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Washington health insurance

Nine insurers offer 2020 health plans; Washington expects to have public option plans available for purchase as of November 2020.

Health insurance in Washington

Washington’s health marketplace

State legislative efforts to preserve or strengthen provisions of the Affordable Care Act

Washington State is one of the states fighting the hardest to preserve the Affordable Care Act’s gains. See the steps Washington has taken.

Washington State operates its own exchange, Washington Healthplanfinder. The state also has a strong off-exchange market (though subsidies are only available through Washington Healthplanfinder.)

Carrier participation in the exchange is robust, with nine insurers offering plans on Washington Healthplanfinder.

Enrollment in plans for 2020 ended up at 212,000 people, which was the second straight year of declining enrollment.

Read more about Washington State’s health insurance marketplace.

COVID-19 special enrollment period extended until May 8, 2020

Open enrollment for 2020 coverage in Washington ended on December 30, 2019. The next open enrollment period, for coverage effective in 2021, will begin on November 1, 2020. But due to the COVID-19 pandemic, Washington Healthplanfinder opened up a special enrollment period in order to allow uninsured residents to sign up for health coverage through the exchange. Washington was the first state to do this, but nearly all of the other state-run exchanges have followed suit.

Washington Healthplanfinder’s special enrollment period was initially scheduled to end on April 8, but it has been extended through May 8. People who enroll by April 8 will have coverage effective April 1. People who enroll between April 9 and May 8 will have coverage effective May 1.

The special enrollment period only applies to people who don’t have minimum essential coverage, so people who are already insured cannot use this as an opportunity to change plans (although they can change plans if they have a qualifying event, as is always the case). Coverage such as short-term health insurance and health care sharing ministry plans are not considered minimum essential coverage though, so people with these types of coverage do have an opportunity to enroll in ACA-compliant coverage during the COVID-19 special enrollment window.

A public option: Washington is a state to watch

In 2019, Washington enacted legislation (S.B.5526; the House version was H.B.1523) that calls for the creation of a “public option” health plan in the state, starting in 2021. The term “public option” has often been used to describe Medicaid buy-in programs and new coverage options that are administered by the government (at the state or federal level), but Washington’s approach is different, and the details are clarified in the final version of the legislation, which was signed into law by Governor Jay Inslee in May 2019.

[Nevada lawmakers passed a Medicaid buy-in public option in 2019, but the governor vetoed it. Colorado enacted legislation in 2019 that directed the state to explore a public option that would leverage current infrastructure, but without directing exactly how the program would work — that’s up to the legislature to sort out in 2020, although state regulators have provided substantial guidance and the program is expected to be available by 2022. Washington’s public option is thus expected to be the first in the nation, although some have argued that its design will be different from what people tend to think of as a “public option.” This side-by-side analysis shows a high-level comparison of what Washington and Colorado are doing with their programs.]

Under the terms of S.B.5526, Washington will contract with one or more private health insurance companies to offer qualified health plans at the bronze, silver, and gold levels in the Washington exchange starting in 2021. The plans, dubbed “Cascade Care,” will be standardized, and at least initially, they will also cap provider reimbursements at 160 percent of the Medicare reimbursement amounts (with the exception of rural hospitals, which will be guaranteed reimbursements of at least 101 percent of Medicare-approved costs, primary care providers, whose reimbursements will be at least 135 percent of Medicare rates, and instances in which the plan can’t develop an adequate network under the prescribed reimbursement constraints; note that there were several earlier versions of the legislation, so while the bill initially called for rates to be equal to Medicare reimbursement, lawmakers eventually settled on 160 percent of Medicare rates in an effort to ensure adequate provider participation).

The idea behind S.B.5526 is to provide additional plan options to individual market enrollees, and the state hopes that the cap on reimbursement rates will result in premiums that are 5-10 percent lower than other plans in the market. But the legislation does not require the Cascade Care plans to be available statewide. The hope is that they will be, but the legislation states that an insurer’s contract with the state would be to offer the plans “in a single county or in multiple counties.”

S.B.5526 also directs the state to “develop a plan to implement and fund” premium subsidies for people with modified adjusted gross income up to 500 percent of the poverty level. Under the ACA, the federal government provides premium subsidies to people with MAGI up to 400 percent of the poverty level, but people with income between 400 and 500 percent of the poverty level are often impacted by the subsidy cliff, which can be particularly onerous for older enrollees and people in areas where premiums are particularly high.

Another provision of S.B.5526 directs the state to create up to three standardized plan designs at the bronze, silver, and gold metal levels (several states already have standardized plans, but Washington is not among them). Insurers that offer plans in the exchange would have to offer at least one standardized plan at the silver and gold level starting in 2021 (and at the bronze level, assuming the insurer offers any plans at the bronze level — which is not always the case in Washington).

The legislation allows insurers to continue to also offer non-standardized plans, but it directs the state to analyze what the impact would be if all plans were required to be standardized starting in 2025. A report on this will be delivered to the legislature by 2023 so they can take action to require all plans to be standardized by 2025 or not, depending on what the analysis determines. California is currently the only state that requires all plans to be standardized.

Medicaid expansion in Washington State

When the ACA was implemented in 2014, Washington accepted federal funding to expand Medicaid eligibility to those earning up to 138 percent of poverty. In early 2014, the Kaiser Family Foundation estimated that about 47 percent of the uninsured population in Washington would be eligible for expanded Medicaid or CHIP.

As a result of Medicaid expansion, total enrollment in Washington Medicaid and CHIP grew by more than 622,000 people between the fall of 2013 and August 2018. That was an enrollment growth of 56 percent, the eighth-highest percentage increase in the nation.

Read more about Medicaid expansion in Washington State.

Short-term health plans in Washington State

Washington insurance regulators implemented new rules for short-term health insurance plans, which took effect in January 2019, limiting the plans to no more than three months in duration and prohibiting renewals.

The new state regulations also include a list of other provisions designed to help consumers avoid confusion during open enrollment and protect buyers with pre-existing conditions.

Read more about short-term health insurance in Washington State.

How has Obamacare helped Washington residents?

Since the Affordable Care Act took effect in 2013, Washington has seen one of the nation’s greatest reductions in the percentage of uninsured residents.

According to U.S. Census data, 14 percent of Washington residents were uninsured in 2013, and that had dropped to 6 percent by 2016. For perspective, the national uninsured rate was 14.5 percent in 2013, and had fallen to 8.6 percent by 2016. By 2018, the uninsured rate in Washington had inched up a little, to 6.4 percent (nationwide, the uninsured rate also increased slightly by 2018 — under the Trump administration — to 8.9 percent).

As a result of Washington’s decision to expand Medicaid (Apple Health), enrollment in Washington Medicaid and CHIP grew by 53 percent between the fall of 2013 and late 2019.

Washington’s elected officials and the ACA

In 2010, both of Washington’s U.S. Senators – Maria Cantwell and Patty Murray – were supportive of the health reform law. Both are still in the Senate and have continued to defend the ACA while calling for improvements to the law.

Washington’s U.S. House delegation includes ten representatives, with a seven-three margin for Democrats in 2020. The seven Democrats are supportive of the ACA or additional health care reforms (such as a shift towards a single-payer system), while the three Republicans support either full repeal or significant modification of the law.

Gov. Jay Inslee, a Democrat, is very supportive of the ACA and has enthusiastically worked with his state officials to implement the law in Washington. The state is running the Washington Health Benefit Exchange and also opted to expand Medicaid.

Does Washington have a high-risk pool?

Before the ACA brought guaranteed issue health insurance to the individual market, plans were underwritten in nearly every state. Pre-existing conditions could prevent an applicant from getting a policy at all, or could result in significantly higher premiums or policy exclusions. The Washington State Health Insurance Pool (WSHIP) was created in 1987 to provide people with an alternative if they weren’t able to get private health insurance because of their medical history.

Now that the ACA has been implemented, all health insurance plans are guaranteed issue, largely eliminating the need for risk pools. But WSHIP is one of a few state-run pools that is still operational and will be for the next few years – and indefinitely for some Medicare enrollees.

The pool closed to most new non-Medicare enrollees at the end of 2013, but existing members can stay on the plan until the end of 2017. Under some conditions, WSHIP is continuing to enroll Medicare members as well as some non-Medicaid eligible applicants.

Medicare in the Evergreen State

As of late 2019, there were 1,374,926 Washington residents with Medicare coverage. That’s about 17.5 percent of the state’s population – slightly lower than the national average.

You can read about Medicare in Washington, including the state’s robust consumer protections for Medigap enrollees, as well as details about Medicare Advantage and Medicare Part D plans in Washington.

Washington State health insurance resources

State-based healthcare reform legislation

The Washington legislature has been very active in the area of healthcare, addressing numerous issues that impact public health. In 2019, several pieces of health care reform legislation were implemented including:

  • H.B.1065, which provides strong consumer protections against surprise balance billing for emergency services received at out-of-network facilities and also for services performed by an out-of-network provider at an in-network facility. Washington Insurance Commissioner, Mike Kreidler, has long championed legislation to protect consumers from surprise balance billing, and was a driving force behind 2019’s successful effort (see his summary of the 2019 legislation here). Similar legislation failed to pass in 2017 (H.B.2114) and 2018 (HB 2114) but lawmakers successfully revisited the issue and it was signed into law in May 2019, and takes effect in January 2020:
    • The new law applies to plans that are regulated by the Washington Insurance Commissioner. This does not include self-insured group plans — which account for the majority of very large group plans — which are regulated by the federal government instead, under ERISA. Self-insured group plans can choose to opt into the state’s balance billing protection rules.
    • It requires insurers to maintain adequate networks.
    • Out-of-network providers cannot balance bill patients in emergency situations or in situations in which the out-of-network services were received at a facility that was in-network with the patient’s insurance.
    • In these situations, insurers must pay out-of-network providers “a commercially reasonable amount, based on payments for the same or similar services provided in a similar geographic area.”
    • If the provider and insurer don’t agree on the payment amount, it is sent to binding arbitration. The patient is no longer caught in the middle.
  • H.B.1870, which codifies ACA consumer protections into state law.
  • S.B.5526, which creates standardized plans, a public option, and additional premium subsidies.
  • S.B.5741, which improves the state’s all-payer claims database.

Scroll to the bottom of this page for a summary of other recent Washington bills related to healthcare reform.

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 Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.