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Health Coverage Basics

Open Enrollment

What is open enrollment?

Open enrollment is the time of year when you can enroll in a Qualified Health and Dental Plan. Open enrollment begins November 1.

You may be able to sign up year-round on Washington Healthplanfinder if: You are eligible for or renewing your Washington Apple Health (Medicaid) coverage

  • American Indians/Alaska Natives who are members of a federally-recognized Tribe or Alaska Native Corporation
  • You are signing up for Washington Healthplanfinder Business

Essential Health Benefits

What are essential health benefits?

  • The 10 essential health benefits are:
  • Doctor visits and hospital stays
  • Trips to the emergency room
  • Care before and after your baby is born
  • Mental health and substance use treatment services
  • Prescription drugs
  • Services and devices to help you recover if you get injured, or have a disability or chronic condition
  • Lab tests
  • Preventive services including counseling, screenings and vaccination
  • Management of a chronic disease, like diabetes or asthma
  • Pediatric care (including dental and vision)

Plans Offered

Who decides which plans are offered through Washington Healthplanfinder?

The Washington State Office of the Insurance Commissioner (OIC) coordinates the approval and certification process for Qualified Health and Dental Plans to be offered through Washington Healthplanfinder. The Qualified Health and Dental Plans are evaluated by the OIC on quality, cost, and access. The Washington Health Benefit Exchange Board of Directors developed the evaluation criteria and approves the plans that will be offered.

Metal Levels

What are metal levels?

Health plans come in four categories called metal levels. They’re available in Bronze, Silver, and Gold. The difference between the plans is what percentage of the cost of care they cover (for example, Bronze plans cover 60% of the costs, where Gold covers 80%).

Health Maintenance Organization

What is a Health Maintenance Organization (HMO)?

A Health Maintenance Organization (HMO) is a health care organization and plan that provides medical services, and also contracts with a network of selected health care providers (such as hospitals and doctors). You’ll need to select a primary doctor who will help you manage your health care. Similar to a Preferred Provider Organization (PPO), if you go outside the contracted network, you might have higher out-of-pocket costs, or the care may not be covered at all.

Preferred Provider Organization

What is a Preferred Provider Organization (PPO)?

A Preferred Provider Organization (PPO) is a type of health plan that contracts with a network of selected health care providers (such as hospitals and doctors) that you can choose from. You may go outside the network but might have higher out-of-pocket costs. You don’t need to select a primary doctor and you don’t need a referral to see other doctors in the network.

Premiums

What is a monthly premium?

This is the amount you’ll pay monthly for your coverage. This does not include any out-of-pocket health care costs.

Tax Credits

What are tax credits and how do they work?

Tax credits (also known as health insurance premium tax credits, premium tax credits, or advanced premium tax credits) help lower the cost of your monthly health plan premium.

If you are eligible for tax credits, you can choose to use some or all of your tax credits to lower your monthly premium payments, or wait to get all of your tax credits when you file your tax return. You must file your taxes when you get tax credits.

You are eligible for tax credits if you:

  • Buy health insurance through Washington Healthplanfinder
  • Are within certain income limits
  • Don’t have access to other insurance options through work or another government program
  • Are a U.S. citizen or a legal resident
  • Don’t file a tax return as married filing separately

Grace Period

What is a grace period?

A short period — usually 60-90 days — after your monthly health insurance payment is due. If you haven't made your payment, you may do so during the grace period and avoid losing your health coverage.

The grace period for health insurance is usually 60-90 days if both of the following are true:

  • You have a health plan through Washington Healthplanfinder
  • You qualify for financial help (tax credits).

Note: The length of your grace period may be different if you don’t qualify for a premium tax credit. Contact your insurance company for information on grace periods in your state.

Quality Star Ratings

What are quality star ratings?

Plans receive a quality rating from 1 to 5 stars. The ratings are based on survey results and data provided by carriers*.

Overall quality rating is based on three categories:

  • Medical Care
  • Patient Experience
  • Insurance Company Service

*Plan quality ratings and enrollee survey results are calculated by CMS using data provided by health insurance plans in the previous plan year. The ratings displayed are for the current plan year.

Threshold Requirement

What is the threshold requirement?

The tax return filing threshold is the minimum amount of gross income an individual must make to be required to file a tax return. This displays for each member who has an income and are either under the age of 19 or has a tax filing status of "dependent of someone not in the household". Adult Disabled Dependent of someone not on the application.

Only report income of tax dependents and children who are 18 and younger if their income meets or exceeds the tax filing threshold requirements to file a federal tax return. This rule applies regardless of whether or not the individual actually files a tax return.

*Please note, the federal tax filing threshold requirements are updated by the IRS every year.

Learn more about tax dependents.

Auto-renewal

What is auto-renewal?

If your information on Washington Healthplanfinder is up to date, your coverage will be automatically renewed. If your current plan is available next year, you'll be renewed into that same plan. If it is not, we'll select a new plan for you to continue coverage. 

You'll receive a letter in the mail before open enrollment letting you know that your coverage will be renewed. If you want a different plan next year, sign in to your account and shop for a new plan during open enrollment.

Referrals

Why do I need a referral to see a specialist?

Some plans ask you to get a referral from your primary doctor before receiving certain specialist services. If you don't get a referral for these services, the plan will not cover them under the deductible, co-pay, and/or co-insurance.

Cost-sharing Reductions

Do plans with cost-sharing reductions still have premiums?

Cost-sharing reductions are a discount that lowers the amount you pay for deductibles, co-insurance, co-payments, and other out-of-pocket expenses (like lab tests and drugs). However, you will still need to pay a premium for a plan that includes cost-sharing reductions.

Catastrophic Plans

Who can sign up for a catastrophic health plan?

Catastrophic health plans are available for adults up to age 30.

Enrolled in a Catastrophic Plan

How do I know if I was enrolled in a catastrophic health plan?

If you were enrolled in a catastrophic health plan, you won't receive a 1095-A. Instead, you should check a box on your tax return to confirm that you had minimum essential coverage.

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