Apple Health managed care

Find information about how to use Apple Health managed care.

Managed care explained

Most Apple Health clients have “managed care,” which means Apple Health pays a health plan a monthly fee for your care, including preventive, primary, specialty and other health services. The health plan then pays the provider that cared for you.

Most Apple Health clients receive managed care for most services, but some services are paid through “fee-for-service.” That’s what we call it when Apple Health pays doctors and providers directly for each service they do. Most Apple Health clients don’t get fee-for-service for their regular health care. Most get “managed care” through their health plans for most of their services.

Fee-for-service benefits include dental care, long-term care, and in-patient psychiatric care for physician services. Your primary care provider or health plan will help you find these benefits and coordinate your care.

What is the difference in the plans?

All plans cover the same basic services, but they have some differences in the way they provide services. The Welcome to Washington Apple Health booklet lists the basic services. Each health plan has its own network of providers. Please verify with the health plan that the providers you prefer are in the plan’s network.

Before you can be in a managed care program, you must apply for services.

Changes to Apple Health managed care

Health Care Authority implemented changes to the Apple Health managed care program. You may learn more about these changes below.

Changes in January 2017

If you have Apple Health (Medicaid) and other primary health insurance

If you or someone in your household has Apple Health (Medicaid) coverage in addition to primary private health insurance (such as Kaiser Permanente or Blue Shield), changes are coming to how the Washington State Health Care Authority (HCA) provides your Apple Health coverage.

On January 1, 2017, the agency began enrolling most fee-for-service Apple Health clients who have other primary health insurance into an agency-contracted managed care organization (MCO). Learn what you need to do.

Changes in April 2016

Newly eligible Medicaid clients and renewing clients choose or are auto-assigned into a managed care organization (MCO) the day they become eligible. Their managed care enrollment will be backdated to the beginning of the current month. The intent of the change is to close the fee-for-service (FFS) gap between eligibility and enrollment. This change decreases the time on FFS with quicker care coordination. Instead of having to wait another month or possibly two months before being enrolled, the client now enters the plan on the first day of the month that they became eligible.

Clark and Skamania Counties, also known as SW WA region, create the first region in Washington State to initiate Fully Integrated Managed Care (FIMC). This means that physical health, mental health, and drug and alcohol treatment are coordinated through one managed care plan.

Clients may choose from Community Health Plan of Washington (CHPW) or Molina Healthcare of Washington (MHW) in the SW WA region.

Behavioral Health – Administrative Service Organization (BH-ASO) or mental health crisis services and short-term substance use disorder (SUD) crisis services are provided by Beacon Health Options of Washington in SW WA.

Behavioral Health Services Only (BHSO) in the SW WA region are available to clients who are Medicaid eligible but not eligible for managed care. They will have a choice of CHPW or MHW for these behavioral health services. These clients include:

  • Dual eligible – Medicare/Medicaid
  • Foster care
  • American Indian/Alaska Native (AI/AN)
  • Medically needy
  • Clients who have met their spenddown
  • Non-citizen pregnant women
  • Individuals in Institutions Mental Disease (IMD)
  • Long-term care residents
  • Clients with other carrier coverage

The Department of Social and Health Services (DSHS) manages the contracts for mental health and substance use disorder (SUD) services for 9 of the Regional Service Areas (RSA) in the state, excluding the Southwest Washington (SW WA) Region. The BHOs replace the Regional Support Networks (RSN). BHOs are integrating mental health and SUD services (known as behavioral health services), transforming two service delivery systems into one region wide system. View a listing of BHOs in Washington.

Coordinated Care of Washington (CCW) provides physical health care (medical) benefits, lower-intensity outpatient mental health benefits and care coordination for all Washington State foster care enrollees through a single, statewide managed care plan called Apple Health Core Connections. Inpatient services and higher-level outpatient mental health services will be provided by the BHSO in the SW WA region or the BHO in BHO regions.

These clients include children and youth:

  • Under the age of 21 who are in foster care
  • Under the age of 21 who are receiving adoption support
  • Age 18 to 26 years old who aged out of foster care on or after their 18th birthday

AHCC clients are auto-enrolled to CCW. Members who want to stay in fee-for-service must contact HCA's Forster Care Unit. Children and young adults with comparable medical insurance and American Indian/Alaska Native (AI/AN) children are not auto-enrolled.

Apple Health managed care plans available

You can choose any one of the five available plans that serve your area when you enroll in Apple Health. Not all plans are available in all areas.

View the health plans available in your area:

Medicaid plan selection

To choose or change your health plan, visit www.wahealthplanfinder.org. See more information about how to change your health plan.

Contact your Apple Health plan

You'll need to contact your Apple Health plan if you want to:

  • Find a new doctor or see if the doctor you want to see is in your Apple Health plan.
  • File a complaint because you're not happy with the service you were provided by your doctor or the health plan.
  • Replace your Apple Health plan benefits card.
  • Find out more information about your Apple Health plan.

Apple Health managed care plans

Amerigroup (AMG) 1-800-600-4441
Community Health Plan of Washington (CHPW) 1-800-440-1561
Coordinated Care of Washington (CCW) 1-877-644-4613
Molina Healthcare of Washington, Inc. (MHW) 1-800-869-7165
United Healthcare Community Plan (UHC) 1-877-542-8997

All Apple Health plans offer the same basic services.

Crisis services

Find support available to you, based on where you live:

24-hour crisis line

Statewide

Phone: 1-800-273-8255
Online: http://www.suicidepreventionlifeline.org

In Clark and Skamania counties only

Phone: 1-800-626-8137
TTY: 1-866-835-2755
Online: http://wa.beaconhealthoptions.com/

Contact