Individual & Family first time application – set up information
If this is the first time you are enrolling for an Individual/Family medical insurance plan – You will most likely need to set up an account on the WA Health Plan Finder (WAHPF). Also Known as the WA Exchange or WA Marketplace. Once your account is set up you can shop for medical and dental insurance plans.
10 Things you need to know about your medical insurance options and setting up an application for the first time.
- Four Insurance Carriers are available in Pierce, King and Snohomish Counties – AmBetter (Coordinated Care), Kaiser HMO, Molina and Premera.
- All medical insurance plans have a limited Narrow provider Network. Either a Health Maintenance Organization (HMO) or an Accountable Care Organization (ACO). Only emergency care out of area will be covered (Except for Kaiser who has a limited multistate HMO network). There are no PPO plans available.
- Bronze level plans and Health Savings Account (HSA) qualified plans are only available from Premera or Kaiser HMO.
- I have created a ‘2019 Rates’ table that is posted on my website. On a single page you will be able to see all the Silver and Bronze plans available in King, Pierce and Snohomish counties. It shows very basic information as well as full premiums (before any Premium Tax Credit) in 10-year increments. This information will save you some time instead of scrolling page after page on the WAHPF to get an initial view of your many options. You will still need to view your options on the WAHPF to find your specific age, tobacco use and zip code based premium.
- You will most likely need to set up an account at the WAHPF and select a plan from one of the four medical Insurance Carriers. If you want to enroll with Kaiser HMO, they have different options ON Exchange and OFF Exchange (Direct). Kaiser HMO is the only remaining medical Insurance Carrier that offers a direct application – OFF Exchange. The rates are the same both ON and OFF Exchange. Contact me about the OFF Exchange direct Kaiser application for more details.
- The Annual Open Enrollment deadline is December 15 for a January 1st start date. This is much shorter time period than prior years. Its only 45 days long.
- Go to www.wahealthplanfinder.org to view all your WAHPF options using the ‘Browse Plans’ link – and then when you are ready to move forward set up a WAHPF account using the ‘Sign In’ link or ‘Apply Now’ link. If you or a family member has set up an account at the WAHPF in the past do not set up a new account (contact me).
- If your group medical insurance coverage is ending at the end of the current or the next month mark NO the question – Do you have group medical insurance from an employer? Even if you currently have coverage, because it will be ending shortly.
- Do you want to apply for Apple Health (Medicaid/Healthy Options) or a Premium Tax Credit to reduce your monthly premiums
- Mark the Box YES – If you want to know if you are eligible for Apple Health or a Premium Tax Credit. You will need to provide income information on the application.
- Mark the Box NO – If you know that your household income is above the amount to be eligible for a Premium Tax Credit. If you answer NO, then you will not need to provide income information on your application. Taking this step will simplify your application. You may still be eligible for a Premium Tax Credit at the end of the year if you answer NO.
- After you set up your application and before you log out please go to your home page. On the right side of the page under – Quick Links – select – Request help from a Broker. Look me up with just two items – Last Name Johnson in zip code 98092. Then agree to the next two or three prompts. There is no charge for my services. Now you can go shopping and enroll in a plan, anytime up to the open enrollment deadline, after you finish setting up an account.
- You must select a plan and then go through checkout to finalize your choice.
- I can help you with selecting a plan and assist you with looking up providers in the limited networks. I’m available for a telephone and computer screen sharing appointment seven days a week during the Annual Open enrollment (November 1st to December 15th) from 8AM to 8PM on the hour. Please send me an email requesting an appointment and provide me with a few dates and times that will work with your schedule and I will email you back with a confirmed appointment time.
Remember I’m here to help. I will return your email or phone call, but it may take several days. I generally get caught up by the end of the weekend. So please be patient.
I help anyone at any age with
Individual Medical and Dental Insurance options
as well as Medicare
Map of the Market – Network
|Apple Health||ON Exchange||OFF Exchange (Direct)|
|Medicaid||Qualified Health Plan||Qualified Health Plan|
|No cost if income eligible||Premium Tax Credit may reduce premium||Premium Tax Credit not available|
|All Narrow Network Plans||All Narrow Network Plans||All Narrow Network Plans|
|Coordinated Care||AmBetter - HMO|
|Kaiser - HMO, HSA||Kaiser - HMO, HSA|
|Molina||Molina Marketplace - HMO|
|Premera - ACO, HSA|
2018 Map of the Market – Networks
AmBetter – HMO
- CHI Franciscan (Pierce County locations only), Evergreen, Providence and Swedish
Kaiser Permanente – HMO
- HMO Clinics and Community Providers in outlying areas
Molina – HMO
- Multicare, CHI Franciscan, UW, Overlake, Swedish and Providence
Premera – ACO, HSA – Accountable Care Organization – Premera Personal Care Plan
Select one Hospital/Clinic System after application
- Everett Clinic
- Evergreen Health Partners
- Northwest Physicians Network
- UW Medicine
- Virginia Mason plus Poly Clinic
I listed the major clinics for the four remaining insurance carriers. There are many independent providers that will be contracted IN Network.
Accountable Care Organization/ Accountable Care Network: An ACO/ACN is a network of doctors and hospitals that shares financial and medical responsibility for providing coordinated care to patients. In our area the ACO/ACN is organized by Hospital and Clinic Systems. Such as Swedish, Virginia Mason, University of Washington, Multicare or Evergreen. Similar to an HMO, with an ACO/ACN you must use network providers – doctors, hospitals and other health care providers – that participate in the plan. Your network is limited to the Hospital and Clinic System you elect. The only exception is for emergency care.
EPO (Exclusive Provider Organization): Similar to an HMO, with an EPO you must use network providers – doctors, hospitals and other health care providers – that participate in the plan. The only exception is for emergency care. Unlike an HMO, you do not need to select a Primary Care Physician, nor do you need to contact your PCP for referrals to specialists.
HMO (Health Maintenance Organization): If you are in an HMO, you must use network providers – doctors, hospitals and other health care providers – that participate in the plan. The only exception is for emergency care. An HMO generally requires the selection of a Primary Care Physician (PCP) to manage your care. Referrals are usually needed from your PCP to see a specialist, who must also be in the network.
A health savings account (HSA) is a tax-advantaged medical savings account available to individuals who are enrolled in a HSA eligible high-deductible health plan (HDHP). The funds contributed to an HSA account reduce taxable income for the year similar to deposits to an Traditional IRA or a 401(k). HSA funds may be used to pay for qualified health care expenses (such as medical, dental and vision) that are not covered by an insurance plan without paying federal tax on the withdrawal or a penalty. Funds from an HSA cannot be used to pay for medical or dental insurance premiums.
These are general terms and the plan you select may be organized differently. Read the Insurance Carriers’ summary of benefits for plan specifics.
Medical Open Enrollment Information
All four medical insurance carriers currently available in Pierce, King and Snohomish Counties will renew coverage for 2019. Renewal rates are on average increasing in 2019:
Ambetter +14.37% (lowest cost option, small network)
Molina + 7.18%
Premera +2.18% (highest cost option, narrow networks)
AmBetter is eliminating Balanced Care 10 in 2019. If you are on this plan you will be moved to another plan with AmBetter.
Kaiser (formerly Group Health) is eliminating Bronze 18. If you are on this plan you will be moved to another plan with Kaiser.
Molina will be renewing all plans.
Premera will be renewing all plans. And they are adding a PersonalCare Bronze HSA qualified plan for 2019.
Kaiser and Premera are both offering Health Savings Account (HSA) Qualified plans in 2019. An HSA is a tax reduction qualified account (like a Traditional IRA) with special rules. Before Tax Deposits up to the annual limit can be made to a Bank or Credit Union. Then the HSA funds can be withdrawn to pay for unreimbursed medical, dental and vision expenses income tax free.
The Annual Open Enrolment ends December 15th. If you want to make a plan change or add family members you must select a plan and then go through checkout to finalize your choice.
With few changes by the Insurance Carriers it’s expected that 88% of individual will be receiving automatic renewal notices.
Always log into your WAHPF account at least once every Annual Open Enrollment. There may be a notice you missed or a request to upload a document.
Pay attention to the ‘Time to Renew Your Coverage’ letter from the WAHPF mailed or available by logging into your WAHPF account.
Your letter will have one or more notices. Examples of some but not all notices you may receive:
No action needed
We’ve renewed the plan(s) below, so you don’t have a gap in coverage next year. You can pick new coverage during open enrollment. You’ll enroll into the plan(s) selected if you don’t take any action during open enrollment.
We couldn’t renew your coverage for next year. Review your application, shop, and select next year’s coverage by the end of the open enrollment period.
We need more information from you. Review your application to make sure everything is correct. If that doesn’t fix the issue, you’ll get a request for documents to submit through your Document Center. You may lose coverage or financial help if you don’t submit information.
As always please contact me with any questions you may have.
Dental Open Enrollment Information
Dental insurance plans available from the WA Exchange – WAHPF https://www.wahealthplanfinder.org/
Delta Dental is removing major services (crowns, bridges, root canals) from their Adult WAHPF plan in 2019. So, I cannot recommend that plan any longer for Adults.
If you want dental coverage that includes major services in 2019, I recommend going to my website and enrolling directly with Delta Dental on the Premium plan ($2,000/y maximum benefit) or the Enhanced plan ($1,000/y maximum benefit). You will be given credit towards the 12-month waiting period for major services with the amount of time you were on the WAHPF/Delta Dental plan or the time you were on a group dental insurance plan prior to enrolling. In other words, if you were on the WAHPF/Delta Dental plan for the entire year of 2018 and you enroll directly with Delta Dental with no more than a 60-day break in coverage you will not have to satisfy the 12-month waiting period for new enrollees.
If you cancel your WAHPF Delta Dental plan in November, then coverage will end November 30.
If you cancel your WAHPF Delta Dental plan in December, then coverage will end December 31.
Both the Dentegra Dental and the Delta Dental plans available through the WAHPF do not cover major services for Adults. These insurance plans cover preventive care – exams and cleanings and fillings, but not major restorative services like crowns, bridges and root canals.
Dentegra Dental $26.43/m/Adult Preventive care, fillings, NO major services.
Delta Dental $38.08/m/Adult Preventive care, fillings, treatment of gums, NO major services. This benefit with major services covered and a $1,000/y maximum benefit was available in 2018 for $41.41/m/Adult
Delta Dental plans available directly from Delta Dental – http://https://jbjinsurance.com/dental/
Think of dental Insurance as a way to budget your expenses over the year on a monthly basis with just a little bit of insurance thrown in. I only offer Delta Dental for insurance coverage. It’s a reasonable price in my opinion and has the largest network (its Nationwide). Member dentists can not bill you for charges above the contracted amount. This feature has saved me 25% off the billed rate from my dentist.
Delta Dental Premium $58/m/Adult Preventive care, fillings, treatment of gums, major services. $2000/y maximum benefit.
Delta Dental Enhanced $48/m/Adult Preventive care, fillings, treatment of gums, major services. $1000/y maximum benefit.
Billed rates are based on age and can change at anytime.
You can apply for coverage right now with a start date of 1/1/2019
Income Eligibility Chart – Apple Health/Premium Tax Credit
|Family size||Monthly / Annual|
|Monthly / Annual|
|Monthly / Annual
|1||$1,436 / 17,232||$4,046 / 48,560||$4,046 / 48,560|
|2||$1,945 / 23,340||$5,486 / 65,840||$5,486 / 65,840|
|3||$2,453 / 29,436||$6,926 / 83,120||$6,926 / 83,120|
|4||$2,961 / 35,532||$8,366 / 100,400||$8,366 / 100,400|
|5||$3,470 / 41,640||$9,806 / 117,680||$9,806 / 117,680|
|6||$3,978 / 47,736||$11,246 / 134,960||$11,246 / 134,960|
|You may qualify for…||Apple Health for Adults||Marketplace / Exchange||Marketplace|
|Medicaid||Qualified Health Plan||Qualified Health Plan|
|There is no cost for |
(zero monthly premium)
|Premium Tax Credits and|
possible cost sharing reductions
to reduce your monthly
premiums and out of
|You will pay the full
premium without any
Premium Tax Credit
|Federal Poverty Level||Under 138%||Between 138% and 400%||Above 400%|
Income guidelines are based on Federal Poverty Levels. These numbers are estimates and typically change annually. This chart was updated April 2019.
When you apply at WAHealthPlanFinder.org your household size and income will determine if you are eligible for Apple Health or a Qualified Health Plan. You can apply during the annual open enrollment from November 1 to December 15. Or within 60 days of loss of Employer/Union Group Health Plan Medical Insurance coverage, moving from another State (with proof of prior coverage), Marriage, Divorce and other qualifying events.
All household members expected to be listed on the current year’s Federal Income Tax report must be entered on the application with their income. Household members can be listed as not seeking coverage on the WAHealthPlanFinder application.
Eligibility for Apple Health is based on income going forward. In other words, income prior to being laid off is not reported. So, unemployment income (or zero income) going forward would be reported as current income.
Eligibility for a Premium Tax Credit is based on expected income (MAGI) for the entire calendar year. So, you may have to calculate your average monthly income on the application. The Premium Tax Credit is not available for any household member who is offered Employer/ Union Group Health Plan Medical Insurance (even if the offer is refused).
Networks, Doctor, Pharmacy and Prescription formulary links
- Doctor and Pharmacy Finder – Choose Core Network
- Summary of Benefits – Direct and through WAHealhPlanFinder
- Plan Information – Overview, Application, etc
- Doctor, Pharmacy, and Dentist Finder – You have to choose one of the Personal Care Networks
- Plan Information – Quotes, SOB’s, etc
- EPO Information by County – Shows Personal Care Partners
- Formulary – Use M2 for the Bronze and M4 for the Silver and Gold