Qualified Health Plans

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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”). #5708EN

Part 1. Introduction

It is a state-approved private health insurance plan. You buy it through Healthplanfinder.

Yes, if all these are true about you:

You must qualify financially. You should apply to see if you qualify. 

Maybe. If the insurance is not minimum value, affordable coverage, you might qualify to get help paying for a QHP.

If you do qualify for this kind of help, a QHP might cost less than the insurance through your job.

There are now 3 kinds of help: subsidies, cost-sharing reductions, and premium assistance.

Subsidies are also called health insurance premium tax credits. They help pay for your premium. Your premium is what you pay every month to have health insurance.

You can get the subsidy monthly so your premium costs less each month. Or you can get it in a 1-time tax refund payment at the end of the year.

Enrolled members of federally recognized Indian Tribes or Alaska Natives who are shareholders in an Alaska Native Corporation with limited household income can get a special subsidy. You pay no out-of-pocket costs after your monthly premium payment.

They help pay out-of-pocket expenses like co-payments and deductibles. You can get cost-sharing reductions if you qualify financially, and you choose a Silver plan. (See "Can I choose my QHP," below.)

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.

If you meet the income requirements for this help, you can get it in addition to the subsidies mentioned above. This assistance also lowers the cost of your monthly premium.

You can get premium assistance if you choose a plan that has this assistance anytime. These plans have the word Cascade in their name.

Part 2. Applying

You can apply online at wahealthplanfinder.org, by calling 1-855-923-4633, or you can ask for a paper application from DSHS or Healthplanfinder.

Yes. There are Navigators and others who are qualified to help you enroll.

Generally, no. However, you might qualify for Apple Health or a "special enrollment period" (exception) might apply to you. See below.

Healthplanfinder generally only takes applications during an open enrollment period. The next enrollment period will start November 1, 2023.

Part 3. After you are approved

Yes. Different companies offer different "metal" levels of plans (Bronze, Silver, Gold, or Platinum). You must decide which plan is right for your budget and health needs.

If you are under age 30, you can get a catastrophic plan. These cost less. Their benefits are limited.

Yes. You can search for and enroll in dental plans on Healthplanfinder. But any tax credits you are eligible for apply to the health plan only.

Maybe. You can check when searching plans at wahealthplanfinder.org. You can also call customer support at 1-855-923-4633 to ask them. You can also ask your doctors which plans they accept.

It depends on which one you choose. You may be able to get help paying for it. See above.

Yes. You should report immediately any change in your household income or size, if a child on your plan is turning 26 years old, or if a household member has a change in immigration or citizen status, health care coverage, or tax filing situation.

These changes during the year could cause you to lose your coverage. Or they can change the cost of your QHP.

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

Go to your account at wahealthplanfinder.org or call customer support at 1-855-923-4633.

You get bills directly from your health or dental insurance company. You pay the premium directly to the QHP. Payment deadlines vary. If 2 different companies provide your health and dental insurance, you must pay each.

Ask your health or dental insurance company about billing, payment deadlines, or grace periods.

Part 4. If you have problems

Find help near you. Persons qualified to help might be able to help you figure out your options. You should also talk to a lawyer right away.

If you do not get subsidies, you might lose your health coverage after the first missed payment. If you get subsidies, you have 3 months to pay the premiums. They might bill you directly for medical services you used during those months.

You should appeal with Healthplanfinder within 90 days of getting your "Eligibility Decision" packet in the mail from them. You can ask for an appeal online, by calling customer support at 1-855-923-4633, or through one of the other ways listed in the "Eligibility Decision" packet.

You should also talk to a lawyer right away.

Contact your QHP provider right away to file a grievance or appeal. Ask the plan's customer support how.

If that does not take care of it, you can ask for a review by an independent organization. Read Office of Insurance Commissioner Guide to Appeals to learn more. You should also talk to a lawyer right away.

Yes. You must renew your coverage during open enrollment each year.

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

You don't have to wait for open enrollment in certain situations, such as getting married, having a baby, or being released from prison. Read a longer list of examples and see if you qualify for special enrollment.

Enrolled members of a federally recognized Indian Tribe or Alaska Natives who are shareholders in an Alaska Native Corporation can switch plans monthly. Open and special enrollment periods do not apply to you.

You might be able to apply during a special enrollment period. If you qualify for Apple Health, you can apply any time.

p>You should appeal with Healthplanfinder within 90 days of getting your "Eligibility Decision" packet in the mail. You can ask for an appeal online, by calling Healthplanfinder at 1-855-923-4633, or through other ways listed in the "Eligibility Decision" packet.

You should also talk to a lawyer right away. 

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Last Review and Update: Feb 13, 2023
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