Washington State residents have several options for obtaining health insurance coverage. If you do not have health insurance through your employer or government programs, you can buy insurance for yourself and your family through the “individual insurance market.”

This page provides information about applying for and comparing individual insurance plans in Washington, including through the state’s official health plan marketplace, Washington Healthplanfinder. You may also find this resource on other health care coverage options in Washington helpful.

Is Individual Health Insurance the Right Option?

Individual health insurance is one of several health coverage options for Washington residents. Most Washington residents get health insurance through an employer or government source. If you have other coverage options, you may not need to buy individual insurance. For example:

• Employer-Sponsored Insurance. If you have affordable insurance available through an employer, you still can buy individual insurance as supplemental coverage, but you may not qualify for government financial assistance.
• Medicaid (Apple Health). If you are eligible for Medicaid, called Apple Health, you do not need to buy individual insurance. Apple Health provides free coverage to individuals and families with annual incomes below 138% of the Federal Poverty Level ($20,784 for an individual and $43,056 for a family of four in 2024).¹ There are higher income levels for children,  pregnancy/postpartum, and certain other circumstances – for more information, see NoHLA's general overview for an overview and this information from the Washington Health Care Authority (HCA). If you are eligible, you can keep employer or other coverage that you have and still get Apple Health.
• Medicare. If you are over the age of 65 or have qualified for Social Security Disability Insurance benefits for more than two years, you are probably eligible for Medicare. You may want to consider supplementing that policy since you are still responsible for some costs. However, Medicare enrollees do not need to purchase full individual insurance.

NoHLA provides more information about these and other coverage options.

If you don’t have health insurance through another source, an individual health plan may be right for you. While there is no longer a tax penalty for being uninsured, health plans can offer important financial protection when you need health care.

Individual Insurance: What Are Your Choices?

There are two ways for Washington residents to buy an individual health plan: through the state’s official “Exchange” website (Washington Healthplanfinder) or “off-Exchange” directly with an insurance company. Most people choose to apply through the state Exchange website.

The Washington Health Benefit Exchange Marketplace

Washington residents can compare and shop for health insurance through the state Health Benefit Exchange website, Washington Healthplanfinder, that offers health and dental plans that meet the health reform standards of the Affordable Care Act. Learn more about these Qualified Health Plans or QHPs.

Applying for coverage through Washington Healthplanfinder is the best way to learn if you qualify for a free or reduced-cost plan. When you apply through Washington Healthplanfinder, the application will ask questions about your household and finances to see if you qualify for many different health coverage programs, including the free Apple Health (Medicaid) program or a reduced-cost private plan. If you qualify for a reduced-cost private plan, Washington Healthplanfinder will help you find plans that have lower costs due to federal and state financial assistance (subsidy) programs, such as:

• Federal premium tax credits. Federal tax credits reduce the cost of your monthly premium You can be eligible for federal premium tax credits with an income below 400% of the Federal Poverty Level ($58,320 for an individual or $120,000 for a family of four in 2024) or in some cases higher income in 2024 and 2025 due to temporary increases in the available premium tax credits.²   This KFF article explains how the tax credits work. You can choose to have your tax credit sent directly to your health plan to reduce your premiums, or you can pay more each month and get your tax credit at tax time instead. If you take the full credit up front, you must report any subsequent changes in income or else you may need to repay some of the tax credit at tax time.
• State premium assistance. State premium assistance also helps reduce the cost of your monthly premium, if you select certain “Cascade Care Savings” gold or silver plans and have income below 250% of the Federal Poverty Level ($36,450 for an individual or $75,000 for a family of four in 2024).²
• Cost sharing reductions. You can also qualify for reduced cost-sharing if you select a silver plan and have income below 250% of the Federal Poverty Level ($36,450 for an individual or $75,000 for a family of four in 2024).² This will help lower your deductible, copayments, and coinsurance when you visit the doctor or fill prescriptions.
• Other financial assistance programs. There are also other financial assistance options available for certain Washington residents, such as people who are tribal members or people who work at licensed child care centers.

Note: In November 2023, undocumented people became eligible to buy private health plans through the Exchange and Washington Healthplanfinder for the first time. Learn more from NoHLA’s Immigrant Access to Health Care in Washington State publication.

Buying Coverage Directly from an Insurer

As an alternative to the Exchange, you can buy insurance directly from insurance companies that operate plans outside the Exchange. These plans are available to all state residents, including undocumented people, but do not provide financial assistance to help with the costs of coverage.

You may wish to buy health insurance directly from an insurance company if your doctor or provider is not available through any of the Exchange health plans but is available through a plan sold directly by an insurer. If you are considering doing this, ask your providers which plans they participate in before enrolling, make sure you understand any limitations on short-term plans, and beware of “scam plans” that do not meet minimum federal and state standards. You can get assistance with enrollment from a licensed insurance broker and the Office of the Insurance Commissioner (OIC) provides information on how to select a broker.

The OIC provides a list of plans that are offered in the different regions of the state with information about the individual and family premiums that is updated annually.

When Should You Enroll in a Plan?

Usually, you need to enroll in health insurance and renew your coverage during the annual open enrollment period. Open enrollment for individual plans typically runs from November 1 – January 15 each year, though dates may vary. Apply by December 15 for coverage starting January 1 and apply by January 15 for coverage starting February 1.

You can only enroll in insurance outside of the open enrollment period if your household has a qualifying event or special circumstance that makes you eligible for a special enrollment period.

How Much Will You Pay for Insurance?

Seeing a doctor or filling a prescription at a pharmacy can be very expensive.  When you buy health insurance, you agree to pay a monthly premium, and in return, the insurance company agrees to pay part of the cost of your medical bills for covered benefits.

Not every health insurance plan helps you pay your bills in exactly the same way. There are differences between plans that affect how much you will need to pay for your health care, and it is important to keep track of each of them when comparing plans. These include monthly premiums, cost-sharing when you get services, and out-of-network charges). Here are some considerations:

Monthly Premiums

When you buy health insurance you will need to pay premiums each month to keep your coverage. The premiums need to be paid monthly, before the month you want coverage, regardless of whether you use the insurance or not. In general, the higher the monthly premium for a plan, the lower the average cost-sharing when you access care.

Cost-sharing. When you buy healthcare services with insurance, the insurance company will pay a portion of the bill from your medical provider and you will be responsible for the rest of the bill. The amount of the bill that you pay is called “cost-sharing.”

There are three main types of cost-sharing: co-payments, co-insurance, and deductibles.

• A co-payment (also called a co-pay) is a set amount of money you pay for a healthcare service covered by the plan, such as $20 for a prescription.
• Co-insurance is the percentage you pay of the total cost of a service covered by the plan, such as 20% of the cost of an office visit.
• A deductible is another type of cost-sharing. It is an amount of money that you must spend on healthcare in a year before your health insurance company will begin helping you pay your bills for healthcare services. For example, if your plan has a $1,000 deductible, you will be responsible for 100% of the first $1,000 that you spend on health care every year (some services are exempt from the deductible). Once you have spent $1,000, the insurance company will begin paying your bills, except for your co-payments and co-insurance amounts. Sometimes, your plan will have a deductible on certain services and not others.

“Out-of-pocket” refers to the amount of cost-sharing you can be required to pay for your health care coverage in a single year. The ACA requires that all health insurance plans place a cap on out-of-pocket costs for essential health benefits in a given year. If your healthcare costs for these services exceed the cap, then the insurer must pay for all of your costs for the rest of the year and may not charge you any covered cost-sharing as long as you get services from health care providers participating in your plan’s network. This means that the lower the maximum, the less you can be forced to pay. In 2024, this cap can be no higher than $9,450 for an individual and $18,900 for a family.

You can learn more about cost-sharing and out-of-pocket maximums.

The ACA requires health insurance companies to label every plan they sell with a “metal level” based on the value of the benefits in the plan. While all levels include the essential health benefits (EHB) and free preventive services, different metal levels will require you to pay different cost-sharing when you access care. The different metal levels are:

• Bronze – For the average customer, the insurance company pays 60% of medical costs.
• Silver – For the average customer, the insurance company pays 70% of medical costs.
• Gold – For the average customer, the insurance company pays 80% of medical costs.
• Platinum – For the average customer, the insurance company pays 90% of medical costs. (No Platinum plans are offered on the Washington Exchange in 2024).

The percentages listed above are average medical costs that each type of plan will cover based on a typical healthcare consumer. They are used to set a plan’s co-payments, co-insurance, and deductible to make it easier for you to compare the total average cost of different plans. The amount that you are responsible for varies from plan to plan and depends on what services you receive. It is also important to compare premiums at different metal levels—for example, a gold plan may not always be more expensive than a silver plan, depending on your circumstances.

The Exchange offers an overview of health care coverage and services.

Provider Network

There are many different types of health insurance plans. Almost every plan comes with a defined network of health care providers that your insurance company prefers. These plans will make you pay much more to purchase health services from a provider who is not included in the network.  Out-of-network charges can be very large, and some health plans don’t cover out-of-network services at all.  These “surprise bills” or “balance bills” can come as a shocking surprise to patients after receiving services either for emergencies or for procedures in which they weren’t aware that one or more providers were out-of-network.

When selecting a plan, it is very important to make sure that your regular doctors or other providers are included in the network. You can use WA Healthplanfinder to start shopping for plans. Once you enter your information, the website has a “Smart Planfinder” tool to help you choose a plan by searching for your providers, facilities and prescriptions

In Washington, consumers are now protected from some kinds of out-of-network “surprise bills” under the state Balance Billing Protection Act and federal No Surprises Act. These laws apply to individual health plans, and many other kinds of plans – your insurance company can tell you if they apply to your plan. If the laws apply to your plan, you cannot be billed more than the in-network cost-sharing amount for care you receive in two kinds of situations: (1) emergency services from an out-of-network facility or provider (including mental health & substance use crisis emergency and post-stabilization care), and (2) non-emergency surgical, anesthesia, pathology, neonatology, radiology, lab, or hospitalist services from an out-of-network provider while you are at an in-network hospital or outpatient surgical facility. Learn more about the protections against surprise medical bills for out-of-network care.

Benefits

Before the ACA, many plans had benefit limits. These were caps on the amount that the insurance company would pay for your coverage; if the amount the insurance company paid exceeded the cap, you would be forced to pay for all costs above the cap on your own. Under the ACA, however, most plans are not allowed to have annual benefit limits and none are allowed to have lifetime benefit limits.

The ACA set new minimum standards for all health plans. There are no longer pre-existing condition limitations or questionnaires about your health status to complete. Insurers are required to provide their customers with a summary of their plans’ coverage, which must include all services listed in the Washington state benchmark plan. In addition to required services, insurers can choose to include additional services in their plans. Your plan must give you a summary of benefits and coverage (SBC) and a glossary of commonly used terms before you enroll and each year when you renew your plan. State law requires your insurer to give you certain other information if you request it. If you use the Healthplanfinder website to compare plans, you will be able to compare the benefits of different plans.

[1] For Apple Health, income eligibility maximums are updated annually in April. For example, Apple Health will use the 2024 Federal Poverty Level (FPL) standards shown on this page until the FPL standards are next updated in April 2025, then will use the 2025 standards.

[2] For Washington Health Benefit Exchange Qualified Health Plans, income eligibility maximums are updated annually in January with a one-year lag. For example, the Washington Health Benefit Exchange will use the 2023 Federal Poverty Level standards shown on this page to determine eligibility for Qualified Health Plans issued between January-December 2024.

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.