If you need to go to the doctor but you cannot afford to pay for health insurance, Medicaid can help. Medicaid is a health care program for people who do not have a lot of money.
In Washington state, the Medicaid program is called Washington Apple Health.
This guide will explain everything you need to know about Washington Apple Health. We will explain what it is, who can get it, what it pays for, and how you can sign up. We write this using plain, simple words so you can understand your choices and get the care you need.
Medicaid is a large health insurance program in the United States. According to the rules found on medicaid.gov, Medicaid provides health coverage to millions of Americans. This includes low-income adults, children, pregnant women, elderly adults, and people with disabilities.
The federal government and the state government work together to pay for Medicaid. Because both governments pay for it, the federal government makes some basic rules, and each state makes its own specific rules.
In Washington, the state government runs the program and calls it Washington Apple Health. You might hear people call it Medicaid, or you might hear them call it Apple Health. They are the exact same thing.
The goal of Apple Health is simple. It makes sure that people with lower incomes can still see a doctor when they are sick. It makes sure you do not go bankrupt if you have to go to the hospital. For most people who qualify, the coverage is completely free.
Not everyone can get Medicaid. You have to meet certain rules. The biggest rule is about how much money you make. But there are also rules about where you live and your age or family status.
You must meet these basic rules to get free health coverage through Washington Apple Health.
| Group | Income Limit (Federal Poverty Level) |
|---|---|
| Adults (Ages 19-64) | 138% of the FPL |
| Pregnant Individuals | 193% of the FPL |
| Children (Under Age 19) | 210% of the FPL (for free coverage) |
| Children (Premium Program) | Up to 312% of the FPL |
Medicaid looks at people in different groups. The rules for how much money you can make are different depending on which group you belong to.
1. Adults (Ages 19 to 64) If you are a normal adult who is not pregnant and not disabled, you can get Apple Health based purely on your income. You do not need to have children to get Medicaid in Washington.
2. Children (Under Age 19) The state wants to make sure kids stay healthy. Because of this, the income limits for children are much higher than they are for adults. Even if parents make too much money to get Medicaid for themselves, their children might still qualify for Apple Health for Kids.
3. Pregnant People When someone is pregnant, they need a lot of medical care to keep themselves and the baby safe. Washington gives Medicaid to pregnant people at a higher income limit. Once the baby is born, the mother gets to keep her health coverage for 12 months (one full year) after the birth.
4. Seniors (Age 65 and Older) When you turn 65, you usually get Medicare. However, if your income is very low, you can get both Medicare and Medicaid at the same time. Medicaid helps pay for the things that Medicare does not cover, like long-term care in a nursing home.
5. People with Disabilities or Blindness If you have a disability that keeps you from working, or if you are legally blind, you can qualify for Apple Health under special rules.
To get Medicaid, your income must be below a certain line. The government calls this line the Federal Poverty Level, or FPL for short.
The Federal Poverty Level is a money guide set by the U.S. government each year. It is based on the size of your family. A family of four has a higher poverty level than a single person who lives alone.
When Washington decides if you get Apple Health, they look at your income as a percentage of the FPL.
Because the exact dollar amounts change every single year in the spring, we use percentages to explain the rules.
| Who is Applying | Income Rule | What This Means |
|---|---|---|
| Single Adult | 138% of FPL | Must have a low income to get free care. |
| Pregnant Person | 193% of FPL | Can make more money and still get free care. |
| Child (Free care) | 210% of FPL | Most kids qualify if the family has a modest income. |
| Child (Small fee) | 312% of FPL | If family income is higher, kids can still get covered for a small monthly fee. |
When Medicaid asks how much money you make, they want to know your gross income. This means the money you make before taxes are taken out of your paycheck.
They count money from:
They do not count:
Your household size is very important. The larger your household, the more money you can make and still qualify.
For Medicaid, your household usually includes the people you put on your tax return.
You must count everyone in your tax household, even if only one person actually needs health insurance.
Washington Apple Health is excellent health insurance. It covers almost everything you need to stay healthy or get better when you are sick.
Under the law, Medicaid must cover what are called “Essential Health Benefits.”
If you get a cold, break your arm, or need a regular checkup, Medicaid pays for it. You can see a primary care doctor for regular visits. If you have a special problem, like a heart issue, Medicaid pays for you to see a specialist, like a heart doctor.
If you get very sick and have to stay in the hospital, Apple Health pays the hospital bill. It also pays for emergency room visits if you have a real medical emergency.
When the doctor gives you a prescription for medicine, you can take it to the pharmacy. Apple Health pays for the medicine. You might have to use the generic version of a drug instead of the expensive name brand, but the medicine works exactly the same.
Mental health is just as important as physical health. Apple Health covers counseling, therapy, and visits to a psychiatrist. It also pays for treatment if you need help stopping the use of drugs or alcohol.
Apple Health pays for all your doctor visits while you are pregnant. It pays for the hospital bill when you give birth. After the baby is born, the baby automatically gets health coverage. The mother also keeps her coverage for a full 12 months after the baby is born, so she can heal and get the care she needs.
Many states do not give dental coverage to adults on Medicaid. Washington is different. Washington Apple Health covers dental care for both children and adults. You can get regular teeth cleanings, exams, x-rays, fillings to fix cavities, and even tooth extractions (getting a tooth pulled).
For children under age 19, Apple Health covers eye exams and pays for glasses. For adults over age 19, Apple Health covers the eye exam to check your vision, but it usually does not pay for the actual glasses or contact lenses.
Sometimes people cannot get to the doctor because they do not have a car, and there is no bus near their house. Apple Health has a program called Non-Emergency Medical Transportation. If you have no other way to get to your medical appointment, the state can help pay for a ride, like a special van or a bus pass, so you do not miss your visit.
Medicaid is paid for by the state, but the state does not run the doctor’s offices. Instead, Washington uses “Managed Care Organizations.”
A Managed Care Organization is a private health insurance company. The state pays the private company a flat fee every month, and that company manages your health care.
When you get approved for Apple Health, you will be asked to pick a health plan. You might see names of real insurance companies.
All of these plans cover the exact same basic medical services. The state makes sure of that. The difference between the plans is their “network.”
A network is a list of doctors, clinics, and hospitals that work with a specific insurance company.
When you pick a health plan, you must go to the doctors that are inside that plan’s network. If you go to a doctor who is not in your plan’s network, the insurance will not pay the bill, and you will have to pay for it yourself.
If you already have a doctor you like, you should call their office. Ask them, “Which Apple Health managed care plans do you accept?” Then, pick the plan that your doctor takes.
Most Medicaid plans are HMO plans. You can learn more about how HMO plans work by reading our guide to HMO vs. PPO networks.
Applying for Medicaid is easier than it used to be. You do not have to go to a government building and wait in a long line if you do not want to. You can do it from your computer or phone.
Here are the main ways to apply:
1. Apply Online The fastest way to apply is on the internet. Washington state uses a website called Washington Healthplanfinder. You create an account, type in your name, address, and income, and the system will tell you very quickly if you qualify.
2. Apply Using a Mobile App Washington has an app called WAPlanfinder. You can download it on your smartphone and apply right from your phone. You can even use the phone’s camera to take pictures of any documents they ask for.
3. Apply by Phone If you do not like using computers, you can apply over the telephone. You can call the Washington Healthplanfinder customer support line. A real person will ask you the questions and type your answers into the computer for you.
4. Apply in Person If you need extra help, you can find a “Navigator” in your town. A Navigator is a person trained by the state to help people fill out health insurance applications. Their help is completely free. You can find a Navigator by searching on the state’s Healthplanfinder website.
Before you sit down to apply, you should gather some papers so you have the answers ready. You will need:
For most private health insurance, you can only sign up during a small window of time in the winter. This is called Open Enrollment.
Medicaid is different. There is no deadline for Medicaid. You can apply for Washington Apple Health on any day of the year. If you lose your job in July and your income drops, you can apply in July. If you have a baby in October, you can apply in October.
If you are approved for Washington Apple Health, a few things will happen next.
First, the state will mail you a light blue plastic card. It is called a ProviderOne services card. This is your main state Medicaid card. Keep this card safe in your wallet. Do not throw it away, even if you switch health plans later. You will keep this same blue card for as long as you are on Medicaid.
After you are approved, you will need to choose one of the managed care plans we talked about earlier. If you do not choose one, the state will just guess and assign one to you. It is better if you pick it yourself, so you can make sure your favorite doctor is in the network.
After you pick your managed care plan, that specific private insurance company will mail you a second card.
When you go to the doctor or the pharmacy, you should hand them both cards: the blue ProviderOne card from the state, and the specific plan card from your managed care company.
Your managed care plan will ask you to pick a Primary Care Provider (PCP). This is your main doctor. When you get sick, this is the first person you call. If you do not pick one, the insurance company will assign one to you. You can usually call the insurance company at any time to change your main doctor if you are not happy with them.
Having health insurance is great, but knowing how to use it is just as important. Here is exactly what to do when you need care.
If you have a true emergency—like you cannot breathe, you have chest pains, or a bone is broken and sticking out—go straight to the Emergency Room at a hospital, or call 911. Apple Health will pay for it.
However, if you just have a bad cold, a minor cut, or a sore throat, you should call your regular doctor first. If they are closed, you can go to an “Urgent Care” clinic. Urgent Care clinics are faster than the Emergency Room for small problems, and Apple Health covers visits to Urgent Care clinics that are in your network.
Once you get Apple Health, it does not last forever automatically. You have to prove that you still qualify every year.
Once a year, the state will check to see if you still have a low income. This is called a renewal.
Sometimes, the state can check your income using electronic tax records and they will renew you automatically. They will send you a letter saying, “Good news, your coverage is renewed.”
Other times, they cannot find your income electronically. When this happens, they will send you a letter asking for proof. They might ask for a recent pay stub. You must answer this letter. If you ignore the letter, they will cancel your health insurance, even if you are still poor enough to qualify. Always open mail from the Washington State Health Care Authority.
You do not have to wait for your yearly renewal to tell the state about changes. In fact, the rules say you must tell the state right away if your life changes in a big way.
You must contact the state if:
You can report these changes online using your Washington Healthplanfinder account, or by calling their customer service number.
Sometimes, people get a good job and start making more money. This is a good thing for your life, but it might mean your income goes over the Medicaid limit.
If your income goes over the limit, you will lose your free Apple Health coverage. But you will not be left without choices.
If you lose Medicaid because you make too much money, you qualify for a Special Enrollment Period on the state’s health insurance marketplace. You can buy a private ACA health plan.
Because you still have a moderate income, the federal government will give you tax credits (subsidies) to help pay for the new private plan. You can read more about how this works in our guide to Enrollment & Eligibility Dates.
Medicaid and Medicare sound alike, but they are very different.
Medicaid is for people of any age who have a low income. It is run by both the federal government and Washington state.
Medicare is mostly for people who are 65 years old or older. It does not matter how much money you make; if you are 65 and worked in the U.S., you get Medicare. It is run only by the federal government.
Yes. If you are 65 or older, and you also have a very low income, you can have both Medicare and Medicaid at the same time. This is called being “Dual Eligible.”
When you have both, Medicare pays your doctor and hospital bills first. Then, Medicaid pays for the leftover bills that Medicare did not cover. Medicaid can also help pay for your Medicare monthly premiums. If you want to know more about how Medicare works, read our article on Medicare Advantage in washington.
In the past, many immigrants could not get Medicaid unless they had a green card for at least five years.
Washington state has made special rules to help more people get health care. Washington has a state-funded program called the Apple Health Expansion. This program gives free health coverage to adults who have a low income but do not qualify for regular federal Medicaid because of their immigration status (including undocumented immigrants).
The state also covers all children under age 19 whose families meet the income limits, no matter what their immigration status is.
If you need health insurance, you should apply. The application system is safe, and applying for health insurance for yourself or your children does not hurt your chances of getting a green card or becoming a citizen.
If you apply for Apple Health and the state sends you a letter saying “No,” read the letter carefully. It will tell you exactly why they said no. Usually, it is because your income is too high, or because you forgot to send them a required document.
If you think the state made a mistake, you have the right to ask them to look at your application again. This is called filing an appeal.
You can ask for an appeal by following the instructions on the denial letter. You usually have to ask for an appeal within a certain number of days (usually 90 days), so do not wait. You can request an administrative hearing where a neutral judge will listen to your side of the story, look at your pay stubs, and decide if the state was right or wrong.
If you need more information about Medicaid, it is important to look at official government websites.
You can read the broad federal rules about Medicaid by visiting medicaid.gov.
For the exact rules about Washington state, you should also check the Washington State Health Care Authority website. They are the state agency that runs Apple Health. They have detailed manuals and help guides for people who need assistance.