Overview of Coverage Options
Washington Apple Health includes 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 for these, you must have low-income or special health needs, such as pregnancy or disability. Apple Health 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. 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.
Qualified Health Plans are commercial (private) health insurance plans that meet health reform standards and offer federal subsidies to help with costs for those that meet income standards. 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. This program is currently 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 Adults: Adults aged 19-64 may qualify for Apple Health. To qualify, you cannot be on Medicare and you must have monthly household income under 138% of the FPL (in 2024: $1,732 for one person, $2,351 for two people). 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 the Apple Health section in Health Care Coverage Options in Washington State. If you have a disability, visual impairment, or are age 65 or older, see Coverage for Those Who Are Over 65, or Have Long-Term Care Needs below.
Apple Health for Families: Medicaid benefits are available to parents and other relatives caring for children through Washington Apple Health for Families. To qualify, you must have monthly household income under $511/month for an individual or $658/month for a 2-person household (in 2024) or experienced a recent increase above that level due to earnings. Since a person whose income increases above that level would also qualify for Apple Health for Adults, this mainly benefits those whose income increases to a level above 138% of the FPL because as custodial parents and relatives, they can get an extension of Medicaid. 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: People who are pregnant or postpartum can get Medicaid through Apple Health for Pregnant Individuals and After Pregnancy Coverage. To qualify, you must have monthly household income under 198% of the FPL (in 2024: $3,373 for two people, $4,260 for three people). In November 2024, the FPL amount will increase to 210%. Note that a pregnant person'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 Washington state resident. You can get After Pregnancy Coverage for up to a year after your pregnancy ends, even if you did not previously have coverage during your pregnancy. Pregnancy and After Pregnancy coverage are available even if your pregnancy ends in miscarriage or abortion.
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, COVID care, and nursing facility care. For more information including new programs for immigrants starting in 2024, see Immigrant Access to Health Care In WA.
What Is Covered?
Enrollees in Apple Health for Adults receive full-scope coverage with a broad range of services; for a list, see those under the "ABP" category.
Enrollees are not required to pay cost sharing, co-payments 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, status as an American Indian/Alaska Native, living in a county where managed care participation is voluntary, or being a Medicare enrollee.
Coverage may be retroactive, up to 3 months before the month you apply. You can use this form to request retroactive coverage.
Other Things to Know
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. You can also apply or renew with in-person assistance with applying or renewing. Find a navigator in your community.
If your family income changes over the year, you may apply based on an average of that income.
Family Planning Coverage:
The Washington State Health Care Authority offers Family Planning Only for individuals not eligible for full Apple Health coverage, individuals age 18 or younger, and others who need confidential services. The income limit is 265% of the FPL ($3,326 month for an individual in 2024) and there is no resource limit. This program is available regardless of immigration status. Individuals can apply through family planning providers or on their own. If you're a teen, you may be eligible for Apple Health coverage on your own. More information is available by calling Washington Healthplanfinder at 1-855-923-4633.
Qualified Health Plans and Other Individual Insurance
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 (some exceptions); 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.
You can shop and apply for coverage at Washington Healthplanfinder. Other individual health insurance plans are available outside the QHP marketplace at full price. Learn more about individual health insurance options.
Coverage for Children
Washington Apple Health for Children (Apple Health for Kids)
Who Is Eligible?
Newborns are automatically eligible when born to a parent who received Apple Health 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 monthly income is less than 317% of the FPL (in 2024: $3,978 for one person, $5,400 for two people). Children under age 6 remain eligible regardless of changes in income. 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 Washington State resident.
What Is Covered?
Enrollees receive Categorically Needy (CN) coverage, which is comprehensive. The general categories of CN service are listed in WAC 182-501-0060(6); all medically necessary services are covered.
Enrollees are not required to pay cost-sharing, co-payments 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, status as an American Indian/Alaska Native, living in a county where managed care participation is voluntary, or being a Medicare enrollee).
Coverage may be retroactive, up to 3 months before you apply. You can use this form to request retroactive coverage.
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
Children and adults can buy Qualified Health Plans if they 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 with some exceptions; not qualifying for public programs like Apple Health (Medicaid and CHIP) or Medicare with some exceptions; and not having an affordable offer of coverage through a parent's employer.
You can shop and apply for coverage at Washington Healthplanfinder. Other individual health insurance plans are available outside the QHP marketplace at full price. Learn more about individual health insurance options.
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 Savings Programs for Low-Income Medicare Enrollees below.
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 is available at the Medicare Interactive website.
Medicare Savings 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) is for those with income at or below 110% of the Federal Poverty Level (in 2024: $1,401 + $20 disregard for one person, $1,894+ $20 disregard for two people). The program pays their Medicare deductibles, co-payments, coinsurance, Parts A and B premiums (or with Medicare Part C, the premiums for Part A and B). They also qualify for Medicare Part D without a premium and lower prescription drug co-payments. There is no longer a resource limit to determine eligibility.
Special Low-Income Medicare Beneficiary (SLMB) is for those with income between 110% and 120% of the Federal Poverty Level (in 2024, $1,526 + $20 disregard for one person, $2,064 + $20 disregard for two people). The program pays their Part B Premiums. They also qualify for Medicare Part D without a premium and lower prescription drug co-payments. There is no longer a resource limit to determine eligibility.
Expanded Special Low-Income Medicare Beneficiary (ESLMB, or "QI-1") is for those with income between 120% and 138% FPL (in 2024, $1,752 + $20 disregard for one person, $2,371 + $20 disregard for two people). The program pays their Medicare Part B premiums (subject to an annual agency funding limit). These individuals also qualify for Medicare Part D without a premium and lower prescription drug co-payments. There is no longer a resource limit to determine eligibility.
Qualified Disabled Working Individuals (QDWI) is for individuals under age 65 with income between 135% and 200% FPL (in 2024, $2,530 + $20 disregard for one person, $3,427 + $20 disregard for two people). The program pays their Medicare Part A premiums. There is no longer a resource limit to determine eligibility.
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.
SSI-Related Categorically Needy Apple Health
Who Is Eligible?
People who are considered disabled (according to Social Security's definition), blind, or are 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 co-payments.
Other Things to Know
Alternate coverage: Apple Health 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 Apple Health 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 have income over the "Medically Needy Income Level" and are age 65 or older, or are considered blind or disabled (according to Social Security’s definition).
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 the chart at 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 2024, $943 + a $20 disregard for one person, called the Medically Needy Income Level or MNIL). You can learn more about the Medically Needy "Spenddown Program.
Those who are also on Medicare (“dual eligibles”) receive most prescription drugs through Medicare Part D and 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: Apple Health for Adults 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.
Other Programs for People with Disabilities
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 Housing and Essential Needs (HEN) or Aged Blind Disabled (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, because you are either over age 65 or you do not meet federal immigration requirements for Medicaid. There are some restrictions on which immigration statuses are included. Income and resource standards apply.
What Is Covered?
MCS covers a more limited range of services than Categorically Needy Medicaid. For example, it does not cover hospice care or personal care services. See the chart at WAC 182-501-0060(6), listing MCS covered service categories.
Retroactive coverage is not available.
Other Things to Know
You can learn more about ABD/HEN or apply for coverage 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.
Health Care for Workers with Disabilities
Who Is Eligible?
Washington state residents who meet federal disability requirements and are employed on a full-time or part-time basis, including self-employed persons can be eligible for the Apple Health for Workers with Disabilities (HWD) Program. Immigration status and other general requirements apply. There is no income limit or upper age limit and no resource limit.
What Is Covered?
Enrollees receive Categorically Needy coverage (CN). The general categories of CN service are listed in the chart at WAC 182-501-0060(6); all medically necessary services are covered.
Enrollees must pay a monthly premium based on their income for the insurance coverage provided by HWD. The maximum premium is 7.5% of counted earned plus unearned income but may be less.
Other Things to Know
Apply for coverage by phone or online. By phone: call 1 (800) 871-9275 to leave a message with designated staff who complete HWD applications. They will contact you directly and check their direct message line daily or you can apply online through Washington Connection.
For more information, see the Health Care Authority’s HWD brochure and eligibility manual.
HWD enrollees can keep savings from their earnings without the risk of losing health coverage if they must switch later to a different Medicaid program with resource limits. These savings must be designated by the enrollee and placed into an account that has no other funds in it. Switching to a different Medicaid program may be necessary if the worker stops meeting the work or any other requirement for the HWD program.
Enrollees are approved for HWD for a 12-month period, effective the first month the enrollee applies and meets the program requirements. If you experience job loss within the 12-month period, you may keep your coverage under HWD if the job loss was the result of an involuntary dismissal or health crisis and you continue to pay your monthly premium.
Retroactive coverage is available for up to 3 months before you apply for the program as long as you met the eligibility requirements during that time. If eligible, you will need to pay premiums for the retroactive coverage.
An individual enrolled in HWD may also receive long term services and supports from the Developmental Disabilities Administration (DDA) or the Aging and Long Term Support Administration (ALTSA) when the person meets the functional requirements for those programs, is approved for those services, and chooses to enroll in HWD.
Updated April 15, 2024.
The information contained on this website is intended for general information only and does not constitute legal advice. For individual legal advice on your particular situation, contact an attorney. CLEAR (Coordinated Legal Education, Advice and Referral) is a toll-free legal hotline for people with low incomes, managed by Northwest Justice Project, an organization providing legal assistance to eligible low-income families and individuals needing help with civil (non-criminal) legal problems in Washington state.