Shopping for a health plan
Most health plans on the market include a standard set of benefits, also known as essential health benefits. These include services, such as maternity and newborn care, preventive services and prescription drug coverage. In addition, most plans cannot require preexisting condition waiting periods.
When shopping for health insurance, it's important to understand what services each policy you're considering covers and what your out-of-pocket costs may be. Find out if there is a coinsurance cost, copay or deductible and how often you will need to pay them. Read what the plan covers and if there are limits on the number of times you can access a service. Every plan is different.
Comparing health plans
If you're comparing health insurance policies and thinking about switching yours, make sure the type of care you're looking for is covered and that your current doctors are in the plan's network if you'd like to keep them. Look to see if any specific types of care are excluded. You'll also want to check out the plan's list of covered drugs — sometime's called the plan's formulary — to make sure your current prescriptions are covered.
Some health plans have special requirements to get care covered. For example, you may need prior authorization from a primary care provider before you access certain services or treatments.
To help you compare plans, use our health plan comparison form.
Your Summary of Benefits and Coverage
Once you've bought a health plan, your insurer should send you a Summary and Benefits of Coverage. If they don't, you have the right to ask for one. It's a document that explains your benefits and coverage in easy-to-understand language. It's also a good idea to make sure you understand how your health insurance claims process works in case you need to appeal a health insurance denial later.
Benefits your health plan must cover
Certain health benefits are required to be covered by Washington state law for individual, family and group plans that you purchase — for example, mammograms and mental health treatment. Benefits and services required by the federal Affordable Care Act (ACA) to be covered on individual, family and small employer health plans include:
- Ambulatory patient services: Covers outpatient care without being admitted to a hospital
- Emergency medical services in an emergency department: Covers services provided in an emergency department if a medical provider believes the patient is having an emergency
- Hospitalization: Surgery and overnight stays
- Maternity and newborn care: Coverage for maternity and newborn health care
- Mental health substance abuse disorder services: Behavioral treatment, mental and behavioral health inpatient services and substance abuse disorder treatment
- Lab services: Such as blood draws or urinalysis, a medical provider orders
- Pediatric services: Health care for children from birth to age 19, including dental and vision care
- Prescription drugs: Medications a medical provider prescribes that patients buy through a pharmacy
- Preventive and wellness services and chronic disease management: Preventive services, such as shots and screening tests, at no cost to the patient when a medical provider from the plan's network delivers the service
- Rehabilitative and habilitative services and devices: Services and devices to gain or recover mental and physical skills for people with injuries, disabilities or chronic condition
Learn more about health insurance options for people with disabilities (PDF 1.31MB).
Where you can buy a health plan
There are multiple ways you can find and buy health insurance. These are the most common.
Employer-related health insurance
You may be able to purchase health insurance through your employer, or through your spouse, domestic partner or parent's employer. These types of plans may be cheaper than policies purchased from the individual market because many employers pay a portion of your monthly premiums.
Generally, you can enroll in your employer health plan within the first 90 days of starting your job. If you miss your initial enrollment period, you'll need to wait until the next general enrollment unless you qualify for a special enrollment period. Your employer can tell you when the general enrollment period is each year.
If you lose your employment, you may be able to keep your insurance policy through COBRA.
Individual health plans
You can buy a health plan for yourself or your immediate family through the Washington Healthplanfinder or directly from an insurance company during the annual open enrollment period from November 1 through January 15. If you miss the enrollment period, you can still enroll if you qualify for Apple Health or a special enrollment period.
Apple Health
You may qualify for our state’s Apple Health program — also called Medicaid — if you cannot afford coverage for yourself or your kids. You can sign up for Apple Health through the Washington Healthplanfinder at any time during the year.
Medicare
You can qualify for Medicare if you are at least 65 years old or if you have received Social Security Disability benefits for at least 24 months.
Small business owner health insurance
If you have a small business (1-50 employees), you're not required to offer your employees health insurance. If you do, you might qualify for tax credits.
Small business owners may be able to purchase an association health plan or a small business health insurance plan. Businesses with 1-50 employees can buy health insurance from the small employer market directly from an insurance company or from an insurance agent or broker. They may also choose to not offer health insurance and let employees purchase their own individual health plans.