Overview

Washington State has a range of options for residents who need health coverage or assistance with medical costs. These options fall into four general categories:

Washington Apple Health, including Medicaid, CHIP, and state programs. Medicaid and CHIP are medical insurance programs administered by the state and funded by the federal government and the state. The state also funds some programs and services separately. To qualify, you must have low-income or special health needs, such as pregnancy or disability. In Washington, Medicaid, CHIP, and state medical programs are also known “Washington Apple Health.” These programs are run by the state’s Health Care Authority (HCA) and Department of Social and Health Services (DSHS), in partnership with the state’s Health Benefit Exchange (known as Washington Healthplanfinder). You can apply for these programs through Washington Healthplanfinder, but some programs may require additional screening by DSHS.

Medicare is a medical insurance program administered and funded by the federal government, not the state. To qualify, you must be on Social Security Disability or Retirement Benefits (Title II). This program is run through the federal Social Security Administration, which is also where you can apply. Some Medicare enrollees purchase supplemental insurance through the Washington State Health Insurance Pool (below).

Qualified Health Plans are private health insurance plans that meet special health reform standards and offer federal subsidies to help with costs. To qualify for subsidies, you must have low-to-moderate income. These plans are regulated by the Office of Insurance Commissioner and the Health Benefit Exchange. You can buy these plans through the Washington Healthplanfinder.

Commercial Insurance Plans are private health insurance plans for individuals or employers. These plans are regulated by the Office of Insurance Commissioner. You can buy these plans directly from insurance companies or insurance brokers.

Washington State Health Insurance Pool is a health insurance program for persons with significant medical needs or seeking coverage to supplement Medicare. As of January 1, 2014, this program was largely closed to new enrollees, except the Medicare supplement program.

Coverage for Adults

Washington Apple Health for Families, Pregnant Women, and Adults

Who Is Eligible?

Apple Health for Families: Parents and other relatives caring for children can get Medicaid through Washington Apple Health for Families. To qualify, you must have household income under 54% of the Federal Poverty Level ( FPL) or experienced a recent increase above that level due to earnings or child support. You must also meet other requirements to be eligible, such as US citizenship or qualifying immigration status, and state residency. Adults and children who are not eligible may still qualify for the Apple Health programs below.

Apple Health for Pregnant Women: Pregnant women can get Medicaid through Apple Health for Pregnant Women. To qualify, you must have household income under 198% of the FPL (note that a pregnant woman's household size is increased by the number of unborn children). You do not need to be a citizen or have a qualifying immigration status to be eligible, but you must be a state resident.

Apple Health for Adults: Other adults aged 19-64 may qualify for Medicaid through Apple Health for Adults. To qualify, you cannot be on Medicare and you must have household income under 138% of the FPL. You must also meet other requirements to qualify, such as US citizenship or qualifying immigrant status, and state residency. Enrollment in Apple Health for Adults is year round—you can apply any time. For more information, see Health Care Reform –Medicaid Expansion. If disabled, blind, or age 65 or older, see Coverage for People Who Are Over 65, Have Disabilities, or Have Long-Term Care Needs.

Coverage for Immigrants: Alien Emergency Medical (AEM) offers limited coverage for other immigrants who have an emergency medical condition. These programs are available for emergency hospital care, cancer treatment, kidney dialysis and nursing facility care. For more information, see Health Care Reform: Immigrant Eligibility.

What Is Covered?

Enrollees in Apple Health for Adults receive the Alternative Benefits Plan (ABP) scope of coverage. The scope of coverage under ABP is similar to CN coverage. The benefit package may differ slightly from that for adults qualifying under other programs.

Enrollees are not required to pay cost sharing, copayments or deductibles for any service.

Enrollees are usually required to be in a managed care plan called Apple Health Managed Care. This means you must have a primary provider who is the gatekeeper to other medical providers, and the plan determines which providers will be covered under their plan. There are exemptions from Apple Health Managed Care for certain reasons, such as the need to continue with a treating provider, homeless, or private insurance other than Apple Health (Medicaid). For more information, see Apple Health Managed Care & Your Rights.

Coverage may be retroactive, up to 3 months before the month you apply.

Other Things to Know

For Apple Health for Pregnant Women, coverage can start at any point during your pregnancy and lasts for two months after the pregnancy ends or baby is born. You can then transition to another Apple Health program or other insurance.

Pregnant teens under age 19 can apply on their own without their parents. They must use a paper application to apply, available from the Health Care Authority.

There are no time limits, work requirements or limits on resources you can own.

You can apply for Apple Health coverage year round or renew your coverage through Washington Healthplanfinder (www.wahealthplanfinder.org). You can also apply or renew with in-person assistance with applying or renewing. Find a navigator in your community by clicking here.

If your family income changes over the year, you may apply based on an average of that income.

Qualified Health Plans and other Individual Insurance

Who is Eligible?

Adults and children can buy private health insurance known as Qualified Health Plans (QHPs) if they are US citizens or have a qualifying immigration status, are state residents, and are not in jail/prison.

Adults and children can get subsidies to help with the costs of buying a QHP if they meet other requirements, including: having household income under 400% of the Federal Poverty Level ; not qualifying for public programs like Apple Health (Medicaid and CHIP) and Medicare (some exceptions); not having an affordable offer of coverage through an employer; and filing taxes (jointly if married).

You can enroll in QHP coverage only if you apply during open enrollment, unless you have a life event that qualifies you for a Special Enrollment Period [MAKE THIS A PDF LINK]. The current open enrollment period started November 1 and continues through January 31,2016. You can shop and apply for coverage at the Washington Healthplanfinder. Other individual health insurance plans are available outside the QHP marketplace at full price.

Coverage for Children

Washington Apple Health for Children (Apple Health for Kids)

Who is Eligible?

Newborns are automatically eligible if their mother received WAH at the time of the child's birth. The eligibility will last for 12 months.

Children under age 19 may be eligible if their family’s income is less than 317% of the FPL. To be eligible above 215% of FPL, children must not be covered by other insurance, and families must pay a monthly premium to HCA (between $20-30 per child). You do not need to provide a citizenship or immigrant status to be eligible, but you must be a state resident.

What Is Covered?

Enrollees receive Categorically Needy (CN) coverage, which is comprehensive. The general categories of CN service are listed inWAC 182-501-0060(6); all medically necessary services are covered.

Enrollees are not required to pay cost sharing, copayments or deductibles for any service.

Enrollees are usually required to be in a managed care plan called Apple Health Managed Care. This means you must have a primary provider who is the gatekeeper to other medical providers, and the plan determines which providers will be covered under their plan. There are exemptions from Apple Health Managed Care for certain reasons, such as being a foster child or children with special health care needs.

Coverage may be retroactive, up to 3 months before you apply.

Other Things to Know

There are no time limits, work requirements, or limits on assets you can own.

Apply for coverage and renew coverage through Washington Healthplanfinder.

If your family income changes over the year, you may apply based on an average of that income.

Qualified Health Plans and Other Individual Insurance

Who Is Eligible?

Children and adults can buy Qualified Health Plans if they are US citizens or have an eligible immigration status, are state residents, and are not in jail/prison.

Children and adults can get subsidies to help with the costs of buying a Qualified Health Plan if they meet other requirements, including: having household income below 400% of the Federal Poverty Level; not qualifying for public programs like Apple Health (Medicaid and CHIP) or Medicare (some exceptions); and not having an affordable offer of coverage through a parent's employer.

QHP coverage became available January 1, 2014. The next open enrollment period runs from 11/1/15 through 1/31/16 but in some cases you can apply before or after those dates. Other individual health insurance plans are available outside the QHP marketplace at full price.

Coverage for those who are over 65, have Disabilities, or Long-Term Care Needs

Medicare for Aged or Disabled

Who is Eligible?

Coverage begins at age 65, or two years after an individual becomes eligible for Social Security Disability Insurance (SSDI) benefits.

There are no financial eligibility requirements.

 

What Is Covered?

Hospital Insurance—Part A: Covers some of the cost of hospital and related care, home health care, hospice care and care in a skilled nursing facility following a hospital stay.

Medical Insurance—Part B: Covers some of the cost of physician visits, outpatient hospital services, and other services. Preventive care is provided without cost-sharing. In addition, Medicare requires recipients to pay premiums, deductibles, and co-payments. These premiums may be deducted from the recipient’s monthly Social Security check. For those who qualify, Medicaid will cover these premiums and many of the costs not paid by Medicare. See Medicare Buy-in Programs [NEED LINK DOWN PAGE HERE].

Prescription drugs –Part D: Provides some coverage for prescription drugs. Enrollees must select a Prescription Drug Plan available in the region; each plan has its own drug formulary. “Dual eligibles” and others with limited income qualify for “extra help”— a Part D subsidy from the federal government.

 

Other Things To Know

Apply for coverage and learn more through the federal Medicare website.

Additional information at the Medicare Rights Center website.

Medicare Buy-in Programs for Low-Income Medicare Enrollees

These Washington Apple Health (Medicaid) programs pay Medicare premiums and cost-sharing for very low-income individuals.

 

Who Is Eligible and What is Covered?

Qualified Medicare Beneficiary (QMB): An individual with income at or below 100% Federal Poverty Level (in 2015: $981 + $20 disregard for one person, $1,328 + $20 disregard for two people) can get assistance with their Medicare deductibles, co-payments, Part B premiums, or with Medicare Part C premiums for Part A and B. They automatically get Medicare Part D without a premium and lower co payments. The resource limit is $7,280 for an individual and $10,930 for a couple in 2015.

Special Low-Income Medicare Beneficiary (SLMB): An individual with income between 100% the Federal Poverty level and 120% of the Federal Poverty Level (in 2015, $1,177 +$20 disregard for one person, $1,593 + $20 disregard for two people) can get funding for their Part B Premiums. They automatically get Medicare Part D without a premium and lower co payments. The resource limit is $7,280 for an individual and $10,930 for a couple in 2015.

Expanded Special Low-Income Medicare Beneficiary (ESLMB, or "QI-1"); and Qualified Disabled Working Individual (QDWI) are for those with income between 120% and 200% FPL. QI-1 clients have income below 135% FPL (in 2015, $1,325 for one person, $1,793 for two people) and qualify for Medicare Part D zero premium and lower co-payments. The resource limit is $7,280 for an individual and $10,930 for a couple in 2015.

 

Other Things to Know

Apply for coverage by filling out a Supplemental Application through DSHS, online at Washington Connection or at a Community Services Office.

Washington Apple Health (Medicaid) Programs for people who are Disabled, Blind, or Age 65 or Older

SSI-Related Categorically Needy WAH

Who Is Eligible?

People who are disabled (according to Social Security's definition), blind, or age 65 or older and have limited income and resources.

Some people with income over the SSI limit (such as disabled widows/widowers) also qualify.

Immigration status requirements apply.

What is Covered

Enrollees receive Categorically Needy (CN) coverage. The general categories of CN service are listed in WAC 182-501-0060(6).

Coverage goes back to the date of application, once it is approved. Retroactive coverage is available if disability is established.

There are no co-payments or deductibles for this program.

Some people on SSI-related Medicaid also receive Medicare coverage. For these "dual eligibles," most prescription drugs are available only through Medicare Part D, and they are required to pay small copayments.

Other Things to Know

Alternate coverage: WAH for Adults is also available for individuals in this income range who are under age 65 and not on Medicare, without the need to meet disability or other SSI-related requirements.

Apply for coverage through Washington Healthplanfinder. If you state you have a disability on the application, you will be asked to fill out a Supplemental Application through DSHS. If eligible you will receive WAH for Adults pending the DSHS determination.

Medically Needy Washington Apple Health for People Not on SSI, but Aged or Disabled

Who is eligible?

People who are over age 65, blind or disabled (according to Social Security’s definition), who have income over the "Medically Needy Income Level"

Resource limits apply.

Immigration status requirements apply.

What Is Covered?

Enrollees receive Medically Needy (MN) coverage. The general categories of MN service are listed in WAC 182-501-0060(6).

The state does not provide coverage until you incur a specified level of medical costs, called a “spenddown” amount. The spenddown amount is based on income. it is the amount by which countable income exceeds a certain income level (in 2015, $733 + a $20 disregard for one person, called the Medically Needy Income Level or MNIL). You can learn more about spenddown here.

Those who are also on Medicare (“dual eligibles”) receive most prescription drugs  through Medicare Part D, and they are required to pay co-payments that vary according to income.

Other Things to Know

Apply for coverage through Washington Healthplanfinder. If you state you have a disability on the application, you will be asked to fill out a Supplemental Application through DSHS.

Alternate coverage: WAH for Adults [LINK TO PAGE HERE] may also be available without the need to meet disability or other SSI-related requirements, for adults under age 65 and not on Medicare, with income below 138% FPL. Qualified Health Plan coverage with subsidies is an option for some adults above 138% FPL not on Medicare. In some cases this may cost less than Medically Needy coverage. For more information, see The Medically Needy Spenddown Program.

Other Programs for People with Disabilities

Medical Care Services

Who Is Eligible?

Low-income persons who receive ABD or HEN financial assistance and do not qualify for Medicaid, usually due to their immigration status, are in these programs.

Medical Care Services for Immigrants who are over age 65 or incapacitated

Who Is Eligible?

People whom the state does not expect to qualify for Medicaid, but who meet the incapacity or age standards of the HEN or ABD program, can get Medical Care Services (MCS) coverage through the Department of Social and Health Services.

To qualify, you must receive HEN or ABD and be ineligible for an adult Medicaid program, either because you are over age 65 or an immigrant who is lawfully present but does not meet federal immigration requirements for Medicaid. Income and resource standards apply.

 

What Is Covered?

MCS covers a more limited range of services than Categorically Needy Medicaid. It does not cover: hospice care or non-institutional personal care services. See WAC 182-501-0060(6), listing MCS covered service categories.

Retroactive coverage is not available.

 

Other Things to Know

Apply for coverage for ABD/HEN at a DSHS Community Services Office. You will also be screened for Medicaid and MCS when you apply for these programs.

Washington Healthplanfinder does not yet screen for MCS eligibility, but if it identifies you as potentially eligible, you may receive a letter about how to apply through DSHS.