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All plans on Washington Healthplanfinder cover essential health benefits. The ten essential health benefits must be covered by law according to the Affordable Care Act.
- Doctor visits and hospital stays
- Trips to the emergency room
- Care before and after your baby is born
- Mental health and substance use treatment
- Prescription drugs
- Services and devices to treat injuries, disabilities or chronic conditions
- Lab tests
- Preventive services
- Management of a chronic disease
- Pediatric care
Answers by Topic
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 Washington Apple Health (Medicaid) coverage.
American Indians or 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?
People in Washington state can still get the COVID-19 and other vaccines. Read the state's vaccine recommendations. Washington state has even more essential health benefits. View more benefits health plans must cover under Washington state law.
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 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?
There is no one-size-fits all plan when it comes to health insurance. That is why health plans are grouped into levels so you can choose a plan that meets your health care needs and your budget.
There are three levels of plans offered on Washington HealthplanfinderTM: Bronze, Silver and Gold.
Health Maintenance Organization
What is a Health Maintenance Organization (HMO)?
An HMO is a health care plan that works with a network of specific health care providers (such as hospitals and doctors). You will need to choose a primary doctor to manage your care. Similar to a Preferred Provider Organization (PPO), if you use providers outside the network, you may have to pay more or the care might not be covered.
Preferred Provider Organization
What is a Preferred Provider Organization (PPO)?
A PPO is a health care plan that works with a network of specific health care providers (such as hospitals and doctors) that you can choose from. You may use providers outside the network, but you may have higher out-of-pocket costs. You do not need to select a primary care doctor with a PPO, and you do not need a referral to see other providers in the network.
What is a monthly premium?
This is the amount you will 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 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
Do not have access to other insurance options through work or another government program
Are a U.S. citizen or a legal resident
Do not 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 have not 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 do not qualify for a tax credits. Contact your insurance company for information on grace periods.
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, has a tax filing status of "dependent of someone not in the household,” or is an Adult Disabled Dependent of someone not on the application.
Only 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.
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 will be renewed into that same plan. If it is not, we will select a new plan for you to continue coverage.
You will 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 do not get a referral for these services, the plan will not cover them under the deductible, co-pay, 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
A catastrophic health plan meets all the requirements of other qualified health plans (QHPs), but does not cover any benefits other than three primary care visits per year before the plan’s deductible is met.
Catastrophic health plans have lower monthly premiums but higher deductibles, copays and co-insurance. You cannot use a premium tax credit to reduce your monthly cost for a catastrophic plan.
Who can sign up for a catastrophic health plan?
You must be under 30 years old OR get a hardship exemption based on your income. To qualify for a hardship exemption, please submit an application to the Centers for Medicare and Medicaid Services.
Once your application is approved, submit it to Washington Healthplanfinder, email [email protected].
How do I know if I was enrolled in a catastrophic health plan?
If you were enrolled in a catastrophic health plan, you will not receive a 1095-A. Instead, you should check a box on your tax return to confirm that you had minimum essential coverage.