for (free) Washington Apple Health coverage.

What if they denied my QHP application?

You should appeal with Healthplanfinder as soon as possible, within 90 days of getting your "Eligibility Decision" packet in the mail from them. Ask for an appeal by

  • Going online at www.wahbexchange.org/appeals.

  • Calling a customer support representative at 1-855-923-4633 (1-855-WAFINDER).

  • Other ways listed in the "Eligibility Decision" packet.

Talk to a lawyer right away.

What if I need a medical service that my QHP does not cover?

Contact your QHP provider right away to file a grievance or appeal. Your plan's customer service hotline can tell you how.
If the plan does not resolve the situation, you have a right to a review by a neutral, independent organization. (See Office of Insurance Commissioner Guide to Appeals.) Talk to a lawyer right away.

Do I have to apply for a QHP every year?

Yes. You must renew your coverage during open enrollment each year. The next open enrollment period is November 1, 2017, through January 15, 2018. If you do not apply during open enrollment and do not qualify to apply during a special enrollment period, you will not be able to get a QHP until the next year. You may owe the IRS for not getting health insurance.

*If you lost coverage during the previous year because you did not pay premiums, the same insurer may deny you coverage until you pay up.

What is a "special enrollment" period?

You can apply for a QHP within 60 calendar days of one of these "special enrollment" events:

  • Losing your job and the affordable health coverage you got through it.

  • Your income goes up and you lose Washington Apple Health coverage.

  • A divorce causes you to lose 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 from another state.

  • They deny your Medicaid application.

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

  • Leaving jail/prison.

  • There was an error in your enrollment process or other special circumstances or complex cases. (See below.)

*Becoming ill is NOT a "special enrollment" event.

Some of these events might have extra requirements. Call Healthplanfinder at 1-855-923-4633 for more info.

Enrolled members of a federally recognized Indian Tribe or Alaska Natives who are shareholders in an Alaska Native Corporation can switch plans as often as once a month. The open and special enrollment periods do not apply to you.

What if I missed open enrollment?

Talk to a lawyer right away about whether you can apply during a special enrollment period. If you qualify for Washington Apple Health, you can apply any time.

"Complex Cases Special Enrollment": If you have a complex case, call 1-855-923-4633 (1-855-WAFINDER) or email customersupport@wahbexchange.org as soon as possible to report your situation. The deadline is generally 60 days from the event. Complex cases include:

  • A natural disaster.

  • Unexpected hospitalization.

  • Misinformation, misrepresentation, or inaction by people/entities helping you enroll.

  • The insurance company did not get your info due to a technical issue.

  • System errors related to immigration status.

  • Display errors on the Healthplanfinder website.

  • Error messages kept you from finishing your application on Healthfinder.

  • You could not submit an application because you could not verify your income.

  • You are a domestic violence survivor trying to enroll in a plan separate from your abuser.

What if my premium is too high or subsidy amount is too low?

You should appeal with Healthplanfinder as soon as possible, within 90 days of getting your "Eligibility Decision" packet in the mail. Ask for an appeal by

  • Going online at www.wahbexchange.org/appeals.

  • Calling the Healthplanfinder at 1-855-923-4633 (1-855-WAFINDER).

  • Other ways listed in the "Eligibility Decision" packet.

Talk to a lawyer right away.

How can I apply for coverage?

  • Through Healthplanfinder at www.wahealthplanfinder.org,

  • By phone at 1-855-923-4633 (1-855-WAFINDER).

  • Using a paper application from Healthplanfinder or your local DSHS office.

Make sure you use the right website (www.wahealthplanfinder.org). Similar sites are copycat scams.

Can I get help applying or understanding my options?

Call an In-Person Assister (Navigator) or an insurance broker. Search for In-Person Assisters at WashingtonLawHelp.org, or go to www.wahealthplanfinder.org and click on the link to search for a navigator/broker in your area.

 

 

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 June 2017.

© 2017 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: Jun 27, 2017
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