Managed care is a system that many customers encounter when seeking medical services, and it plays a significant role in how healthcare is delivered and accessed. For individuals enrolled in programs like Apple Health, understanding what a managed care medical program entails is crucial. This article aims to provide a comprehensive explanation of managed care, specifically within the context of customer healthcare programs.
Decoding Managed Care: A Customer-Centric Overview
Managed care is a healthcare delivery system organized to manage cost, utilization, and quality. In essence, a managed care medical program for customers integrates the financing and delivery of healthcare within a network of providers. For customers, particularly those in programs like Apple Health in Washington State, managed care means their healthcare benefits are administered through a managed care organization (MCO).
Apple Health, the Medicaid program in Washington, utilizes managed care plans across the state. These plans are designed to coordinate a comprehensive suite of services, encompassing physical health, mental health, and substance use disorder treatments. This integrated approach ensures whole-person care under a single health plan umbrella.
For the majority of Apple Health recipients, managed care is the standard. The state pays a monthly premium to the chosen managed care plan for each enrolled customer. This premium covers a wide spectrum of healthcare services, including preventative care, primary care, specialist consultations, and other necessary medical services. A key aspect of managed care for customers is the network: individuals within a managed care plan typically need to seek care from providers within their plan’s network. Seeking out-of-network care may require prior authorization, except in cases of urgent or emergency medical needs.
Upon becoming eligible for or renewing their Apple Health coverage, customers are required to select a managed care plan or are automatically assigned to one. This enrollment is effective retroactively to the start of the current month. Flexibility is built into the system, allowing customers to change their managed care plan at any point. Plan changes generally take effect the month after the change is requested, provided the request is not made in the final seven business days of the month.
Behavioral Health Service Options within Managed Care
Within the framework of managed care, specific provisions are made for behavioral health services. Apple Health provides Behavioral Health Services Only (BHSO) plans statewide for eligible customers who are not enrolled in standard managed care due to specific circumstances. This includes:
- Individuals who are dually eligible for both Medicaid and Medicare or are enrolled in Apple Health Medicare Connect.
- Those classified as Medically Needy.
- Individuals who have met their spenddown requirements for Medicaid eligibility.
These Medically Needy BHSO plans are managed by the same health plans that administer standard managed care. Customers eligible for Apple Health coverage but not managed care (often referred to as fee-for-service) have the option to select a BHSO plan. If a customer does not actively choose a BHSO plan, the Health Care Authority (HCA) will automatically enroll them. More detailed information can be found in the BHSO fact sheet.
Behavioral Health – Administrative Services Organizations (BH-ASO) represent another facet of behavioral health support, funded through state and federal block grants. BH-ASOs serve as navigators within the mental health and substance use disorder (SUD) service landscape. They offer crucial services such as:
- Round-the-clock regional crisis hotlines for mental health and SUD emergencies.
- Mobile crisis outreach teams for immediate on-site support.
- Short-term SUD crisis services for individuals experiencing public intoxication or incapacitation.
- Administration of behavioral health involuntary commitment statutes, including 24/7 availability for Involuntary Treatment Act (ITA) assessments and detention filings.
BH-ASOs have the discretion to provide outpatient behavioral health services or arrange voluntary psychiatric inpatient hospitalizations for individuals who are not Apple Health customers, further extending the reach of community behavioral health support. The BH-ASO fact sheet offers deeper insights into these services.
Specialized Managed Care for Foster Care: Apple Health Foster Care
The Apple Health Foster Care (AHFC) program is a specialized managed care initiative providing comprehensive physical and behavioral health coverage throughout Washington State. This program is designed for specific populations, including:
- Individuals under 21 years of age in foster care (out-of-home placement).
- Individuals under 21 receiving adoption support services.
- Young adults aged 18 to 26 who aged out of foster care on or after their 18th birthday (alumni of foster care).
Apple Health Core Connections, a single, statewide managed care plan administered by Coordinated Care of Washington (CCW), delivers care coordination for all Washington State foster care enrollees. This dedicated plan ensures streamlined and specialized support for this vulnerable population. Apple Health Core Connections can be contacted directly at 1-844-354-9876.
Choosing Your Apple Health Managed Care Plan
When enrolling in Apple Health managed care, customers have a choice among five available plans, depending on their geographic location. It’s important to note that plan availability varies by region. To identify the health plans serving your area, resources are available online.
Plan Differences and Service Coverage
While all Apple Health managed care plans provide the same core set of basic services, distinctions exist in how these services are delivered. Each plan maintains its own network of healthcare providers, hospitals, and pharmacies. Customers are advised to confirm that their preferred providers are included within a plan’s network before making a selection.
The Washington Apple Health Plan Report Card offers a comparative overview of each managed care plan under Apple Health, aiding customers in making informed decisions.
Prior to enrolling in a managed care program, individuals must first apply for Apple Health coverage.
Beyond the standard Medicaid benefits, each managed care plan also offers Value-Added Benefits to its members. These additional benefits, not part of the standard Medicaid package, are administered directly by the MCO, not the HCA, enhancing the overall customer experience.
Making Your Apple Health Plan Selection
For most customers, selecting or changing their health plan is easily done through the Washington Healthplanfinder website. Detailed instructions on how to change your health plan are also readily available.
Contacting Your Apple Health Plan for Support
Direct communication with your Apple Health plan is essential for various needs. Contact your plan to:
- Locate a new doctor or verify if a specific doctor is in your plan’s network.
- File complaints regarding dissatisfaction with services received from a doctor or the health plan itself.
- Request a replacement for your Apple Health plan benefits card.
- Obtain further information about your specific Apple Health plan and its offerings.
Apple Health Managed Care Plan Contact Information
| Plan | Phone number |
|---|---|
| Community Health Plan of Washington (CHPW) | 1-800-440-1561 |
| Coordinated Care (CC) | 1-877-644-4613 |
| Molina Healthcare of Washington (MHW) | 1-800-869-7165 |
| UnitedHealthcare Community Plan (UHC) | 1-877-542-8997 |
| Wellpoint Washington (previously Amerigroup) (WLP) | 1-833-731-2167 |
All Apple Health plans offer the same basic services, and customers can also access value-added benefits through their managed care plan.
Services Outside Managed Care: Fee-for-Service Apple Health
While managed care is the primary delivery system, some healthcare services under Apple Health are covered outside of managed care, through a fee-for-service (FFS) arrangement. In FFS, Apple Health directly compensates providers for each service rendered, utilizing the customer’s ProviderOne services card.
Fee-for-service coverage is often necessary when a customer’s healthcare situation involves other primary coverage, such as Medicare. Services consistently covered directly by Apple Health via fee-for-service include:
- Dental care.
- Vision hardware (for children only).
- Long-term care services.
- Inpatient psychiatric care related to physician services.
Your primary care provider or health plan can assist in navigating and coordinating these benefits when needed, ensuring seamless access to the full spectrum of covered services.
Accessing Crisis Services
For immediate support in crisis situations, several resources are available.
Statewide 24-hour Suicide & Crisis Lifeline
Nationwide Phone: 988 (or 1-800-273-8255)
Online: 988 Suicide & Crisis Lifeline
