Apple Health for Kids

Apple Health for Kids, also known as Medicaid, provides full medical and dental coverage (including preventive care and check-ups) for children living in Washington state whose families have incomes up to 317% of the Federal Poverty Level (the FPL). This coverage is available for kids under age 19:

• Who live with parents, relatives or friends
• Are in foster care
• Who are homeless and living on their own

A child who was in foster care in Washington and getting Apple Health at age 18 or on the date they aged out of foster care, up to 21 years old, will be eligible for Apple Health coverage until age 26. Former foster youth don’t need to reapply for Apple Health. There’s no income limit for former foster youth. 

Learn more on the Washington State Health Care Authority website.

It depends. 

• Families below 215% of the Federal Poverty Level (FPL) have no costs - no deductibles, no premiums and no co-payments.
• Families between 215% and 265% FPL pay monthly premiums of $20 per month for one child, up to $40 per month total.
• Families between 265% and 317% FPL pay premiums of $30 per month for one child, up to $60 per month total. 

The income of parents and stepparents in the home counts. A child’s income may not count when it’s below a certain amount or is from Social Security. 

Children eligible for foster care, subsidized adoption, and similar services are all eligible. It doesn’t matter what their household income is.

Some other kinds of income to household members also don’t count. Even if your family’s income is more than the levels in the section above, you should still apply.

It depends on family income level. 

• If family income is less than 215% FPL, a child can have other health insurance in addition to Apple Health for Kids. In this situation, Apple Health for Kids provides “wraparound” coverage. It pays premiums, deductibles, and cost sharing required by the other insurance. It also covers services the other insurance doesn’t cover.

Apple Health also may reimburse the parent for the cost of this other insurance. This is the Premium Payment Program. 

• If family income is above 215% FPL, a child gets Apple Health for Kids with Premiums instead. A child in this situation who has access to other health insurance may not be eligible for this Apple Health program. 

Children who have other “creditable” health insurance generally don’t qualify for Apple Health for Kids with Premiums. They might qualify if they have Public Employees Benefits Board (PEBB) or School Employees Benefits Board (SEBB) program coverage. Call HCA at 1-800-562-3022 about your specific insurance.

If you have questions about whether you qualify for Apple Health, call the HCA at 1-800-562-3022.

A child can apply for Apple Health for Kids online, by phone or mail, or by contacting a navigator. 

• Online
• By phone: Call the Healthplanfinder customer support line at 1-855-923-4633.
• By mail: Print the “Application for health care coverage” (form 18-001P, links to forms in other languages). Type “18-001P” in the Search bar near the top of the webpage. Send to the address on the form. Keep a copy of the application for your records. Mailed applications take longer to process.
• Contact a “navigator” or other organization to help: A trained navigator usually can meet with you in person. This free help may also be available through phone or online.  

A child under age 19 can apply separately from their parents if they aren’t living with the parents and the parents don’t claim the child as a tax dependent. In this situation, the parents’ income doesn’t count. But a child applying separately from their parents can’t apply online. For help applying, call HCA’s special contact person for this issue:  

• HCA Contact: 1-855-682-0798
• Email: AskMAGI@HCA.wa.gov

At age 19, Apple Health for Kids ends. You might qualify for Apple Health for Adults (it has a lower income limit), another Apple Health program, or a Qualified Health Plan. 

Renewal might happen automatically. You might need to take some steps to make it happen. HCA will send you a notice about this.

If you’re turning age 19:

• You can apply or renew through a primary applicant who claims you as a dependent on their tax return. HCA will do an automatic renewal without you having to file a separate application.
• You can apply separately even if someone claimed you as a tax dependent. Then you can manage your own account and choose a different health plan if you want.
• You must apply separately if you aren’t the primary applicant’s spouse or tax dependent. This applies even if you don’t file taxes. 

If a child who was or is receiving Apple Health for Kids becomes ineligible, HCA must consider if the child is eligible for other Apple Health programs before ending the child’s Apple Health for Kids coverage.

The child may be eligible for Qualified Health Plan (QHP) coverage. A QHP is a private insurance plan. It’s available through the Healthplanfinder. It comes with tax credits to help pay your premiums. The dollar amount of tax credits depends on your household income. 

If your income is lower, you may qualify for discounts on cost sharing to reduce out-of-pocket expenses. 

If Apple Health coverage is denied or terminated, you have the right to appeal and ask for an administrative hearing.

You generally have 90 days to appeal. However, you must appeal earlier than that if you want your coverage to continue (“continued benefits”) during your appeal.

You can appeal by:

• Phone: The easiest, fastest way to ask for a hearing is to call the Office of Administrative Hearings at 1-360-407-2700 or 1-800-583-8271. Keep notes of the date and number you called, and the staff person’s name.
• Online: Select “Medical Service” and fill out the form. You can also log in to your Healthplanfinder account and submit an appeal.
• Writing: Any request in writing will be considered an appeal. But you can also fill out any form that came with your denial or termination letter or download the Appeal Request Form and fill it out. You may attach a copy of the letter denying or ending (terminating) Apple Health coverage, but this isn’t required. Make a copy of your request before sending, to keep for your records. Then do one of these:
  • Mail to Washington Apple Health, P.O. Box 45504 Olympia, WA 98504-5504. If possible, use certified mail return receipt, or call later to confirm HCA received it.
  • Fax to Office of Administrative Hearings (OAH) at 1-360-664-8721 (Office of Administrative Hearings). Call to make sure OAH got the fax. Keep notes about your call to confirm.

Your appeal request should include:  

• The name and birth date of the person appealing
• The application ID
• The date of the decision you’re appealing
• Contact info for the person asking for the hearing
• Why you’re appealing
• If you want to keep your Washington Apple Health coverage during your appeal (called continued benefits)
• Any help or accommodations you need to understand, communicate, or take part in the hearing process

If English isn’t your preferred language, the agency will provide a sign language or spoken language interpreter and written translations of hearing materials free of charge.  

At the hearing, an administrative law judge will decide if the denial or termination was legally correct. Read about tips to represent yourself at the hearing.

If you decide not to appeal at all, enroll in a QHP right away if you don’t have other health insurance. 

If you appeal either within 10 days from the notice date or before your coverage ends, whichever is later, you may be able to keep getting your Apple Health program while you appeal. If you miss the short deadline to get continued benefits while appealing, your coverage will stop during your appeal. 

If you get continued benefits but lose your appeal, you may be asked to pay something back for the Apple Health for Kids coverage you had during the appeal (you may have an overpayment). 

You also can enroll in QHP coverage while your appeal is being decided. Losing your Apple Health gives you a “Special Enrollment Period” to enroll in a QHP. Act fast. This special enrollment period lasts only 60 days from your loss of Apple Health. 

It can be complicated to decide if you should pay for QHP coverage and ask for tax credits during your appeal, or risk having to pay for continued Apple Health for Kids coverage if you lose your appeal. Try to talk to a lawyer.

If you’re sure you want continued benefits, you should start your appeal and ask for continued benefits right away by phone to make sure you’re on time. Follow up in writing.

Visit Washington Healthplanfinder or call 1-855-923-4633.

To make sure you have no gaps in health coverage, you must do both of these: 

1. Select a plan by the 15^th of the month before the month you want the coverage to start.
2. Pay the premium by the due date.

The due date the plan sets in the bill should be no earlier than the coverage start date and at least 15 days after the bill. 

Check with the health plan to find out how and when to send the payment.