Health Insurance Plans

A broker is another term for agent or producer, but specifies someone who works for the client, as opposed to the insurance company. A broker can be connected to many different insurance carriers. It is their job to help you find the coverage that best meets your needs. “Of record” refers to the broker that is listed with your insurance carrier or in Healthplanfinder account, granting us access to communicate with them regarding your account.

Brokers are trained, Exchange certified, and state licensed to sell in-exchange and carrier-direct qualified health plans (QHP’s). They can make plan recommendations based on your specific needs, provide enrollment guidance, assist with carrier documentation requirements and submission, educate on enrollment deadlines to avoid a gap in coverage, have access to dedicated support teams at the Exchange and with most carriers to assist with enrollment, billing, or claims issues and questions. Brokers can assist with general questions for insurance companies they do not represent or for state programs such as Washington Apple Health (WAH) or Cascade Care. Navigators are another group of people trained to assist with HPF applications, though they are not able to make plan recommendations. They generally only help with the application, and do not track enrollment or assist with ongoing issues with the exchange or insurance carrier.

Qualified Health Plan (QHP) premiums are regulated and approved by the Washington State Office of the Insurance Commissioner (OIC). Premiums are the same whether or not a broker is used. Brokers may receive a commission from the insurance carrier for writing and servicing a QHP. Due to the reduction or elimination of commissions, some brokers have implemented professional fees to continue providing their services.

A QHP is an insurance plan that is certified by the state or federal health insurance marketplace, provides essential health benefits, follows established limits on cost-sharing (such as deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act (ACA). All QHP’s meet the ACA requirement for having health coverage, known as “minimum essential coverage.” There are some limited benefit and short-term medical policies available in Washington state that do not meet ACA requirements. For example, healthcare sharing membership programs are nonprofit organizations whose members have a common set of ethical or religious beliefs and share medical expenses consistent with those beliefs. Healthcare share programs are not required to meet ACA provisions and are not regulated by state insurance law. Consumers considering joining such an organization should carefully review coverage limitations, exclusions, and provider networks for these types of policies and programs to ensure adequate coverage. Some of these types of policies may be a good fit for a short period or if purchased as supplemental coverage to an existing health policy but may not provide ample catastrophic coverage.

Click Here for additional information on individual and family health insurance from the Washington State Office of the Insurance Commissioner’s website.

With few exceptions this is the only time of year when you can enroll in a Qualified Health Plan (QHP) or make carrier/plan changes for the upcoming plan year. OEP runs from November 1 through December 15 of each year for plans starting January 1 of the following year. If enrolling outside the OEP, you may still be able to enroll in a QHP if you qualify for a Special Enrollment Period (SEP).

Job-based plans may have different enrollment periods. Check with your employer for more information if you are enrolled on a plan through your work.

You can apply and enroll in Medicaid (Washington Apple Health) or the Children's Health Insurance Program (CHIP) any time of year if you qualify based on household size and income.

A SEP is a time outside the annual OEP when you can enroll on a QHP. You qualify for a SEP if you have a Qualifying Life Event (QLE), such as involuntary loss of health coverage, moving, getting married, having a baby, or adopting a child. Depending on your SEP type, you may have 60 days before or 60 days following the event to enroll in a plan.

If you miss your SEP window, you may have to wait until the next OEP to apply. To avoid experiencing a gap in coverage applicants should submit applications and make plan selections in advance of losing health coverage. Brokers can assist in determining application submission deadline dates based on the type of qualifying life event (QLE). You can enroll in Medicaid (Washington Apple Health) or the Children’s Health Insurance Program (CHIP) any time of year, if you are eligible, whether you qualify for a SEP or not.

Click Here for additional information from Washington Healthplanfinder on qualifying life events and special enrollment periods.

A QLE is a change in your situation — like getting married, having a baby, or losing health coverage — that can make you eligible for a Special Enrollment Period (SEP), allowing you to enroll in health insurance outside the annual Open Enrollment Period (OEP). Proof of a QLE may be required by the Exchange or insurance carrier as proof of SEP eligibility before a policy is effectuated.

Click Here for more a more extensive list of QLE's.

Click Here to visit the Washington Healthplanfinder (HPF) browse and compare plans feature. Please note that financial assistance such as advanced premium tax credits and cost sharing reduction (explained below) will be determined once an HPF application has been submitted. Visit carrier direct quoting and plan option section above for more information. Please note in and off Exchange carrier/plan availability is based on county of residence.

Financial assistance is only available to those who enroll through the Washington Healthplanfinder and not to those who enroll on a carrier direct plan.  Click Here for information on eligibility for advanced premium tax credits (APTC), cost share reduction (CSR) and state Medicaid, also known as Washington Apple Health (WAH).

APTC is used to lower your monthly insurance payment (called your premium) when you enroll in a plan through the Washington Healthplanfinder (HPF) or other state or federal Health Insurance Marketplace. APTC is based on the income estimate and household information you put on your HPF application. If your estimated income falls between 139% and 400% of the federal poverty level for your household size, adults on the application may qualify for APTC.

You can use any amount up to the full approved APTC amount to lower your monthly premium. Note that the approved amount is based on the reported income in your application and will be reconciled when you file your tax return for the year.

• If you use more APTC than you qualify for based on your final yearly income, you must repay the difference when you file your federal income tax return.
• If you use less APTC than you qualify for, you will get the difference as a refundable credit when you file your taxes.

You can buy health insurance through other sources, but the only way to get a premium tax credit is through the state or federal Health Insurance Marketplaces.

A discount that lowers the amount you pay for deductibles, copayments, and coinsurance. It will also lower out-of-pocket maximum — the total amount you could have to pay for covered medical services per year. When you reach your out-of-pocket maximum, your insurance plan covers 100% of all covered services.

If you qualify, you must enroll in a plan in the Silver category to get the extra savings.  When you fill out a Healthplanfinder application, you will find out if you qualify for advanced premium tax credits (APTC) and CSR. You can use the APTC for a plan in any metal category. But if you qualify for CSR, you’ll get those savings only if you pick a Silver plan.

If you're a member of a federally recognized tribe or an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, you may qualify for additional cost-sharing reductions.

In Washington State, Medicaid is called Washington Apple Health (WAH). WAH provides low or no cost health care services to adults and children that meet certain eligibility requirements. Click Here to find out more about WAH eligibility and coverage.

Cascade Care offers new coverage options (standard plans and public option plans) to Washingtonians that will be available through Washington Healthplanfinder starting November 1, 2020 for coverage effective January 1, 2021.

The goal of Cascade Care is to increase benefits and reduce cost for enrolled members through standardized benefits, public option plans, and potentially increasing the income limit to receive financial assistance.

Click Here for additional information on Cascade Care.