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Additional state-funded subsidies available to households with income up to 250% FPL in 2023, via new Cascade Care Savings plans
The state of Washington operates its own health insurance exchange – Washington Healthplanfinder.
Twelve insurers offer plans through the exchange for 2023, which is the same as 2022 insurer participation (for 2023, Community Health Network of Washington’s plans have moved to their affiliate, Community Health Plan of Washington).
Public option (Cascade Select Plans) and standardized plans (Cascade Plans) — collectively known as Cascade Care — became available as of 2021. As of 2023, Washington is providing state-funded subsidies for people with income up to 250% of the poverty level if they enroll in Cascade Care plans at the silver or gold metal levels. This subsidy program is known as Cascade Care Savings.
Washington is also working to secure federal permission to allow undocumented immigrants to enroll in health plans through Washington Healthplanfinder starting in 2024 (without any federal subsidies). If successful, this would allow the state to provide this population with Cascade Care Savings subsidies if their income doesn’t exceed 250% of the poverty level.
Washington runs its own exchange, Washington Healthplanfinder.
Washington was one of the first states to move ahead with a state-run health insurance marketplace as envisioned by the Affordable Care Act. Former Gov. Chris Gregoire signed legislation creating the state exchange in May 2011.
For the first two years it was in operation, Washington Healthplanfinder collected premiums from enrollees and sent them to insurers (enrollees had the option to send payments directly to the insurers, but about 80% opted to pay premiums to the exchange). But the exchange struggled with billing problems and ultimately decided to switch to the approach used in other states, in which enrollees pay their premiums directly to insurers, rather than the exchange. This change took effect in September 2015.
Washington Healthplanfinder charges a per member per month fee to fund the exchange. For 2016 through 2018, the fee was $7.46 per member per month. So a family of four was paying almost $30/month in fees to fund the exchange, as part of their health insurance premiums. But because enrollment grew so much in 2018, and because the exchange has been working to improve its financial efficiency, the fee was reduced by 55% for 2019, to just $3.36 per member per month. Although enrollment declined in 2019, the exchange kept the $3.36 per member per month fee in effect for 2020 as well (and reduced the fee on dental plans from $1.54 to $0.81 per member per month).
In March 2014, Washington legislators tried to pass a bill that would have created much more transparency in the state’s health insurance industry, providing consumers with data on how much insurers are paying for services in each region of the state. It had widespread support, but opposition from Premera Blue Cross — the state’s largest insurer — sank the bill and Washington did not join the 11 other states that had all-payer claims databases by 2014. But lawmakers persisted, and in 2015, SB5084 was signed into law, advancing the process of creating an all-payer claims database in Washington state. Subsequently, S.B.5741 was enacted in 2019, to improve the state’s all-payer claims database.
For 2023 coverage, there are twelve insurers that offer exchange plans in Washington, with coverage areas that vary from one insurer to another:
For 2023, Community Health Network of Washington clarified that their plan would be moving to their affiliate, Community Health Plan of Washington. Enrollees will be automatically enrolled into the corresponding new Community Health Plan of Washington plan during the open enrollment period for 2023 coverage (but will have the option to pick a different plan, as is always the case during open enrollment). Community Health Plan of Washington will also be available in two new counties — Ferry and Whitman.
PacificSource is expanding its coverage area significantly for 2023, adding 11 new counties.
Insurer participation in Washington’s exchange has changed significantly over time (a detailed list of the counties where each carrier offered plans is available here).
In 2019, there were 14 counties in Washington with only one insurer offering plans in the exchange, up from nine in 2018. And when rates were initially filed for 2018, there were two counties where no insurers had proposed plans. That was eventually remedied before the start of open enrollment, but lawmakers also wanted to address the issue in the 2018 legislative session.
H.B. 2408 (signed into law in March 2018) mandates that as of 2020, any insurer that offers coverage to school employees must also offer at least one silver and one gold plan in the individual market via Washington Healthplanfinder in any areas where the insurer offers coverage for school employees. In the meantime, if necessary, the legislation would have made coverage in the Washington state health insurance pool more affordable for people who live in counties where no insurers offer exchange plans. But all areas of the state have continued to have plans available in the exchange from at least one insurer.
Here’s a summary of insurer participation in Washington’s exchange has changed over time:
The open enrollment period in Washington runs from November 1 to January 15. Outside of open enrollment, a qualifying event is necessary to enroll or make changes to your coverage.
Native Americans can enroll at any time. And so can anyone who is eligible for Apple Health (Medicaid) in Washington. There is also a year-round special enrollment opportunity for applicants who are eligible for Cascade Care Savings and who enroll in a Cascade Care plan at the silver or gold level.
In May 2022, the Washington Office of the Insurance Commissioner published a summary of the proposed individual/family market rate changes for 2023, along with a chart showing the counties where each insurer will offer plans in 2023. The average approved rate change ended up being slightly larger than the insurers had initially proposed, at 8.1%.
The dozen insurers that offer plans in Washington’s exchange have implemented the following average rate changes, which amount to an overall average increase of 8.1% (up the 7.2% average rate increase the insurers had proposed):
In addition, two insurers offer coverage only outside the exchange: Asuris Northwest, and Providence Health Plan (a third insurer, Health Alliance Northwest, offered plans outside the exchange as of 2022, but does not appear to be continuing those plans for 2023).
For 2020 and 2021, average rates declined in Washington’s individual market, but they increased modestly for 2022, and increased again for 2023.
When the exchange began offering health plans for 2014, premiums were essentially an educated guess, as there was no ACA-compliant individual market claims experience on which to base rates. Here’s a summary of how full-price (ie, pre-subsidy) premiums have changed over the years in Washington’s exchange:
239,566 people enrolled in private plans through Washington Healthplanfinder during the open enrollment period for 2022 coverage. This was nearly a record high, but didn’t quite reach 2018’s enrollment, when more than 242,000 people signed up during open enrollment (nationwide, enrollment hit a record high in 2022).
For perspective, here’s a look back at enrollment in Washington Healthplanfinder since the exchange opened for business in 2014:
2014: As of April 2019, 163,207 people had enrolled in private health plans through Washington Healthplanfinder and paid their premiums to effectuate their coverage. In addition to the private plan enrollments, 909,752 people had enrolled in Medicaid through the Washington exchange by mid-April (nearly half of those people were already enrolled previously, but renewed their Medicaid coverage through the exchange).
2015: Total enrollment in qualified health plans through Washington Healthplanfinder amounted to 160,732 people by the end of open enrollment. On April 22, Washington Healthplanfinder announced that total private plan enrollment for 2015 had reached 170,101 people. This was the third-highest total (behind California and New York) of any of the state-run exchanges. All of these enrollees had paid for their coverage; Washington only reported enrollments in 2014 and 2015 if they were paid-up.
2016: HHS announced that Washington Healthplanfinder’s total enrollment for 2016 was 200,691 as of February 1 (this was the first year that Washington switched to reporting all enrollments — instead of only effectuated enrollments — bringing them into line with how most other states’ enrollments are reported). In June 2016, Washington Healthplanfinder reported that 169,182 people had effectuated their coverage for 2016.
2017: By the time 2017 open enrollment ended, more than 225,000 people had enrolled in private plans (QHPs) through the exchange. This was a 13% increase from the year before, which was notable given that total enrollment among states using HealthCare.gov was slightly lower in 2017 than it was in 2016 (the Trump Administration reduced advertising for HealthCare.gov in the final week of enrollment, while state-run exchanges like Washington Healthplanfinder were able to continue their advertising efforts as planned).
2018: Enrollment in Washington’s exchange reached a record high in 2018, with 242,850 people enrolled in private plans (CMS reported a slightly higher official enrollment total of 243,227). Although HealthCare.gov switched to a much shorter enrollment window (just over six weeks long) for 2018 coverage, Washington Healthplanfinder was one of ten state-run exchanges that opted for a longer enrollment window that year, allowing people to enroll until January 15, 2018.
2019: Enrollment dropped in 2019, with 220,765 people purchasing plans during open enrollment. Nationwide, there was an average decline in enrollment, although it was only about 2.4 percent. And among state-run exchanges, average enrollment increased slightly in 2019. Washington Healthplanfinder was one of just four state-run exchanges (out of 12 total) where enrollment declined in 2019.
2020: Enrollment dropped again, to 212,590.
2021: Enrollment grew to 222,731. And more than 57,000 people enrolled in plans through Washington’s exchange during the COVID/American Rescue Plan special enrollment period, which ran from February 15 to August 15, 2021.
2022: Enrollment grew to 239,566 people, nearly reaching the record high that had been set in 2018.
Under the Affordable Care Act, a person must be lawfully present in the United States in order to enroll in a health plan through any exchange — including those that are fully state-run.
Washington has submitted a 1332 waiver proposal to the federal government, asking that Washington Healthplanfinder be allowed to open up eligibility to include undocumented immigrants as of 2024 (but without eligibility for federal premium subsidies, so the federal government would not be funding any of the cost for undocumented immigrants to enroll).
The waiver proposal was submitted in May 2022, and a public comment period ran through mid-July 2022. You can read the details of the state’s waiver proposal here, and see the public comments that were received (100% of the public comments were in support of the waiver proposal, and urged CMS to approve the waiver).
If this waiver is approved, it would be the first of its kind in the country in terms of allowing undocumented immigrants to use the health insurance exchange. California submitted a similar waiver proposal in late 2016, but withdrew it in early 2017 on fears that the Trump administration might use immigration data obtained by the exchange to aid in deporting people. But Colorado has created a separate platform (Colorado Connect/OmniSalud), which is not part of the state’s health insurance exchange, to allow undocumented immigrants to enroll in coverage as of 2023, with state-funded premium subsidies.
The idea behind Washington’s waiver proposal is to allow undocumented immigrants to obtain coverage through the exchange, and to receive financial assistance through the state-funded Cascade Care Savings program, which debuted as of the 2023 plan year and is described in much more detail further down this page.
Under the Cascade Care Savings program, the state provides subsidies to make Cascade Care coverage (standardized or public option plans) more affordable for people with household income up to 250% of the poverty level. But people have to enroll through Washington Healthplanfinder in order to benefit from the state subsidies, and ACA rules prohibit undocumented immigrants from enrolling through an exchange.
So the state is seeking to waive the rule, through at least 2033, in order to allow undocumented immigrants to take advantage of state-funded subsidies. But undocumented immigrants would still be ineligible for federally-funded premium tax credits.
As of late 2022, Washington’s 1332 waiver proposal was still under review by CMS.
The budget legislation enacted in Washington in 2021 provides funding for a new program to help child-care workers obtain health coverage. Enrollment in the program began November 1, 2021, and funding has been allocated to provide benefits through the end of 2023.
Employees of licensed child-care facilities are eligible for the program as long as their household income isn’t more than 300% of the poverty level (for 2023, that’s $40,770 for a single individual, and $83,250 for a family of four), and as long as they’re not eligible for Medicare or Medicaid.
Eligible enrollees can obtain premium-free coverage as long as they enroll in a Cascade Care (standardized) Silver plan and accept all federal subsidies that are available to them.
The state initially allocated $30 million to cover the 2022 premium costs that these enrollees would otherwise have had to pay themselves, after the federal premium subsidies are applied. And the legislature subsequently extended funding for the program through 2023.
Up to 36,000 child-care workers in the state are potentially eligible for the program, and Washington Healthplanfinder reported in late 2021 that several hundred had enrolled just in the first couple of weeks after enrollment began.
Washington S.B.5313, enacted in May 2021, requires Washington’s Medicaid program (Apple Health) and state-regulated health insurance plans to cover medically necessary gender-affirming health care as of January 2022. The Medicaid program added this care in May 2021, well in advance of the requirements in the new legislation.
All plans sold in the Washington exchange are regulated by the state, so the new requirement for gender-affirming care coverage apply to all of them. State laws do not affect self-insured group health plans, however, as they are regulated at the federal level instead. Nationwide, the majority of workers with employer-sponsored health coverage are enrolled in self-insured plans.
In May 2019, Washington enacted legislation (S.B.5526; the House version was H.B.1523) calling for the creation of standardized health plans and a “public option” health plan (available as of 2021), plus additional premium subsidies that will be available for the 2023 plan year. The legislation is known as “Cascade Care” and implementation work began as soon as the bill was enacted.
HealthCare.gov is once again offering standardized plans as of 2023, and several states already had standardized plans available through state-run exchanges. Washington joined them for 2021, with standardized plans — and a public option in about half of the state’s counties — available through Washington Healthplanfinder.
As outlined in a 1332 waiver proposal that Washington submitted in 2022, the standardized plans are known as Cascade Plans, while the public option plans (which are also standardized) are known as Cascade Select Plans. Together, they’re referred to as Cascade Care.
In July 2020, the state confirmed that five insurers would offer Cascade Select Plans (public option plans) in 2021, but noted that the public option plans would only be available in 20 of the state’s 39 counties in 2021. There are still five insurers offering Cascade Select Plans in 2022, and the plans are available in 25 counties. Standardized plans (Cascade Plans) are available statewide.
Roughly a third of all Washington Healthplanfinder enrollees have Cascade Care plans as of 2022, but it’s unclear how that’s divided across Cascade Plans versus Cascade Select Plans.
Standardized plans (Cascade Plans, or Cascade Care Standard)
Under the terms of the Cascade Care legislation, Washington officials were tasked with designing up to three standardized plan designs at the bronze, silver, and gold metal levels. In October 2019, the exchange published a draft proposal with four standardized plan designs: One gold, one silver (plus CSR variations), and two bronze, one of which is an HDHP and would allow an enrollee to contribute to an HSA.
The standardized plan designs include a wide variety of services, all of which are covered with the same cost-sharing regardless of which insurer offers the plan (ie, the deductible, out-of-pocket maximum, coinsurance, and various copays would be the same from one plan to the next). The idea is to make it easier for a consumer to compare plans based on things like provider networks and customer service, since the dollar-level benefits won’t vary.
Insurers that offer plans in the exchange had to offer at least one standardized plan at the silver and gold level starting in 2021. If an insurer offers plans at the bronze level, they have to offer at least one standardized bronze plan, but some Washington insurers have chosen, in some years, to not offer bronze plans. (For the 2023 plan year, all of Washington Healthplanfinder’s insurers will offer plans at the bronze level.)
(For the public option, discussed below, insurers must offer plans at each metal level, including bronze.)
Cascade Care 2.0 legislation, which was enacted in 2021, simplifies the standardized plans so that there is just one at each metal level; participating exchange insurers must offer the standardized silver and gold plans, and if they offer any bronze plans, they must offer the standardized bronze plan.
For the time being, insurers are able to continue to also offer non-standardized plans, but the state will have to analyze what the expected impact would be if all plans were required to be standardized starting in 2025, with a report that has to be delivered to the legislature by 2023. California requires all plans to be standardized, but all of the other states with standardized plan designs also allow insurers to offer non-standardized plans.
Public option (Cascade Select Plans, or Cascade Care Select) and changes under Cascade Care 2.0 (2021 legislation)
Washington’s public option plan, which became available for purchase in the fall of 2020, for coverage effective in 2021, is the first of its kind in the nation. But some have argued that its design is different from what people tend to think of as a “public option,” as that term is often used to describe Medicaid buy-in programs and new coverage options that would be administered by the government. But Washington is taking an approach that involves private insurers.
(Colorado has created a public option program, but the version that was ultimately enacted — for coverage effective in 2023 — involves standardized, highly regulated private plans instead of a government-run public option; Nevada enacted public option legislation in 2021, but the plans won’t be available until 2026.)
Washington’s Cascade Care “public option” program involves the state contracting with five private health insurance companies to offer standardized qualified health plans at the bronze, silver, and gold levels in the Washington exchange. The standardized plan designs are the same as the regular standardized plans detailed above, but the public option versions were expected to have lower premiums due in large part to lower reimbursements for medical care. This has not turned out to be the case however, with the public option rates as much as 29% higher than other plans’ rates in 2021.
The idea behind S.B.5526 was to provide additional plan options to individual market enrollees. But the legislation does not require the Cascade Care plans to be available statewide. An insurer’s contract with the state would be to offer the plans “in a single county or in multiple counties.” They were available in 20 of the state’s 39 counties for 2021, and in 25 counties as of 2022.
Ultimately, only about 2.5% of all new enrollees in Washington’s marketplace selected Cascade Care Select (public option) plans during the open enrollment period for 2021 coverage. There was far higher enrollment under the overall Cascade Care umbrella, but most people chose standardized plans (Cascade Plans) as opposed to public option plans (Cascade Select Plans).
For most services, the public option plans cap provider reimbursements at 160% of the Medicare reimbursement amounts (there are exceptions for rural hospitals and primary care, and also for situations in which the plan can’t maintain an adequate network under the prescribed reimbursement constraints).
The initial Cascade Care legislation went through several iterations, and the cap on provider reimbursements changed each time, but lawmakers ultimately settled on 160% of Medicare rates — a middle-of-the-road approach designed to keep pricing at least a little lower than other comparable plans (the state was aiming for 5-10% lower), while still ensuring adequate provider participation.
Legislation (S.B.5377) introduced in 2021 initially called for capping the hospital reimbursement rate at 135% of Medicare rates, and requiring hospitals and surgical facilities that receive reimbursement from public health plans (Medicaid, as well as the plans for public employees and school employees) to be in-network with a public option plan, if the public option plan requests this.
S.B.5377 was signed into law in May 2021, but those initial measures were watered down substantially. There is no longer a reimbursement cap of 135% of Medicare rates (instead, it’s still 160%), and the participation requirements have been changed as well.
Under the final version of the bill (which was still controversial), if there are areas of the state that still don’t have public option plans available as of 2022, any hospital that contracts with the state for Medicaid or public employee health benefits would have to enter into a network agreement with at least one public option plan, assuming it receives a network offer. That rule change will take effect as of 2023, since there are still 14 counties in 2022 that don’t have public option plans available.
State-based premium subsidies (Cascade Care Savings) debut for the 2023 plan year for applicants with household income up to 250% FPL
2019’s S.B.5526 also called for the state to “develop a plan to implement and fund” premium subsidies for people with modified adjusted gross income up to 500% of the poverty level. (At that time, federal ACA premium subsidies extended to enrollees with MAGI up to 400% of the poverty level, creating a subsidy cliff above that level. But the American Rescue Plan temporarily eliminated the subsidy cliff nationwide, and the Inflation Reduction Act extended that through 2025.)
S.B.5526 was an effort to help make coverage more affordable for people in this income range, and called for net premiums to be capped at 10% of MAGI. Washington Healthplanfinder worked with stakeholders to develop a state-based premium proposal, and submitted their report to the legislature in October 2020. The idea was that lawmakers would then be able to act on the report during the 2021 legislative session, to create state-based premium assistance. (H.B.2901 was introduced in 2020, calling for the creation of state-based premium subsidies that would have been available by 2022. But it did not advance in the 2020 session.)
S.B.5377, which was enacted in 2021, created the framework for the state-based subsidies, which debuted for the 2023 plan year. But the income limit for eligibility was reduced to 250% of the poverty level, in an effort to concentrate financial assistance on enrollees with income at the lower end of the spectrum (the text of the final legislation does not specify an income cap, but the Washington State Senate clarified the specifics in a letter to Governor Inslee).
S.B.5377 clarifies that eligible enrollees will be able to receive the state-based subsidies as long as they’re enrolled in a silver or gold standardized plan (an earlier version of S.B.5377 would have required the enrollee to be covered under the lowest-cost bronze, silver, or gold standardized plan available in their area, but this has been amended during the legislative process).
The amount of the state-funded premium subsidy varies depending on age, income, and location (just like federal premium subsidies), but most eligible enrollees can get coverage for less than $10/month. And the state-funded subsidy can result in some Cascade Care Savings enrollees paying $0/month for their coverage, which was not previously available in Washington (all health plans in Washington’s exchange cover abortion, which means that federal premium subsidies cannot cover the full cost, as at least $1/month must be allocated to an abortion coverage fund that cannot be paid with federal premium subsidies).
As described above, Washington is also seeking federal permission to allow undocumented immigrants to enroll in coverage through Washington Healthplanfinder as of 2024. They would not be eligible for federal premium tax credits, but if the waiver proposal is approved, the state would be able to provide eligible enrollees with the state-funded premium subsidy (for incomes up to 250% of the poverty level), regardless of their immigration status.
Several other states offer state-funded subsidies as of 2023, either to reduce premium costs, cost-sharing amounts, or both.
Governor Jay Inslee signed H.B.1065 into law in 2019, after similar bills failed in the two previous legislative sessions. The new law, summarized here by Insurance Commissioner Mike Kreidler’s office, took effect in January 2020 and provides strong consumer protections against surprise balance billing when a patient receives emergency treatment at an out-of-network facility, or visits an in-network facility but is treated by an out-of-network provider.
As of 2022, a federal law (the No Surprises Act) protects consumers nationwide from surprise balance billing. Unlike state laws, the No Surprises Act also applies to self-insured health plans, which are not subject to state laws.
Washington Healthplanfinder Business, the state-run SHOP exchange, reported in June 2015 that more than 100 small businesses had enrolled in small group plans for 2015. They also announced that they would make coverage available for businesses with up to 100 employees starting in November 2015. But that changed in October 2015 when President Obama signed HR1624 (the PACE Act) into law.
The law repealed the ACA provision that would have expanded the definition of “small group” to include businesses with up to 100 employees. States are free to independently define small groups as businesses with up to 100 employees, but in Washington, Insurance Commissioner Mike Kreidler announced that the state would go along with the PACE Act and continue to define small group plans as those with up to 50 employees.
By March 2016, a total of 174 employers had enrolled in coverage through Washington Healthplanfinder. The plans were covering 606 employees, and 164 dependents. UnitedHealthcare offered small group plans statewide through Washington Healthplanfinder Business in 2016, and Kaiser offered plans in Clark and Cowlitz counties (Moda had planned to offer small business plans state-wide as well, but their last-minute exit from the Washington market at the end of 2015 meant that there was just one state-wide SHOP option in 2016).
And for 2017, United’s exchange exit left Washington Healthplanfinder’s SHOP exchange limited to only Kaiser, and only in Clark and Cowlitz counties. The state noted however, that there continued to be a robust off-exchange market for small businesses, with 11 insurers offering plans in 2017 — although the small business health insurance tax credit is only available through the exchange.
By 2018, even Kaiser had stopped offering SHOP plans in Washington, so there are no longer SHOP plans for sale in the state. Small businesses can select from a wide range of off-exchange small group plans, however, all of which are compliant with the ACA.
Washington Insurance Commissioner Mike Kreidler and Governor Jay Inslee took a strong progressive stance with regards to consumer protections: existing plans that did not meet ACA standards were canceled at the end of 2013 and needed to be replaced in January 2014 with new, ACA-compliant policies. Following President Obama’s announcement that carriers could extend existing plans into 2014 if states allowed it, Kreidler and Inslee were quick to declare that Washington would not allow non-compliant plans to continue into 2014. Thus, the only non-ACA-compliant individual and small group plans in Washington are grandfathered plans; there are no grandmothered plans.
Washington Health Benefit Exchange
Information about marketplace planning and development
State Exchange Profile: Washington
The Henry J. Kaiser Family Foundation overview of Washington’s progress toward creating a state health insurance exchange.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.
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