Apple Health 101
Medicaid provides health care for people who meet federal income requirements. Medicaid is the federal name for the program, while Apple Health is what Medicaid is called in the state of Washington.
As an Apple Health recipient, you’re entitled to choose health insurance that works in your best interest. Understanding your options, costs, and benefits can make a big difference in the quality of your care.Consumer Checklist: What to look for in a Apple Health plan
It can be difficult to find coverage that meets your health care needs. Consider the following qualities when shopping for Apple Health insurance:
- Benefits Offered — Check whether the plan covers the health care services and medications you need. Apple Health plans must meet certain standards, but they’re not all the same.
- Provider Network — Find out if your doctor accepts the type of insurance you’re thinking of getting. Check our provider network.
- Added Benefits — Many insurance companies, including CHPW, offer additional programs and services at no cost to members. We’ve added these services to invest in our members’ long-term health. Look into what’s available to you beyond your baseline coverage.
Medicaid and Apple Health are names for the same program. Apple Health is what Medicaid is called in the state of Washington.
CHPW is a not-for-profit health insurance plan. We work with the state to offer health care plans to Apple Health (Medicaid) and Medicare recipients. We offer excellent care, as well as many benefits not covered by Apple Health alone.
Your benefits include:
If you have CHPW Apple Health coverage as an individual, Medicare Advantage Dual coverage, or Behavioral Health Services Only (BHSO) coverage, covered services and programs that are delivered within network do not cost you anything.
Unless your in-network doctor approves care for you from a provider outside our network, you will likely have to pay the full cost of services provided.
If your child has CHPW Apple Health for Kids coverage, you may pay a low monthly premium. Whether or not you pay a premium depends on your income. Check income requirements for Apple Health for Kids.
Traditional HMOs (Health Maintenance Organizations) and EPOs (Exclusive Provider Organizations) may disallow coverage to providers outside their networks. This lets them keep their premiums lower than other kinds of plans. Unless your in-network doctor approves care for you from a provider outside our network, you will likely have to pay the full cost of services provided.
CHPW is an HMO. We’re proud of our network across Washington state and the care they provide our members.
PPOs (Preferred Provider Organizations) or POSs (Point-of-Service Plans) give you a choice of getting care within or outside of the provider network, although the costs are usually higher if the care is out-of-network.
FFSs (Fee-for-Service Plans) usually don’t have networks. That means you can see any doctor you choose, but you may have to pay more and fill out extra paperwork.
We contract with more than 2,700 primary care providers and more than 14,700 medical specialists.
If you already have health coverage through another program, like Medicare, Tribal Health, or Foster Care, you can get extra coverage just for mental health and substance use services through our Behavioral Health Services Only (BHSO) plan. You won’t have copays for services that are covered or approved from in-network providers.
Substance use services include: Assessment, detox, opiate substitution services, inpatient residential treatment, outpatient treatment.
Mental health services include: Evaluation, medication management, stabilization services, family treatment, crisis services.
Other services include: Emergency services, hospital services, evaluations, lab services.
When you enroll in CHPW you will be sent an ID card. Your member ID card lets your provider know to bill Community Health Plan of Washington for your services.
Each person in your family who signs up with Community Health Plan of Washington will get their own ID card. Separately, the Health Care Authority (HCA) will send you a ProviderOne Services card to show that you are enrolled in Washington state’s Apple Health (Medicaid) program.
You will need to show the Community Health Plan of Washington ID card and your ProviderOne Services card each time you get medical care. That includes medical visits, specialist visits, mental health visits, hospital visits, and when you’re ordering or filling prescriptions.
If you lose your ProviderOne Services card, you can call Apple Health Customer Service at 1-800-562-3022 and follow the prompts to request a new card.
If you need care and don’t have your ProviderOne Services card, go see your provider. They may be able to verify that you are enrolled in Apple Health with your name and date of birth.
Health insurance terms
While shopping for an Apple Health (Medicaid) plan, you may come across unfamiliar terms. We’ve covered a few of the most common ones here.
Remember under an Apple Health plan there are free or low-cost covered services if you meet certain income and life situation requirements.
- Premium — The amount you pay (usually monthly) to a health insurance company for your policy.
- Deductible — How much you pay before your insurance coverage begins.
- Copay/Coinsurance — How much you pay for services after the deductible is met.
- Copay is the dollar amount you may be required to pay as your share of the cost for a medical service or supply. A copay is usually a set amount, rather than a percentage. For example, you might pay $10 copay for a primary care office visit.
- Coinsurance is usually a percentage. It is the amount you may be required to pay as your share of the cost for services or prescription drugs. For example, you might pay 20 percent of the cost for a specialist visit.
- Out-of-Pocket Maximum — The most you will have to pay for your coverage during your policy period (usually one year) before your health insurance company begins to pay 100 percent of the allowed amount. Depending on your plan, this amount may or may not include premiums. The out-of-pocket maximum is sometimes called an out-of-pocket limit.
What is medical necessity or medically necessary care?
In the state of Washington, medical necessity is used to describe care that is reasonable, necessary, and/or appropriate based on evidence-based clinical standards of care.
Other states may use different definitions of medical necessity. To find out whether a particular treatment meets the standard of medical necessity, talk to your CHPW network doctor or care provider.