Washington, DC Health Insurance Consumer Guide

To be eligible to enroll in private individual/family health coverage through DC Health Link, you must:⁶

• Be lawfully present in the United States, and reside in Washington, DC
• Not be incarcerated
• Not be enrolled in Medicare⁷

So most DC residents can enroll in a health plan through the exchange. But eligibility for financial assistance involves some additional parameters. To qualify for income-based federal Advance Premium Tax Credits (APTC) or cost-sharing reductions (CSR), you must:

• Not be eligible to enroll in an affordable plan offered by an employer. If you have access to an employer’s plan and are wondering whether it’s considered affordable, you can use our Employer Health Plan Affordability Calculator to see if you might qualify for premium subsidies via DC Health Link. 
• Not be eligible for DC Medicaid.
• Not be eligible for premium-free Medicare Part A.⁷
• If married, file a joint tax return with your spouse.⁸ (with very limited exceptions)⁹
• Not be able to be claimed by someone else as a tax dependent.⁸

In addition to those basic parameters, DC Health Link premium subsidy eligibility will depend on your household’s income.

In Washington, DC, the open enrollment period begins November 1 and continues through January 31,¹⁰¹¹ which is a couple weeks longer than the enrollment window in most states.

After the open enrollment period ends, you may still be able to enroll or make a plan change if you experience a qualifying life event, such as giving birth or losing other health coverage. 

DC Health Link is one of several state-run exchanges where pregnancy is considered a qualifying life event, making it easier for someone who is pregnant to obtain health coverage.

Some people can enroll year-round even without a specific qualifying life event. And enrollment in DC Medicaid is available year-round. (You can enroll at districtdirect.dc.gov.)

To enroll in an ACA Marketplace/exchange plan in the District of Columbia, you can: 

• Visit DC Health Link – the District’s exchange – to compare the health plans that are available in your area, determine whether you’re eligible for financial assistance, and enroll in coverage during open enrollment or during a special enrollment period. 
• Enroll in a DC Health Link plan with the help of an insurance agent or broker, Navigator, or a certified enrollment assister.

When you enroll in coverage through DC Health Link, you may find that you’re eligible for subsidies that can cover some of your monthly premiums and possibly also reduce your out-of-pocket costs for medical care.

These subsidies are not as common in DC as they are in other states, simply because Medicaid eligibility extends to higher income levels in DC, meaning that many people qualify for Medicaid instead of premium subsidies for private plans. (For adults under age 65, the eligibility limit for Medicaid in DC is 215% of the poverty level, as opposed to 138% in most states.¹²) 

In addition, the fact that there is no “off-exchange” enrollment option in DC also helps to reduce the percentage of subsidy-eligible exchange enrollees. (In other states, people who know they aren’t eligible for subsidies might opt for off-exchange coverage, whereas that’s not possible in DC.) 

So only 22% of DC Health Link enrollees were receiving federal premium subsidies as of 2024, versus 93% of Marketplace enrollees nationwide.¹³

Source: CMS.gov¹⁴

Premium subsidy eligibility will depend on how your household income compares with the cost of the second-lowest-cost Silver plan in your area, which will depend on your age. (In most states, it also depends on your location, but DC is one rating area so there are no location-specific rate differences within the District.¹⁵)

Applicants with household income up to 250% of the federal poverty level are also eligible for federal cost-sharing reductions (CSR), which will reduce the deductible and other out-of-pocket expenses for Silver-level plans. But only 3% of DC Health Link enrollees were receiving these subsidies as of 2024, versus 50% of Marketplace enrollees nationwide.¹³Again, this is due in large part to the fact that people with income between 139% and 215% of the poverty level are eligible for Medicaid in DC, whereas they’re eligible for premium subsidies and CSR in other states.

The plans available through DC Health Link include both standardized and non-standardized plans. All of the plans comply with the ACA, but standardized plans also conform to additional District-specific rules that include pre-deductible coverage for various services.¹⁶ Starting in 2024, outpatient mental health visits for children with standardized DC Health Link plans have only a $5 copay, with no deductible.¹⁷

Learn more about whether you might be eligible for Medicaid in Washington DC.

DC Health Link offers individual/family health insurance from two insurers, although one of them (CareFirst) has both HMO and PPO entities offering plans, while the other (Kaiser) only offers HMO plans.¹⁸

Each of these entities will continue to offer coverage in 2025.¹¹

The following average rate changes have been approved for 2025 individual/family coverage, amounting to a weighted average rate increase of 4.7%, before any subsidies are applied:¹¹

Source: DC Department of Insurance, Securities, and Banking¹¹

Average rate changes apply to full-price premiums, and most DC Health Link enrollees do pay full price (as opposed to most other states, where the large majority of Marketplace enrollees receive subsidies and thus do not pay full price).¹³

But for those who qualify for premium subsidies, the net rate change from one year to the next will depend on how much the subsidy amount changes, as well as how much their own plan’s rate changes.

For perspective, here’s a summary of how average full-price premiums have changed in DC’s individual/family health insurance market over the years:

• 2015: Average increase of 11%.¹⁹
• 2016: Average increase of 4.3%.²⁰
• 2017: Average increase of 7.3%.²¹
• 2018: Average increase of 15.6%.²² (negligible CSR cost; not added to rates)
• 2019: Average increase of 13%.²³
• 2020: Average increase of 7.6%.²⁴
• 2021: Average increase of 0.2%.²⁵
• 2022: Average increase of 5%.²⁶
• 2023: Average increase of 13.6%.²⁷
• 2024: Average increase of 7.8%:²⁸

For 2024 coverage, 14,799 people enrolled in individual/family health plans through DC Health Link during the open enrollment period.²⁹

In most states, Marketplace enrollment has trended upward significantly in the last few years, but that has not been the case in the District of Columbia.

Source: 2014,³⁰ 2015,³¹ 2016,³² 2017,³³ 2018,³⁴ 2019,³⁵ 2020,³⁶ 2021,³⁷ 2022,³⁸ 2023,³⁹ 2024⁴⁰

In contrast to the rest of the U.S., the majority of DC Health Link’s enrollees have small group coverage. As of June 2024, DC Health Link’s enrollment included more than 14,000 people with individual/family coverage, and more than 86,000 people with small-group coverage.⁴¹ 

DC Health Link
The District’s health insurance exchange (Marketplace) for small businesses, individuals, and families.

DC Department of Health Care Finance
Administers DC’s Medicaid program and various other social services programs in the state. 

District of Columbia Department of Insurance, Securities & Banking
Licenses and regulates health insurance companies, brokers, and agents in the District. Provides assistance and information to consumers who have questions or complaints about regulated entities.

DC Department of Aging and Community Living
A resource for DC Medicare beneficiaries and their caregivers.