Understanding health insurance shouldn’t be complicated. Whether you’re applying for coverage for the first time, experiencing a change in income, or wondering whether you still qualify for Medicaid, understanding your options can help protect your health and your finances.

In Washington State, Medicaid is known as Washington Apple Health. It provides free or low-cost healthcare coverage to eligible residents, including children, adults, pregnant individuals, and people with certain disabilities.

But what happens when your income increases? Can you move from Medicaid to private health insurance? What if you lose your job and can no longer afford your current Marketplace plan?

And perhaps most importantly, what changes are coming to Medicaid in 2027?

This comprehensive guide explains everything Washington residents should know about Medicaid, including covered benefits, eligibility, financial requirements, enrollment, and transitioning between Medicaid and Qualified Health Plans (QHPs).

---

1. What Is Medicaid?

Medicaid is a government-funded health coverage program designed to help eligible individuals and families access necessary healthcare services.

The program is funded jointly by federal and state governments, but each state administers its own Medicaid program according to federal guidelines.

In Washington, Medicaid operates under the name Washington Apple Health and is administered by the Washington State Health Care Authority (HCA).

Apple Health provides access to a broad range of medical services, including preventive care, hospital treatment, prescription medications, behavioral healthcare, and other medically necessary services.

Unlike private Marketplace insurance, which generally requires enrollment during Open Enrollment or a qualifying Special Enrollment Period, eligible individuals can apply for Apple Health throughout the year.

Is Medicaid Only for People Who Are Unemployed?

No. This is one of the most common misconceptions about Medicaid.

Many working individuals and families qualify for Medicaid. Eligibility is determined by several factors, including household income, household size, age, residency, and the specific Medicaid program.

For example, a person working part-time, earning self-employment income, or experiencing inconsistent monthly income may still qualify for Apple Health.

Having a job does not automatically disqualify someone from Medicaid.

---

Important: Medicaid coverage is not unlimited. Some services require prior authorization, have benefit limitations, or are unavailable under certain eligibility categories.

2. What Does Washington Apple Health (Medicaid) Actually Cover?

One of the most important questions people ask when considering Medicaid is: Will it cover the healthcare services I actually need?

The answer is that Washington Apple Health provides comprehensive medical coverage for eligible individuals, including preventive care, emergency treatment, hospital services, prescription medications, mental healthcare, maternity care, and much more.

However, understanding what Medicaid covers requires knowing three important health insurance terms.

Understanding Minimum Essential Coverage, Essential Health Benefits, and Medicaid Benefits

Minimum Essential Coverage (MEC) refers to qualifying health coverage recognized under federal law. Most comprehensive Medicaid coverage qualifies as minimum essential coverage. However, some limited-benefit Medicaid programs do not.

Essential Health Benefits (EHB) are 10 categories of healthcare services established under the Affordable Care Act. Non-grandfathered individual and small-group health insurance plans generally must cover these categories.

Mandatory and Optional Medicaid Benefits refer to the services federal Medicaid law requires states to provide and the additional services states may choose to cover.

These terms are related, but they are not interchangeable.

For most adults who qualify through Medicaid expansion, coverage is provided through an Alternative Benefit Plan (ABP), which must include the 10 Essential Health Benefit categories.

Other Medicaid eligibility groups may receive benefits under a different state-plan framework.

The 10 Essential Health Benefits Explained

The Affordable Care Act identifies 10 major categories of healthcare services that form the foundation of comprehensive coverage.

1. Ambulatory Patient Services (Outpatient Care)

Outpatient care includes medical treatment that does not require admission to a hospital.

Examples include routine doctor visits, specialist appointments, outpatient procedures, and treatment for illnesses or injuries.

2. Emergency Services

Emergency services cover evaluation and treatment of serious medical conditions requiring immediate attention.

Examples include severe injuries, difficulty breathing, chest pain, and other medical emergencies.

3. Hospitalization

Hospitalization includes covered inpatient treatment, medically necessary surgeries, and related hospital services.

4. Maternity and Newborn Care

This category includes healthcare related to pregnancy, childbirth, and newborn care.

Examples include prenatal visits, labor and delivery, and covered postpartum services.

5. Mental Health and Substance Use Disorder Services

This includes covered behavioral health treatment for mental health conditions and substance use disorders.

Examples include counseling, psychiatric treatment, medication management, and substance use treatment programs.

6. Prescription Drugs

Prescription drug benefits help members obtain covered medications prescribed to treat or manage health conditions.

Specific medications may be subject to formularies, prior authorization, or other coverage requirements.

7. Rehabilitative and Habilitative Services and Devices

Rehabilitative services help individuals recover or regain abilities following an illness, injury, or medical condition.

Habilitative services help individuals develop or maintain abilities needed for daily living.

Examples may include physical therapy, occupational therapy, speech therapy, and qualifying medical devices.

8. Laboratory Services

Laboratory benefits include medically necessary diagnostic testing used to identify, monitor, or manage health conditions.

Examples include blood tests, urine testing, and other diagnostic laboratory procedures.

9. Preventive and Wellness Services and Chronic Disease Management

Preventive healthcare helps identify medical conditions early and supports long-term health.

Examples include recommended screenings, vaccinations, wellness visits, and care for chronic conditions such as diabetes or high blood pressure.

10. Pediatric Services, Including Oral and Vision Care

Pediatric benefits include healthcare services for children, including dental and vision care.

Eligible children enrolled in Medicaid also benefit from additional protections under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.

Which Medicaid Benefits Are Federally Required?

Federal Medicaid law identifies mandatory benefits that states generally must provide.

These include:

• Inpatient hospital services
• Outpatient hospital services
• Physician services
• Laboratory and X-ray services
• Federally qualified health center services
• Rural health clinic services
• Nursing facility services for eligible individuals
• Home health services for eligible individuals
• Family planning services and supplies
• Nurse-midwife services
• Certified pediatric and family nurse practitioner services
• EPSDT services for eligible children
• Transportation necessary to access covered medical care
• Certain other federally required services

These benefits establish a federal foundation for Medicaid coverage.

However, the exact amount, duration, and scope of services are subject to applicable federal and state requirements.

What Are Optional Medicaid Benefits?

Federal Medicaid law also allows states to cover additional healthcare services.

Examples of federally optional benefits include:

• Prescription medications
• Dental services
• Dentures
• Eyeglasses
• Physical therapy
• Occupational therapy
• Speech and hearing services
• Prosthetic devices
• Hospice services
• Personal care services
• Case management
• Certain home- and community-based services

Optional does not mean that a service is automatically excluded.

It means states have flexibility in deciding whether and how to include the benefit in their Medicaid programs.

Washington Apple Health covers many services classified as optional under federal Medicaid law.

What Additional Benefits Does Washington Apple Health Provide?

Washington Apple Health provides a broad range of healthcare services, including several benefits that are especially important to families and individuals managing ongoing health conditions.

Dental care: Apple Health covers certain preventive and restorative dental services for adults and children. Adult coverage includes services such as examinations, cleanings, fillings, extractions, and certain dentures. Services such as implants, bridges, and most adult orthodontic treatment are generally not covered.

Vision care: Apple Health covers certain eye examinations and medically necessary vision services. Eyeglasses and contact lens coverage differs significantly between children and adults. Standard adult eyeglass frames and lenses are generally not covered under the basic benefit.

Behavioral healthcare: Covered services include qualifying mental health and substance use disorder treatment.

Prescription medications: Apple Health covers many medications, subject to applicable drug coverage requirements.

Medical transportation: Eligible members may receive assistance with transportation to medically necessary appointments.

Interpreter services: Eligible members may receive interpreter assistance when accessing covered medical care.

Long-term services and supports: Certain members may qualify for home-based care, personal assistance, nursing facility services, or other long-term support programs.

Specialized children’s services: Eligible children may receive additional medically necessary services under EPSDT requirements.

Not every member qualifies for every benefit. Coverage depends on the member’s Apple Health program, medical necessity, age, and other applicable requirements.

Are Medicaid Benefits the Same Across All Insurance Companies?

Washington Apple Health uses managed care organizations to coordinate healthcare services for many members.

Although Apple Health managed care plans cover the same basic Medicaid services, they may differ in their provider networks, participating hospitals, pharmacies, and additional value-added benefits.

This means two individuals with Apple Health may have access to the same core benefits but different participating healthcare providers.

Before selecting a managed care plan, members should verify that their preferred doctors, specialists, hospitals, and pharmacies participate.

How Much Do Medicaid Members Pay for Covered Services?

For most adults enrolled in standard Washington Apple Health coverage, monthly premiums are generally $0, and covered services usually have little or no out-of-pocket cost.

However, some Apple Health programs have different cost-sharing or premium rules.

Members should review their specific program’s benefits rather than assuming every Medicaid category has identical costs.

Does Medicaid Cover Every Medical Procedure?

No. Comprehensive coverage does not mean every medical service is automatically approved.

Coverage may depend on:

• Whether the service is medically necessary
• Whether the service is included in the member’s benefit package
• Whether the provider participates in the applicable network
• Whether prior authorization is required
• Age-related or program-specific benefit limits
• Applicable treatment and utilization requirements

Members should review their health plan’s member handbook or contact their Apple Health plan before scheduling nonemergency services when coverage is uncertain.

Where Can You Verify Your Apple Health Benefits?

For the most accurate and current coverage information, visit the official resources below:

Medicaid.gov — Mandatory and Optional Medicaid Benefits

Medicaid.gov — Medicaid Benefits Overview

Washington HCA — Basic Covered Services

Washington HCA — Benefits and Services

Bottom line: Washington Apple Health provides comprehensive healthcare coverage that includes the major categories of medical services people commonly need. Understanding the difference between federally required benefits, state-selected optional benefits, and the ACA’s Essential Health Benefits helps members make informed decisions about their coverage.

---

3. Who Qualifies for Medicaid in Washington in 2027?

Medicaid eligibility is not determined by income alone.

Washington considers several factors, including:

• Household income
• Household size
• Age
• Washington residency
• Citizenship or qualifying immigration status
• Pregnancy
• Disability status
• The specific Apple Health program

Income Requirements for Adults Ages 19–64

For many adults qualifying through Washington’s Medicaid expansion program, the effective income eligibility standard is approximately 138% of the Federal Poverty Level (FPL).

The Federal Poverty Level is updated annually and varies according to household size.

Because eligibility thresholds change, applicants should always consult Washington HCA’s current income chart rather than relying on previous-year amounts.

Important for 2027: The official 2027 income standards may not yet be available as of November 2026. Washington generally updates applicable income standards following annual federal poverty guideline adjustments.

Does Medicaid Count Savings or Assets?

For most adults qualifying through the income-based Medicaid expansion category, eligibility generally does not involve an asset test.

This means having savings or owning certain property does not automatically disqualify someone.

However, Medicaid programs for older adults, people with disabilities, and individuals needing long-term care may have separate asset and resource limits.

What If You’re Self-Employed?

Self-employed individuals can qualify for Medicaid.

Eligibility depends on the applicable income-counting rules and other program requirements.

Because business income may fluctuate, self-employed applicants should provide accurate information about their earnings and report changes as required.

Can Children Qualify When Their Parents Don’t?

Yes.

Children may qualify for Apple Health under different income limits than their parents.

A household can therefore have parents enrolled in private Marketplace insurance while children receive Apple Health coverage.

---

4. Major Medicaid Changes Beginning in 2027

Federal legislation enacted in 2025 introduced significant changes affecting Medicaid eligibility, renewals, and coverage administration.

Washington is preparing to implement these changes through its Apple Health program.

The following requirements are particularly important for adults enrolled through Medicaid expansion.

New Work and Community Engagement Requirements

Beginning in 2027, many adults subject to the new Medicaid community engagement rules will generally need to satisfy 80 hours per month of qualifying activity, unless they meet an applicable exclusion or exemption.

Qualifying activities may include:

• Employment
• Self-employment
• Approved educational activities
• Job training
• Community service or volunteering
• Certain combinations of qualifying activities

Not everyone receiving Medicaid will be subject to these requirements.

Certain individuals may qualify for exclusions or exemptions based on their circumstances, including qualifying caregiving responsibilities, medical conditions, and other federally recognized categories.

Members should review official Washington HCA instructions to determine whether the requirements apply to them and what documentation may be necessary.

Medicaid Renewals Every Six Months

Many adults in the affected Medicaid expansion population will be required to renew eligibility every six months instead of annually.

This means maintaining accurate contact information and responding to renewal notices will become especially important.

Not all Apple Health programs will be subject to six-month renewals.

Shorter Retroactive Coverage Periods

Beginning in 2027, federal rules generally shorten the period for which Medicaid may provide retroactive coverage.

For the affected Medicaid expansion population, retroactive coverage may be limited to one month before application.

For other Medicaid populations, the general retroactive period may be reduced to two months.

Eligibility requirements and applicable exceptions still apply.

Changes Affecting Certain Noncitizen Adults

Federal eligibility changes also affect some noncitizen populations.

Because eligibility depends on immigration classification, program category, and applicable federal and state rules, individuals should seek an official eligibility determination rather than assuming they are automatically ineligible.

How to Protect Your Coverage in 2027

To reduce the risk of losing coverage unexpectedly:

1. Keep your contact information updated.
2. Report required income and household changes.
3. Read all notices from Washington Apple Health.
4. Complete renewals before the deadline.
5. Review whether new community engagement requirements apply.
6. Ask about available exemptions when appropriate.
7. Explore alternative insurance before existing coverage ends.

For the latest implementation details, visit:

Washington HCA — Changes to Apple Health

---

5. Medicaid vs. Qualified Health Plans: What’s the Difference?

A Qualified Health Plan (QHP) is private health insurance certified for sale through the Health Insurance Marketplace.

In Washington, the official Marketplace is Washington Healthplanfinder.

Both Medicaid and Marketplace health insurance can provide comprehensive medical coverage, but they differ in eligibility, cost, and enrollment rules.

Washington Apple Health

Apple Health is generally designed for eligible individuals who meet Medicaid program requirements.

Standard adult Apple Health coverage typically has no monthly premium and little or no out-of-pocket cost for covered services.

Eligible individuals can generally apply year-round.

Marketplace Qualified Health Plans

Marketplace plans are offered by private insurance companies.

Depending on household income and other eligibility factors, individuals may qualify for financial assistance that reduces monthly premiums.

Some individuals also qualify for cost-sharing reductions that lower deductibles, copayments, and other out-of-pocket expenses when enrolled in an eligible Silver plan.

Marketplace coverage generally requires enrollment during Open Enrollment or a qualifying Special Enrollment Period.

Can You Choose Marketplace Insurance Instead of Medicaid?

A person who qualifies for Medicaid may be able to purchase private insurance, but eligibility for full-benefit Medicaid generally prevents them from receiving Marketplace premium tax credits for the same coverage period, subject to applicable exceptions.

This can make unsubsidized private insurance significantly more expensive.

Before choosing private insurance, individuals should understand how their Medicaid eligibility affects financial assistance.

---

6. How to Transition From a Marketplace Plan to Medicaid

One of the most common reasons people move from private Marketplace insurance to Medicaid is a reduction in income.

For example, someone may lose their job, experience reduced work hours, or have a significant change in self-employment income.

These changes may make them eligible for Apple Health.

Step 1: Report Your Income Change

Sign in to your Washington Healthplanfinder account and update your income and household information.

Accurate information is important because eligibility for Medicaid and Marketplace financial assistance depends on your circumstances.

Step 2: Review Your Eligibility Determination

After submitting your updated information, review the eligibility results for each household member.

If you qualify for Apple Health, follow the instructions provided.

Step 3: Confirm Your Medicaid Effective Date

Before ending existing coverage, verify when Apple Health begins.

Also review your assigned managed care plan, participating providers, and prescription coverage.

Step 4: Coordinate Your Marketplace Plan Termination

Once your new coverage is confirmed, follow Washington Healthplanfinder’s instructions for ending your private plan at the appropriate time.

Never assume that simply stopping premium payments is the correct way to cancel insurance.

An improperly coordinated transition may create coverage gaps or unnecessary premium obligations.

Step 5: Review Your Financial Assistance

Eligibility for full-benefit Medicaid can affect Marketplace premium tax credits.

Reporting changes promptly helps reduce the risk of receiving financial assistance for which you are no longer eligible.

---

7. How to Transition From Medicaid to a Marketplace Health Plan

Losing Medicaid does not necessarily mean losing access to affordable health insurance.

If your income increases or your eligibility changes, you may qualify for a Marketplace Qualified Health Plan.

Step 1: Understand Why Medicaid Is Ending

Review the official notice explaining your eligibility determination and coverage termination date.

Coverage may end because of income changes, changes in eligibility, or administrative issues such as incomplete renewal documentation.

Step 2: Check for a Special Enrollment Period

Losing Medicaid or CHIP generally qualifies individuals for a Marketplace Special Enrollment Period.

A Special Enrollment Period allows eligible individuals to enroll in private health insurance outside the annual Open Enrollment Period.

Enrollment deadlines and effective-date rules matter, so review your options promptly.

Step 3: Compare Marketplace Health Plans

When selecting a new plan, consider more than the monthly premium.

Review:

• Monthly premiums
• Annual deductibles
• Copayments and coinsurance
• Out-of-pocket maximums
• Prescription drug coverage
• Primary care and specialist networks
• Hospital participation
• Expected healthcare usage

A lower monthly premium does not always mean a lower overall healthcare cost.

Step 4: Determine Whether You Qualify for Financial Assistance

Depending on your household income and other eligibility requirements, you may qualify for Marketplace premium tax credits.

You may also qualify for cost-sharing reductions if you select an eligible Silver plan.

Financial assistance rules may change from year to year, so always review the assistance available for your intended coverage year.

Step 5: Complete Enrollment and Confirm Coverage

Select your plan within your applicable enrollment period.

Pay any required initial premium and confirm the effective date.

Whenever possible, coordinate the transition so your new plan begins when Medicaid ends.

What If Medicaid Ended Because You Missed Your Renewal?

Contact Washington Apple Health immediately.

Depending on the timing and circumstances, you may qualify for reconsideration or reinstatement.

A termination for missing paperwork does not necessarily mean you no longer meet Medicaid’s financial eligibility requirements.

---

8. Can Someone Have Medicaid and Marketplace Insurance at the Same Time?

Different people within the same household can have different types of insurance.

For example, parents may qualify for Marketplace coverage while their children qualify for Apple Health.

However, an individual generally cannot receive Marketplace premium tax credits for months when they are eligible for full-benefit Medicaid, subject to applicable exceptions.

Some people may have overlapping coverage during transitions or maintain private insurance alongside Medicaid, but coordination-of-benefits and financial-assistance rules must be considered.

---

9. Medicaid Coverage for Children and Pregnant Individuals

Children and pregnant individuals often qualify under different Medicaid eligibility standards than adults in the standard expansion category.

Apple Health for Kids

Apple Health for Kids provides eligible children with comprehensive healthcare benefits.

These can include preventive screenings, vaccinations, medical treatment, dental care, vision services, and medically necessary pediatric care.

Federal Medicaid law provides additional protections for eligible children through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.

Pregnancy Coverage

Eligible pregnant individuals may qualify for Apple Health under pregnancy-specific eligibility rules.

Coverage may include prenatal care, delivery, postpartum care, and other covered services.

Because pregnancy eligibility standards differ from standard adult eligibility, individuals should not assume they are ineligible based solely on the general adult income limits.

---

10. What Happens to Medicaid When You Turn 65?

Turning 65 may change the Medicaid eligibility category under which someone receives coverage.

Many individuals become eligible for Medicare at age 65, although Medicare eligibility can also occur earlier under certain circumstances.

Medicare and Medicaid are separate programs.

Some individuals qualify for both programs and are known as dual eligible beneficiaries.

Depending on eligibility, Medicaid may help with Medicare premiums, certain cost-sharing expenses, and additional covered healthcare services.

Medicaid eligibility for older adults and individuals needing long-term care may involve separate income and resource requirements.

---

11. How to Apply for Washington Apple Health

Eligible individuals can generally apply for Apple Health throughout the year.

For most Washington residents under age 65, Washington Healthplanfinder is the primary application starting point.

Other Medicaid categories, including certain aged, blind, disabled, and long-term care programs, may use different application processes.

Apply Online

Visit Washington Healthplanfinder.

Apply by Phone

Contact Washington Healthplanfinder Customer Support at 1-855-923-4633.

What Information Will You Need?

Be prepared to provide information such as:

• Household members’ names and birth dates
• Household income
• Washington residency
• Applicable citizenship or immigration information
• Current health insurance information

Additional documentation may be requested depending on your circumstances.

Once approved, members receive information about their coverage, ProviderOne services card, and applicable managed care plan.

---

12. Frequently Asked Questions About Medicaid

Is Medicaid the Same as Obamacare?

No. Medicaid is a public health coverage program. The Affordable Care Act expanded Medicaid eligibility in participating states and also established rules for private Marketplace insurance.

Can I Work Full-Time and Still Qualify for Medicaid?

Yes, potentially. Employment does not automatically disqualify someone. Income, household size, and other eligibility requirements determine whether coverage is available.

Can I Apply for Medicaid Outside Open Enrollment?

Yes. Eligible individuals can generally apply for Apple Health throughout the year.

Will I Lose Medicaid Immediately If I Get a Raise?

Not necessarily. Report your income change and wait for an official eligibility determination. Coverage changes depend on your program and applicable notice requirements.

Does Medicaid Cover Dental and Vision?

Washington Apple Health includes covered dental and vision benefits, but specific services and limitations vary by program and age.

Can I Keep My Doctor When Switching Insurance?

Possibly. Your doctor must participate in the new plan’s network or an applicable continuity-of-care arrangement must be available.

Always verify providers before selecting coverage.

Can My Children Qualify for Medicaid Even If I Don’t?

Yes. Children may qualify under different income standards than their parents.

What Happens If I Lose Medicaid?

You may qualify for a Marketplace Special Enrollment Period. Review your termination notice and explore replacement coverage promptly.

Can I Receive Marketplace Subsidies If I Qualify for Medicaid?

Generally, individuals eligible for full-benefit Medicaid cannot receive Marketplace premium tax credits for the same coverage period, subject to applicable exceptions.

What If I Have No Income?

You may qualify for Apple Health depending on your household and other eligibility factors. Beginning in 2027, certain adults may also need to satisfy community engagement requirements or qualify for an exemption.

Can an Insurance Broker Help Me Transition From Medicaid to Marketplace Coverage?

Yes. A licensed insurance broker can help you understand private Marketplace options, compare plans, review available financial assistance, and assist with enrollment.

However, Medicaid eligibility itself is determined by the appropriate government program.

---

13. Need Help Understanding Your Health Insurance Options?

Health insurance needs can change throughout your life.

You may qualify for Medicaid today and private Marketplace coverage next year. A new job, income change, household change, or loss of eligibility can affect which coverage options are available.

Understanding those changes can help you avoid unnecessary gaps in healthcare coverage.

At Ins Made Easy, we help Washington residents understand their health insurance options, compare Marketplace plans, and navigate coverage transitions.

Whether you’re preparing to leave Medicaid, exploring private health insurance, or trying to understand your next steps, we’re here to help make the process easier.

We make buying insurance easy.

Explore Your Health Insurance Options With Ins Made Easy

---

Official Medicaid and Washington Apple Health Resources

For the latest eligibility rules, coverage information, and program updates, consult these official resources:

Federal Medicaid Benefits

Medicaid.gov — Mandatory and Optional Medicaid Benefits

Medicaid.gov — Medicaid Benefits

Washington State Medicaid

Washington Health Care Authority

Washington HCA — Changes to Apple Health

Washington Healthplanfinder

---

Disclaimer: This article is provided for general educational purposes and does not constitute an official Medicaid eligibility determination, legal advice, or tax advice. Medicaid eligibility, benefits, income limits, and enrollment rules may change. For current program information, contact Washington Health Care Authority or Washington Healthplanfinder. Ins Made Easy is an independent insurance agency and is not affiliated with or endorsed by any government agency.

Last updated: November 2026.