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.