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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.
1-800-869-7165
Community Health Plan
of Washington
1-866-418-1009
Beacon Health
Options
1-855-228-6502
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