Wash. HCA Hospice Services Billing Guide, Are clients enrolled in an HCA-contracted managed care organization (MCO) eligible?

Yes. Most Apple Health clients are enrolled in one of HCA’s contracted managed

care organizations (MCOs). For these clients, managed care enrollment will be

displayed on the client benefit inquiry screen in ProviderOne.

A client enrolled in one of HCA’s contracted MCOs must receive all hospice

services, including nursing facility room and board, directly through that MCO.

The client’s MCO is responsible for arranging and providing for all hospice

services. Clients can contact their MCO by calling the telephone number provided

on the client’s Services Card. The MCO is responsible for payment of a client’s

approved hospice care until the client is discharged, as long as the client remains

eligible for Apple Health.

A hospice agency must notify HCA within five business days when a client

elects to receive hospice services. Fax a completed HCA/Medicaid Hospice

Notification form, HCA 13-746, to 360-725-1965. See Where can I download

HCA forms? The hospice agency must comply with the managed care plan’s

policies and procedures to obtain authorization.

Note: A client’s enrollment can change monthly. Providers who

are not contracted with the MCO must receive approval from

both the MCO and the client’s primary care provider (PCP) prior

to serving a managed care client.

Managed care enrollment

Most Apple Health clients are enrolled in an HCA-contracted MCO the same

month they are determined eligible for managed care as a new or renewing

client. Some clients may start their first month of eligibility in the FFS program

because their qualification for MC enrollment is not established until the month

following their Apple Health eligibility determination. Exception: Apple Health

Expansion clients are enrolled in managed care and will not start their first month

of eligibility in the FFS program. For more information, visit Apple Health

Expansion. Providers must check eligibility to determine enrollment for the

month of service.

New clients are those initially applying for benefits or those with changes in their

existing eligibility program that consequently make them eligible for Apple

Health managed care. Renewing clients are those who have been enrolled with

an MCO but have had a break in enrollment and have subsequently renewed

their eligibility.

Checking eligibility

Providers must check eligibility and know when a client is enrolled and with

which MCO. For help with enrolling, clients can refer to HCA’s Apply for or

renew coverage webpage.

Clients’ options to change plans

Clients have a variety of options to change their plan:

• Available to clients with a Washington Healthplanfinder account:

Go to Washington Healthplanfinder website.

• Available to all Apple Health clients:

o Visit the ProviderOne Client Portal website:

o Request a change online at ProviderOne Contact Us (this will generate

an email to Apple Health Customer Service). Select the topic

“Enroll/Change Health Plans.”

o Call Apple Health Customer Service at 1-800-562-3022. The automated

system is available 24/7.

For online information, direct clients to HCA’s Apple Health Managed Care

webpage.

Clients who are not enrolled in an HCA-contracted

managed care plan for physical health services

Some Apple Health clients do not meet the qualifications for managed care

enrollment or have the option to enroll in fee-for-service. These clients are

eligible for services under the fee-for-service program.

In this situation, each managed care organization (MCO) will have a Behavioral

Health Services Only (BHSO) benefit available for Apple Health clients who are

not in integrated managed care. The BHSO covers only behavioral health

treatment for those clients. Eligible clients who are not enrolled in an integrated

HCA-contracted managed care plan are automatically enrolled in a BHSO except

for American Indian/Alaska Native clients. If the client receives Medicaid-covered

services before being automatically enrolled in a BHSO, the fee-for-service

program will reimburse providers for the covered services. Examples of

populations that may be exempt from enrolling into a managed care plan are

Medicare dual-eligible, American Indian/Alaska Native, Adoption Support and

Foster Care Alumni.

Integrated managed care

Clients qualified for enrollment in an integrated managed care plan receive all

physical health services, mental health services, and substance use disorder

treatment through their HCA-contracted managed care organization (MCO).

Integrated Apple Health Foster Care (AHFC)

Children and young adults in the Foster Care, Adoption Support and Alumni

programs who are enrolled in Coordinated Care’s (CC) Apple Health Core

Connections Foster Care program receive both medical and behavioral health

services from CC.

Clients under this program are:

• Age 17 and younger who are in foster care (out of home placement)

• Age 20 and younger who are receiving adoption support

• Age 18-21 years old in extended foster care

• Age 18 to 26 years old who aged out of foster care on or after their 18th

birthday (alumni)

These clients are identified in ProviderOne as “Coordinated Care

Healthy Options Foster Care.”

The Apple Health Customer Services team can answer general questions about

this program. For specific questions about Adoption Support, Foster Care or

Alumni clients, contact HCA’s Foster Care and Adoption Support (FCAS) team at

1-800-562-3022, Ext. 15480.

Fee-for-service Apple Health Foster Care

Children and young adults in the fee-for-service Apple Health Foster Care,

Adoption Support and Alumni programs receive behavioral health services

through the regional Behavioral Health Services Organization (BHSO). For details,

see HCA’s Mental Health Services Billing Guide, under How do providers identify

the correct payer?

American Indian/Alaska Native (AI/AN) Clients

American Indian/Alaska Native (AI/AN) clients have two options for Apple

Health coverage:

• Apple Health Managed Care

• Apple Health coverage without a managed care plan (also referred to as fee-for-service [FFS])

If an AI/AN client does not choose a managed care plan, they will be

automatically enrolled into Apple Health FFS for all their health care services,

including comprehensive behavioral health services. See the Health Care

Authority’s (HCA) American Indian/Alaska Native webpage.