Important Changes to Apple Health (Medicaid) April 1st

HCA Apple Health


Attention All Washington Apple Health Providers!  

Important changes to Apple Health, effective April 1, 2016

These changes are important to all providers because they may affect who will pay for services. Providers serving any Apple Health client should always check eligibility and confirm plan enrollment by asking to see the client’s Services Card and/or using the ProviderOne Managed Care Benefit Information Inquiry functionality (HIPAA transaction 270).  The response (HIPAA transaction 271) will provide the current managed care plan, fee-for-service, and Behavioral Health Organization (BHO) information. A Provider FAQ is available online  

Behavioral Health Organization (BHO) 

The Department of Social and Health Services (DSHS) manages the contracts for behavioral health (mental health and substance use disorder (SUD)) services for nine of the Regional Service Areas (RSA) in the state, excluding Clark and Skamania counties in the Southwest Washington (SW WA) Region. BHOs will replace the Regional Support Networks (RSNs). Inpatient mental health services continue to be provided as described in the inpatient section of the Mental Health Provider guide. BHOs use the Access to Care Standards (ACS) for mental health conditions and American Society of Addiction Medicine (ASAM) criteria for SUD conditions to determine client’s appropriateness for this level of care.

Fully Integrated Managed Care (FIMC) 

Clark and Skamania Counties, also known as SW WA region, is the first region in Washington State to implement the FIMC system. This means that physical health services, all levels of mental health services, and drug and alcohol treatment are coordinated through one managed care plan. Neither the RSN nor the BHO will provide behavioral health services in these counties.  

Clients must choose to enroll in either Community Health Plan of Washington (CHPW) or Molina Healthcare of Washington (MHW). If they do not choose, they are auto-enrolled into one of the two plans. Each plan is responsible for providing integrated services that include inpatient and outpatient behavioral health services, including all SUD services, inpatient mental health and all levels of outpatient mental health services, as well as providing its own provider credentialing, prior authorization requirements and billing requirements. 

Beacon Health Options provides mental health crisis services to the entire population in Southwest Washington.  This includes inpatient mental health services that fall under the Involuntary Treatment Act for individuals who are not eligible for or enrolled in Medicaid, and short-term substance use disorder (SUD) crisis services in the SW WA region. Within their available funding, Beacon has the discretion to provide outpatient or voluntary inpatient mental health services for individuals who are not eligible for Medicaid.  Beacon Health Options is also responsible for managing voluntary psychiatric inpatient hospital admissions for non-Medicaid clients.   

In the SW WA region some clients are not enrolled in CHPW or Molina for FIMC, but will remain in Apple Health fee-for-service managed by the agency. These clients include:           

  • Dual eligible – Medicare/Medicaid
  • American Indian/Alaska Native (AI/AN)
  • Medically needy
  • Clients who have met their spenddown
  • Noncitizen pregnant women
  • Individuals in Institutions for Mental Diseases (IMD)
  • Long-term care residents who are currently in fee-for-service
  • Clients who have coverage with another carrier 

Since there is no BHO (RSN) in these counties, Medicaid fee-for-service clients receive complex behavioral health services through the Behavioral Health Services Only (BHSO) program managed by MHW and CHPW  in SW WA region.  These clients choose from CHPW or MHW for behavioral health services offered with the BHSO or will be auto-enrolled into one of the two plans. A BHSO fact sheet is available online. 

Apple Health Core Connections (AHCC) 

Coordinated Care of Washington (CCW) will provide care coordination for health care services, and lower-intensity outpatient mental health benefits for all Washington State foster care enrollees. These clients include: 

  • Children and youth under the age of 21 who are in foster care
  • Children and youth under the age of 21 who are receiving adoption support
  • Young adults age 18 to 26 years old who age out  of foster care on or after their 18th birthday 

American Indian/Alaska Native (AI/AN) children will not be auto-enrolled, but may opt into CCW. All other eligible clients will be auto-enrolled.  

AHCC complex mental health and substance use disorder services 

AHCC clients who live in Skamania or Clark County receive complex behavioral health benefits through the Behavioral Health Services Only (BHSO) program in the SW WA region.  These clients will choose between CHPW or MHW for behavioral health services, or they will be auto-enrolled into one of the two plans. CHPW and MHW will use the BHO Access to Care Standards to support determining appropriate level of care, and whether the services should be provided by the BHSO program or CCW.  

AHCC clients who live outside Skamania or Clark County will receive complex mental health and substance use disorder services from the BHO and managed by DSHS.  

Contact Information for Southwest Washington   

Beginning on April 1, 2016, there will not be an RSN/BHO in Clark and Skamania counties. Providers and clients must call their agency-contracted managed care organization (MCO) for questions, or call Beacon Health Options for questions related to an individual who is not eligible for or enrolled in Medicaid.  

If a provider does not know which MCO a client is enrolled in, this information can located by looking up the patient assignment in ProviderOne. 

To contact Molina, Community Health Plan of Washington, or Beacon Health Options please call: ​

Molina Healthcare of Washington, Inc.

Community Health Plan of Washington

Beacon Health Options