Apple Health managed care

Managed care explained

What is managed care?

Apple Health offers managed care plans in all regions statewide. Your plan coordinates physical health, mental health, and substance use disorder treatment services to provide whole-person care under one health plan.

Most Apple Health clients have managed care. This means Apple Health pays a managed care plan a monthly premium for your coverage, which includes preventive, primary, specialty, and other health services. If you are in managed care, then you must see providers who are in your plan's provider network, unless prior authorized or to treat urgent or emergent care.

Newly eligible and renewing Apple Health clients choose or are auto assigned into a plan (MCO) the day they become eligible. Your managed care enrollment is backdated to the beginning of the current month. You can change your managed care plan at any time. Changes usually take effect the month following when the change was made, unless the request was made in the last seven business days of the current month.

Behavioral Health Services Only (BHSO)

Apple Health offers Behavioral Health Services Only (BHSO) plans in all regions. These plans cover Behavioral Health services for clients who are eligible for Apple Health, but not eligible for managed care enrollment. This includes Apple Health clients who are:

• Dual-eligible or enrolled in Apple Health Medicare Connect,
• Medically Needy, or
• Have met their spenddown.

Medically Needy BHSO plans are offered by the same health plans as managed care. Clients who are found eligible for Apple Health coverage without a managed care plan (also known as fee-for-service) can select a Behavioral Health Services Only plan. HCA will automatically enroll clients into a BHSO plan if they do not select one. View the BHSO fact sheet to learn more.

Behavioral Health - Administrative Services Organization (BH-ASO)

Behavioral Health – Administrative Services Organizations (BH-ASO) are funded through state and federal block grant funding.

When you visit a BH-ASO, they can help you navigate through mental health or substance use disorder (SUD) services when needed. Some of these services include:

• 24/7 regional crisis hotline for mental health and substance use disorder (SUD) crises,
• Mobile crisis outreach teams,
• Short-term SUD 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 detentions.

The BH-ASO can choose when to provide outpatient behavioral health services or voluntary psychiatric inpatient hospitalizations for individuals who are not Apple Health clients. Read the BH-ASO fact sheet to learn more.

Apple Health Foster Care

The Apple Health Foster Care (AHFC) program provides statewide physical and behavioral health coverage (mental health and substance use disorder treatment services).

This program may be for you if you are:

• 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 Core Connections: Care coordination for all Washington State foster care enrollees is provided through a single, statewide managed care plan called Apple Health Core Connections administered by Coordinated Care of Washington (CCW).

Apple Health Core Connections can be reached at 1-844-354-9876.

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:

• Apple Health (managed care) service area matrix
• Apple Health (managed care) service area map

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. 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 coverage.

Each managed care plan also provides Value-Added Benefits for their members. These are benefits that are not part of the standard Medicaid benefit package and are administered by the MCO not HCA.

Apple Health plan selection

To choose or change your health plan, most clients may visit Washington Healthplanfinder. See more information about how to change your health plan.

Contact your Apple Health plan

Contact your plan 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

All Apple Health plans offer the same basic services. As an Apple Health client, you also have access to value-added benefits offered through your managed care plan.

Apple Health services covered without a managed care plan (also called fee-for-service)

Some services are paid for by Apple Health without a managed care plan, also called fee-for-service (FFS). That's what we call it when Apple Health pays providers directly for each service they do, using your ProviderOne services card.

Most Apple Health clients receive their regular health care coverage through a managed care plan. Apple Health coverage without a managed care plan is sometimes necessary due to the way other coverage works with Apple Health — for instance, when clients have Medicare as their primary coverage.

The following services are always covered by directly by Apple Health using your ProviderOne services card:

• Dental care,
• Vision hardware (children only),
• Long-term care, and
• 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.

Crisis services

Statewide 24-hour suicide & crisis lifeline

Nationwide

Phone: 988 (1-800-273-8255)
Online: 988 Suicide & Crisis Lifeline