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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

Please Note:

  • Read this only if you live in Washington State.

Introduction

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

It depends.

All these must be true:

It depends.

All these must be true:

  • You qualify to get coverage through a QHP. See above.
  • Your job does not offer affordable coverage at a certain level (see below) or you are not eligible to get government health insurance such as Medicare or Tricare.
  • You have limited household income, or you are a lawfully present immigrant who is not eligible to get Apple Health and you have limited income.
  • You file taxes.
  • You are married. You file taxes jointly with your spouse.

Maybe. If the insurance is not minimum value, affordable health coverage, you might qualify to get help paying for a QHP. If you do, 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 9.78% or less of your household income.

  • Household income is the incomes of the person filing taxes for your household and their tax dependents.

If you have minimum value, affordable coverage through your job and you can buy health insurance from your job for your spouse and dependents, then the coverage is "affordable" for them, too.

This is true even if the cost for their insurance plus yours is more than 9.78% of your household income. Your spouse and dependents can buy a QHP instead. They cannot get help paying for it.

There are two kinds of help: subsidies or cost-sharing reductions.

 

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. Alternatively, 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.

To learn if you can use Washington Healthplanfinder to sign up for market coverage or Apple Health (Medicaid) now that federal "public charge" rules are in effect, visit WA Healthplan Finder.

  • You can get help with Healthplanfinder Open Enrollment from a certified Navigator.

Applying

You can apply and get subsidies through Healthplanfinder. It is run by the Washington Health Benefit Exchange. To apply, you can do any of these:

  • Go online at WA Healthplan Finder. Make sure you correctly type the site name. Similar sites are copycat scams.
  • Call 1-855-923-4633.
  • Get a paper application from DSHS or Healthplanfinder.

If you need help applying, call the number above, email customersupport@wahbexchange.org, or ask your local DSHS office for help. Find your local DSHS office.

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 most recent enrollment period was November 1, 2021 – January 15, 2022. You can expect the next enrollment period to start November 1, 2022.

After you are approved

The next Open Enrollment period should be November 1, 2022 – January 15, 2023. Apply by December 15 for coverage starting January 1.  

Report this as soon as possible. Call 1-855-923-4633 or email customersupport@wahbexchange.org.

Maybe 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.

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.

Bronze plans generally have the lowest monthly premiums but highest out-of-pocket expenses. You might choose it for the low premiums, but have high out-of-pocket costs and you do not qualify for cost-sharing reductions. See above.

The Silver plan may be better for you. Out-of-pocket expenses are lower. You can get tax credits and cost-sharing reductions. Generally, Silver's monthly premiums are higher than Bronze's, 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 (read Requirement to Get Health Coverage), you can get a catastrophic plan. These cost less. Their benefits are limited.

It must include these benefits:

  • Doctor visits
  • ER (emergency room) care
  • Hospitalization
  • Prescription drugs
  • Maternity and newborn care
  • Mental health and substance use disorder services
  • Rehab and habilitation if you are hurt or have a disability or chronic condition
  • Lab services, like X-rays
  • Preventive care and chronic disease management
  • Pediatric care, including dental and vision care

Some health plans may also offer other benefits under Washington State law.

Your QHP does not include:

  • Adult dental or 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.

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 can cover:

  • Just adults
  • Adults and children
  • Children only

Any tax credits you are eligible for apply to the health plan only. They do not apply to the dental plan.

Maybe. You can check when searching plans at WA Healthplan Finder. You can also call customer support at 1-855-923-4633 to ask them, or ask your doctors which plans they accept.

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

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

  • Has a change in income.
  • Moves.
  • Gets married or divorced.
  • Gets pregnant or a pregnancy ends, gives birth or adopts a child.
  • A child on your plan is turning or has turned 26 years old.
  • Dies.
  • Adds or removes a dependent.
  • Goes to or gets out of 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.
  • Is American Indian or an Alaskan Native tribal member.

These changes during the year could cause you to 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, you could owe the IRS. If you should have been paying less, you will get credit for the difference on your tax return.

Go to your account at WA Healthplan Finder 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.

If you have problems

Contact the Healthplanfinder. Ask about an In-Person Assister in your area. They might be able to help you pay in a different way, such as cash or money order. They might be able to find a sponsor to pay for you. You should also talk to a lawyer right away.

After your first payment, you can pay for your QHP in other ways. You can write a personal check or set up an automatic debit.

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 3-month "grace period." If you do not pay the premiums by the end of the grace period, you lose coverage. They might bill you directly for medical services you used during those months. If your income has dropped since they calculated your premiums, you might qualify for a lower payment.

  • If you lose coverage, you cannot get a QHP again until the next open enrollment period, unless a special enrollment period applies. You may also have an IRS penalty if you lost coverage in 2018 and earlier.

Tell Healthplanfinder right away. You may be able to start paying less for your QHP, or you may now qualify for Apple Health.

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

  • Going online at WA Health Benefit Exchange.
  • Calling customer support at 1-855-923-4633.
  • Other ways listed in the "Eligibility Decision" packet.

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 a neutral, independent organization. Read Office of Insurance Commissioner Guide to Appeals. Talk to a lawyer right away.

Yes. You must renew your coverage during open enrollment each year. The next open enrollment period is November 1, 2020, to January 15, 2021.

Apply by December 15 for coverage starting January 1. If you do not apply during open enrollment and do not qualify to apply during a special enrollment period, you cannot get a QHP until the next year.  

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

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

  • Losing your job and the affordable health insurance you got through it.
  • Your income goes up. You lose Apple Health.
  • You lose your health insurance in a divorce.
  • Getting citizenship or lawfully present immigration status.
  • Gaining a new dependent, such as a new baby.
  • Getting married.
  • Moving into Washington from another state.
  • Your Medicaid application is denied.
  • Moving away to a new area offering different health plan options.
  • Getting out of jail or prison.
  • An error in your enrollment process, other special circumstances, or complex cases. See below.

* Becoming ill is not a special enrollment event.

There may be extra requirements. Call Healthplanfinder at 1-855-923-4633 for more.

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.

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

Special Circumstances Special Enrollment: If you have a complex case, call 1-855-923-4633 or email customersupport@wahbexchange.org right away. The deadline is generally 60 days from the event. Complex cases include:

  • Natural disaster.
  • Unexpected hospitalization.
  • Misinformation, misrepresentation, or inaction by anyone helping you enroll.
  • The insurance company did not get your information 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 Healthplanfinder.
  • You could not apply because you could not verify your income.
  • You are a domestic violence survivor. You are trying to enroll in a plan separate from your abuser.
  • You bought coverage that you discovered was fraudulent after open enrollment.

* Read Can I Still Enroll in Health Coverage?

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

  • Going online at WA Health Benefit Exchange.
  • Calling Healthplanfinder at 1-855-923-4633.
  • Other ways listed in the "Eligibility Decision" packet.

Talk to a lawyer right away.

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Last Review and Update: Feb 15, 2022
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