Qualified Health Plans
Authored By: Northwest Justice Project
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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
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 your needs, you might have options. You may be able to get free insurance: Apple Health (Washington Apple Health). Read Health Care Reform – General Information.
*Read this only if you live in the state of Washington.
*You can find all the fact sheets we link to here at WashingtonLawHelp.org.
Can I get a QHP?
Yes, if all these are true:
You are a U.S. citizen or have an eligible immigration status. Read Health Care Reform – Immigrant Eligibility.
You live in the state of Washington.
You are not in jail or 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) OR you are not otherwise eligible for a government health insurance plan such as Medicare or Tricare.
Your household 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. You 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 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. It does not include dependents who do not earn enough to file a tax return.
Does getting 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 and 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 9.78% of your household income. Your spouse and dependents can buy a QHP instead. They cannot get help paying for it.
I qualify to get help paying for a QHP. How does this work?
There are 2 kinds of help: subsidies or cost-sharing reductions.
How do subsidies work?
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 one-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.
How do cost-sharing reductions work?
They help pay out-of-pocket expenses like co-payments and deductibles. You can get cost-sharing reductions if you are financially eligible 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.
I am an immigrant with lawful status. Is it okay for me to apply for a QHP?
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.
Part 2. Applying
How do I apply for a QHP?
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:
Get a paper application from DSHS or Healthplanfinder.
Can I get help applying?
If you need help applying, call the number above, email email@example.com, or ask your local DSHS office for help. They can help you find an In-Person Assister. This is someone in your community trained to help you. Find your local DSHS office.
Can I apply anytime?
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 open enrollment should be November 1, 2020 - December 15, 2020.
Part 3. After you are approved
When does coverage start?
For your coverage to start the next month, you must enroll by the 15th of the current month.
The next Open Enrollment period should be November 1, 2020 - December 15, 2020. For coverage to start on January 1, 2021, you must apply by December 15, 2020.
I did not finish my application before December 15, 2020. I had problems with the website or contacting the call center.
Report this 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 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 have very 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.
*The federal government no longer gives states money for cost-sharing reductions. There are still cost-sharing reductions in Washington, but Silver plan premiums have gone up. Review the premium and out-of-pocket amounts carefully.
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.
What will my QHP cover?
It must include these Essential Health Benefits:
ER (emergency room) care
Maternity and newborn care
Mental health and substance use disorder services
Rehabilitation and habilitation if you are injured 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 per Washington state law.
What will a QHP not cover?
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.
Can I get a dental plan?
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
Adults and children
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. You can also call customer support at 1-855-923-4633 to ask them, or ask your doctors which plans they accept.
How much will a QHP cost?
It depends which one you choose. You may be able to get help paying for it. See above.
Do I need to report changes?
Yes. You should report immediately if you or someone in your household:
Has a change in income.
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.
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 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 could 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 or call customer support at 1-855-923-4633.
How do I pay for my QHP?
You will get bills directly from your health or 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 pay each.
*Ask your health or dental insurance company about billing, payment deadlines, or grace periods.
Part 4. If you have problems
I cannot make a payment.
Contact the Healthplanfinder. Ask about an In-Person Assister in your area. They might be able to help you pay in a different way (cash or 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?
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 annual open enrollment period, unless a special enrollment period applies. You may also have an IRS penalty if you lost coverage in 2018 and earlier.
I 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.
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
Calling customer support at 1-855-923-4633.
Other ways listed in the “Eligibility Decision” packet.
Talk to a lawyer right away.
My QHP does not cover a medical service I need.
Contact your QHP provider right away to file a grievance or appeal. Your plan’s customer service hotline can tell you 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.
What my QHP does not cover a medical service I need?
Contact your QHP provider right away to file a grievance or appeal. The plan’s customer support can tell you how.
If that does not resolve the situation, you have a right to a review by a neutral, independent organization. Read 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 expected to be November 1, 2019, - December 15, 2019. 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 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. 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.
Moving into Washington from another state.
They deny your Medicaid application.
Permanently moving to a new area offering different health plan options.
Leaving jail or 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 monthly. Open and special enrollment periods do not apply to you.
I missed open enrollment.
Talk to a lawyer right away about if you can apply during a special enrollment period. If you qualify for Washington Apple Health, you can apply any time.
Special Circumstances Special Enrollment: If you have a complex case, call 1-855-923-4633 or email firstname.lastname@example.org as soon as possible to report your situation. The deadline is generally 60 days from the event. Complex cases include:
Misinformation, misrepresentation, or inaction by people or 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 Healthplanfinder.
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.
You bought fraudulent coverage. You did not become aware it was fraudulent until after open enrollment.
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
Calling Healthplanfinder at 1-855-923-4633.
Other ways listed in the “Eligibility Decision” packet.
Talk to a lawyer right away.
How can I apply for coverage?
- Through Healthplanfinder.
- By phone at 1-855-923-4633.
- Using a paper application from Healthplanfinder or your local DSHS office.
Make sure you use www.wahealthplanfinder.org. Similar sites are copycat scams.
Can I get help applying or understanding my options?
Call an In-Person Assister (Navigator) or insurance broker. 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 search for a navigator or broker in your area.