Washington Health Care Authority · Washington
Apple Health Premium Payment Program
HCA may reimburse private health insurance premiums for Apple Health members when the coverage saves the state money.
Taking applicationsChecked October 11, 2026
Premium reimbursement depends on the policy and HCA cost review. HCA pays no more than one premium per client per month, and some Medicaid-covered cost sharing may also be reimbursed.
Apply for me
We use your saved answers and ask only what is missing. You review and sign before anything is sent.
Who can apply
- HCA must confirm the Medicaid coverage, plan, and cost-effectiveness.
Documents to gather
Current premium payment or recent employer paystub
- Current copies of health insurance payment
- A recent paystub if the employer provides health insurance
Current insurance card
- Current copies of the front and back of the insurance card
Signed W-9
- Print and sign HCA’s linked Substitute W-9 for the private insurance subscriber
Recent paycheck stub · if it applies
- A copy of a recent paycheck stub when insurance is through an employer
Comprehensive health plan enrollment
- Proof of enrollment in a comprehensive individual or employer-sponsored health insurance plan
Policy holder SSN or tax identification number
- Proof of the policy holder Social Security number or tax identification number
The questions on the application (59)
Your name
Telephone number
Email address (optional) · optional
Mailing address
City
State
ZIP code
Name of your private health insurance company
Policy number
Telephone number
Company address
City
State
ZIP code
Source of insurance:
Employer* · COBRA · Individual · Other:
Other: · if it applies
When is your open enrollment date?
Effective date:
Employers name · if it applies
Telephone number · if it applies
How much do you pay for this insurance? $
Is it pre-tax?
Yes · No
What is the annual deductible amount for: Individuals: $
What is the annual deductible amount for: Family: $
How often do you pay?
Weekly · Monthly · Bi-weekly · Semi-monthly
Name of your dental insurance company · optional
Address of dental insurer · optional
Telephone number · optional
Name (as shown on your income tax return)
Business name, if different from above · optional
Individual/Sole Proprietor · optional
Corporation · optional
Medical · optional · if it applies
Attorney/Legal · optional · if it applies
S-Corp · optional
Medical · optional · if it applies
Attorney/Legal · optional · if it applies
Partnership · optional
Medical · optional · if it applies
Attorney/Legal · optional · if it applies
LLC filing as a Corporation · optional
Medical · optional · if it applies
Attorney/Legal · optional · if it applies
LLC filing as Partnership · optional
Medical · optional · if it applies
Attorney/Legal · optional · if it applies
Trust/Estate · optional
Non Profit · optional
Volunteer · optional
Board Member · optional
Federal (inc: Tribal Govt.) · optional
State · optional
Local · optional
Exempt from backup withholding · optional
Address (number, street, and apt. or suite no.)
City, state, and ZIP code
List account number(s) here (optional) · optional
Social security number · optional
Employer identification number · optional
Please list below all family members who are on your Health Insurance policy.: answered for each person (Name (please enter subscriber’s information on line 1), Relationship to subscriber, Date of birth, Enrolled in Apple Health (Medicaid)?, Social Security number or ProviderOne number).
What you agree to
By signing below, I attest that the information provided above is true, correct and complete, the best of my knowledge.
Signature Date
HOH #: ___WA
Under penalties of perjury, I certify that: The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and I am a U.S. person (including a U.S. resident alien).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
Signature of U.S. person ► Date ►
Requester’s name and address (optional)
After you apply
- If you bought an individual plan through the Exchange, complete the HCA eligibility phone consultation within 30 calendar days after submitting a completed intake form.
- Reply by phone or email within 10 business days of HCA outreach to schedule the consultation.
- Keep Apple Health coverage while in the program.
- Submit proof of premiums by the end of the third month after the last coverage month. Submit proof of cost sharing by the end of the sixth month after the service date.
- HCA reviews eligibility annually and when Medicaid, the medical assistance unit, premiums, or private coverage changes.
- You may request an administrative hearing if you disagree with an eligibility, subsidy, or overpayment decision.
- Applications may take up to 30 days after HCA receives all necessary paperwork.
- HCA attempts to reach Exchange individual-plan applicants within seven business days to schedule the consultation.
- For requests above average Medicaid cost, HCA asks for additional documents within 60 days and sends an approval or denial within 90 calendar days under the stated rules.
- HCA may deny the application if the required phone consultation is not completed on time.
- HCA may adjust reimbursement or end PPP eligibility when premiums or Medicaid eligibility change.
- HCA notifies the client of eligibility changes.
- HCA sends written approval or denial of requests for a premium above average cost.
Before you send it
- Put the subscriber on line 1 of the policy-member table.
- The signature and signing date belong to the signing step. The HOH number and W-9 requester details are agency fields. They are kept outside resident questions.
- Keep copies of the front and back of the insurance card.
- Use the tax form for the policy subscriber. A subscriber may differ from the person filling the intake form.
What we could not check
- Public instructions invite completed intake forms. No opening or closing date is stated.
- Some details here could not be confirmed. Check with Washington Health Care Authority before you apply.