Apple Health managed care
Find information about 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.
Health Care Authority implemented changes to the Apple Health managed care program. You may learn more about these changes below.
Integrated Managed Care (IMC) coordinates physical health, mental health, and substance use disorder treatment services to help provide whole-person care under one health plan. By January 1, 2020, integrated managed care will be available in all regions.
Integrated managed care implementation began in 2016 with the Southwest Washington region (Clark and Skamania counties), and expanded in 2018 to the North Central region (Chelan, Douglas, and Grant counties).
Beginning January 1, 2019, Apple Health will also offer integrated managed care plans in the following regions:
- Greater Columbia (Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Walla Walla, Whitman, and Yakima counties)
- King (King County)
- Pierce (Pierce County)
- Spokane (Adams, Ferry, Lincoln, Pend Oreille, Spokane, and Stevens counties)
In addition, Okanogan County will join the North Central region, and Klickitat County will join the Southwest Washington region.
The remaining regions will implement Apple Health Integrated Managed Care on the following schedule:
July 1, 2019
- North Sound (Island, San Juan, Skagit, Snohomish, and Whatcom counties)
January 1, 2020
- Great Rivers (Cowlitz, Grays Harbor, Lewis, Pacific, and Wahkiakum counties)
- Salish (Clallam, Jefferson, and Kitsap counties)
- Thurston-Mason (Mason and Thurston counties)
Apple Health offers Behavioral Health Services Only (BHSO) plans in all regions with integrated managed care. These plans are for clients who are eligible for Apple Health, but not eligible for managed care enrollment, such as:
- Dual-eligible – Medicare/Medicaid
- Medically Needy
- Clients who have met their spenddown
The Behavioral Health Services Only plans are offered by the same health plans administering Integrated Managed Care.
Upon becoming eligible for Apple Health coverage without a managed care plan (also known as fee-for-service), clients may select a Behavioral Health Services Only plan. For clients who do not select a plan, HCA will automatically enroll them into a BHSO plan. A BHSO fact sheet is available online.
In addition to integrated managed care plans, clients in integrated regions have access to a regional Behavioral Health – Administrative Services Organization (BH-ASO). These organizations administer services such as:
- 24/7 regional crisis hotline for mental health and substance use disorder crises
- Mobile crisis outreach teams
- Short-term substance use disorder crisis services for individuals who are intoxicated or incapacitated in public
- Application of behavioral health involuntary commitment statutes, available 24/7 to conduct Involuntary Treatment Act (ITA) assessments and file detention petitions
- Regional Ombuds
Within available funding, a BH-ASO also has the discretion to provide outpatient behavioral health services or voluntary psychiatric inpatient hospitalizations for individuals who are not eligible for or enrolled in Apple Health. A BH-ASO fact sheet is available online.
The Health Care Authority manages contracts with Behavioral Health Organizations for mental health and substance use disorder (SUD) treatment services in regions that have not yet implemented Integrated Managed Care. As Apple Health continues to implement Integrated Managed Care across the state, responsibility for behavioral health coverage transfers to integrated managed care plans.
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).
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:
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. 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.
View the Washington Apple Health Plan Report Card for plan comparisons of each managed care plan under Apple Health.
Before you can be in a managed care program, you must apply for services.
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.
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.
24-hour crisis line
Crisis services are available to support you, based on where you live.
Online: National Suicide Prevention Lifeline