Apple Health managed care
Find information about how to use Apple Health managed care.
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What is managed care?
Most Apple Health clients have “managed care,” which means Apple Health pays a health plan a monthly premium for your coverage, which include preventive, primary, specialty, and other health services. Clients in managed care must see only providers who are in their plan's provider network, unless prior authorized or to treat urgent or emergent care.
What is fee-for-service (FFS)?
Some services are paid "fee-for-service (FFS)." That’s what we call it when Apple Health pays providers directly for each service they do, using the ProviderOne payment system.
Most Apple Health clients don’t get FFS for their regular health care, but this type of coverage is sometimes necessary due to the way other coverage works with Medicaid (Apple Health) — for instance, when clients have Medicare as their primary coverage. In some situations, clients are able to choose whether they receive FFS coverage or are enrolled in a health plan.
Regardless whether you are in a health plan or not, the following services are always covered fee-for-service (FFS).
- Dental care
- Vision hardware (children only)
- Long-term care
- Inpatient psychiatric care for physician services.
Your primary care provider or health plan will help you find these benefits and coordinate your care, when necessary.
What is the difference in the plans?
All Apple Health 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, hospitals, and pharmacies. 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.
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
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
|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.
Health Care Authority implemented changes to the Apple Health managed care program. You may learn more about these changes below.
Integrated Managed Care (IMC), formerly known as Fully Integrated Managed Care (FIMC), coordinates physical health, mental health, and drug and alcohol treatment to help provide whole-person care under one health plan.
These are currently only available in the Southwest Washington (effective April 1, 2016) and North Central Washington (effective January 1, 2018) regions, but Apple Health is expanding this coverage model through 2020, when it will be offered in all regions. Read more about the changes in North Central Washington.
In Southwest Washington, which includes Clark and Skamania counties, you may choose from one of the following plans for care:
- Community Health Plan of Washington (CHPW)
- Molina Healthcare of Washington (MHW)
In North Central Washington, which includes Chelan, Douglas, and Grant counties, you may choose from one of the following plans for care:
- Amerigroup (AMG)
- Coordinated Care of Washington (CCW)
- Molina Healthcare of Washington (MHW)
Behavioral Health Services Only (BHSO) in the Southwest Washington (effective April 1, 2016) and North Central Washington (effective January 1, 2018) regions are available to clients who are eligible for Apple Health, but not eligible for managed care enrollment, including clients who are:
- Dual-eligible – Medicare/Medicaid
- Foster care, as applicable
- American Indian/Alaska Native (by choice)
- Medically needy
- Clients who have met their spenddown
- Non-citizen pregnant women
- Individuals admitted to an Institution of Mental Disease (IMD)
- Long-term care residents
- Clients with other health insurance (by choice)
These fee-for-service clients receive their behavioral health services from one of the Behavioral Health Services Only plans in the region they live in, which are offered by the same health plans administering integrated managed care in that region.
Upon becoming eligible for Apple Health fee-for-service, clients may choose to receive behavioral health services through one of the available Behavioral Health Services Only plans, or do nothing and HCA will enroll them into a randomly-selected Behavioral Health Services Only plan. A BHSO fact sheet is available online.
In addition to integrated managed care and Behavioral Health Services Only plans, clients in the Southwest Washington (effective April 1, 2016) and North Central Washington (effective January 1, 2018) regions have access to a Behavioral Health – Administrative Services Organization (BH-ASO) which covers mental health crisis services and short-term substance use disorder (SUD) crisis services.
- Inpatient services that fall under the Involuntary Treatment Act (ITA) for individuals who are not eligible for or enrolled in Apple Health (Medicaid), and
- Short-term substance use disorder (SUD) crisis services.
Within their available funding, Beacon Health Options also has the discretion to provide outpatient mental health services or voluntary psychiatric inpatient hospital admissions for Washington state citizens who are not eligible for or enrolled in Apple Health. A BH-ASO fact sheet is available online.
The Department of Social and Health Services (DSHS) manages the contracts for mental health and substance use disorder (SUD) services for eight of the Regional Service Areas (RSA) in the state, excluding the Southwest Washington and North Central Washington regions, where these services are covered by integrated managed care and Behavioral Health Services Only plans.
The Behavioral Health Organizations replaced the Regional Support Networks (RSN) in April 2016.
Behavioral Health Organizations are integrating mental health and SUD services (known as behavioral health services), transforming two service delivery systems into one region wide system. As this new system spreads to the rest of the state, Behavioral Health Organization coverage will continue to be transferred to integrated managed care and Behavioral Health Services Only plans through 2020, when the entire state will have adopted the integrated managed care model of delivery.
Changes coming to Foster Care
On January 1, 2019, behavioral health coverage will change for Apple Health Foster Care clients in all 39 counties in Washington state. Coverage will continue to be managed by Apple Health Core Connections through Coordinated Care of Washington.
This coverage will include:
- Mental health services
- Drug and alcohol use disorder treatment
You will still get the same benefits you get today. We are only changing how we approve and pay for them. We will send you a letter in December with more information about these changes.
Learn about the integration of Apple Health in the Foster Care program coming in January 2019.
The Apple Health Foster Care (AHFC) program managed by 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 Behavioral Health Services Only (BHSO) in integrated managed care regions and the Behavioral Health Organizations (BHOs) in all other regions.
A list of the available Behavioral Health Services Only plans in the integrated managed care regions can be found in the Apple Health managed care plans available section. The same plans offering integrated managed care plans in each county also offers a Behavioral Health Services Only plan.
These clients include children and youth:
- Under the age of 21 who are in foster care (out of home placement)
- 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 (alumni)
Apple Health children in foster care (out of home placement) are auto-enrolled to Coordinated Care of Washington. Adoption support and alumni have the ability to opt out with a phone call to the foster care unit at 1-800-562-3022 ext. 15480.
Earlier enrollment (4/1/2016)
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 is 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 health care coordination. Instead of having to wait a month or possibly two months before being enrolled, the client enrolls with the plan on the first day of the month that they became eligible.
Apple Health (Medicaid) and other primary health insurance (1/1/2017)
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 were made 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).
24-hour crisis line
Crisis services are available to support you, based on where you live.
Online: National Suicide Prevention Lifeline
In Clark, Skamania, Grant, Douglas, and Chelan counties
Online: Beacon Health Options