for Individuals with both Medicaid Apple Health and Private Insurance
If you or someone in your family has Medicaid Apple Health coverage in addition to primary private health insurance, you will have received a notice from the Health Care Authority sometime this month, letting you know about a change from fee-for-service medical coverage (aka the “coupon”) to managed care, beginning January 1, 2017.
It’s part of a process that was started a few years ago, when most SSI eligible individuals who receive Medicaid were transitioned to a managed care plan.
What to Expect
STEP 1: Read your letter and booklet from HCA.
The Health Care Authority (HCA) will send you a Welcome to Washington Apple Health booklet that lists basic services. The letter in the booklet will include the name of the managed care health plan you have been enrolled in.
STEP 2: Find out if your health care providers are part of your assigned plan’s network.
Each plan has its own provider network of doctors, clinics, hospitals, pharmacies and specialists. After you receive notification of your managed care plan, contact your current health care provider(s) to find out if s/he contracts with the plan you’ve been enrolled in. Or, contact the plan for information about its provider network. Click here for a list of managed care plans in your area, and contact numbers.
STEP 3: Keep the plan you have been assigned or request a change.
If your provider is not in the plan, or they’re not willing to bill your plan, you may want to change plans. Ask your health care providers which managed care plans they participate in or are willing to bill, and request a change to that plan (if it’s available in your area). HCA contracts with five different managed care plans for its Medicaid Apple Health program. Although not all five are offered in every area, everyone will have at least two plans to choose from. Instructions for requesting a change will be provided in your enrollment letter.
Things to Consider
If there’s a specialist you prefer, check to make sure they are a member of the plan’s provider network.
Think about current or potential treatments when selecting a plan. What is the plan’s hospital affiliation?
Ask about the plan’s process and policies around pharmacy benefits. There may be some differences in each plan’s formularies; however, Apple Health requires that the plans continue your treatment plan, including prescriptions, for 90 days or as soon you can be evaluated by the plan’s provider.
Visit our Apple Health page for information about managed care, plans available in your area, and how to choose or change your plan.