New Program: Hospital Action Required
| To:
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Rural Chief Executive Officers, Chief Financial Officers, Chief Medical Officers, Chief Nursing Officers, Patient & Family Engagement Leaders, Human Resources Leaders, Legal Counsel and Government Affairs Staff
Please forward to managers and staff who may be involved in education, implementation and billing for this new program |
| Staff Contact:
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Caitlin Safford, MHA, Senior Director, Government Affairs Caitlins@wsha.org | 206-696-1430 Mary Storace, Policy Analyst, Government Affairs |
| Subject: | New Program: Apple Health Expansion (AHE) for Undocumented Residents |
Purpose
This bulletin is intended to inform health care providers and hospitals of the Apple Health Expansion (AHE) program, which is a new, wholly state-funded health coverage option for low-income undocumented residents. Applications for the state AHE program went live on June 20, 2024, and the program goes into effect on July 1, 2024. It is administered by the state Health Care Authority (HCA).
On June 21, 2024, HCA released an announcement informing interested parties that the AHE program enrollment limit has been met for individuals aged 19-64.. However, the enrollment cap for Washingtonians aged 65 and older has not yet been reached and applications are still being accepted.
AHE comes from legislatively authorized state-only funding and provides “Medicaid-like” health coverage for adults aged 19 or older earning less than 138% of the federal poverty level, regardless of immigration status. Similar to Medicaid, this program does not contain out-of-pocket costs or copays and will be operated through a separate contract with four of the five existing Medicaid managed care organizations (MCOs). WSHA supported funding for the AHE program during the 2024 legislative session and will continue to support program refinement and expansion.
Applicability/Scope
Eligible undocumented individual residents in Washington can apply for the AHE program and potentially obtain coverage. Among other covered benefits, services provided in the hospital setting are included within the scope of the program. While it is unclear at this time where AHE program clients will be located or seeking hospital services, all hospitals and providers should be prepared to serve this population on July 1.
Recommendations
- Review this bulletin.
- WSHA and the Health Care Authority hosted a webinar on Thursday, June 20 from noon to 1 pm to provide information about the new program, and other state health coverage available to undocumented individuals. The recording and slide deck are available on our dedicated ‘Coverage for Undocumented Individuals in Washington State’ WSHA webpage.
- Ensure that hospital staff are aware of the new billing practices and other new responsibilities under the program.
Overview
The Apple Health Expansion (AHE) program is a new type of health coverage available to adult Washington residents with certain immigration statuses that make them ineligible for federal assistance. To qualify, an enrollee’s income needs to be less than 138% of the federal poverty level annually. Due to a limited budget for the program, the Health Care Authority has determined that about 13,000 adults will be eligible to enroll, including individuals transitioning from other program types.
Determining Coverage: Hospital and Provider Responsibilities under AHE
An AHE specific designation will not be included on managed care organizations (MCOs) health plan ID cards, to ensure that health care information for this population remains protected and confidential. While AHE enrollees will have health plan ID cards, hospital staff are tasked with verifying a patient’s eligibility and benefits through ProviderOne or HCA enrollment files to ensure claims are directed to the appropriate payer for care rendered to AHE clients. This is an important process step as there are a few key differences in how the Medicaid benefit is managed compared to AHE benefits.
Accessing interpreter services.
The interpreter services benefit is a prime example of this difference between AHE and traditional Medicaid. Under the Washington Medicaid program (Apple Health), interpreter services are delivered through a single vendor that is contracted with the Health Care Authority. Under AHE, interpreter service requests will be managed by the four MCOs participating in AHE.
Upon request for interpreter services from an AHE client, a health care provider should reach out to the MCO in which that client is enrolled. MCO enrollment and eligibility for AHE interpreter services can be confirmed only by accessing the ProviderOne portal or HCA enrollment files. Managed care organizations will contract with interpreter service vendors to provide qualified interpreters for prescheduled in-person appointments, on demand phone visits and video remote interpreting.
AHE Program Eligibility
Individuals may be eligible for AHE if they meet the following criterion:
- Are a Washington state resident aged 19 or older;
- Have countable income under 138% of the federal poverty level;
- Ineligible for other Apple Health programs due to immigration status;
- Are not pregnant or did not have a pregnancy end in the last 12 months, and
- Are not eligible for qualified health plans with advance premium tax credits (APTC), federally funded medical assistance programs.
Some undocumented individuals enrolled in other programs will be automatically transitioned to Apple Health Expansion. This includes some Qualified Health Plan (QHP) clients, Alien Emergency Medical (AEM) clients who are currently accessing benefits, individuals nearing the end of their maternity and post-partum coverage, youth transitioning in June and July out of Apple Health for Kids, and new clients enrolling through Apple Health application systems.
AHE Program Covered Services
The Apple Health Expansion program is intended to mirror the federally funded Apple Health (Medicaid) program. The following benefits will be covered under AHE:
- Provider visits;
- Hospital services;
- Preventive services, exams and diagnostic procedures;
- Fillings, periodontal services, endodontic services and dentures;
- Oral surgery;
- Behavioral health services;
- Nonemergency medical transportation and interpreter services; and
- Pharmacy benefits including over the counter and prescription drugs on the Apple Health preferred drug list.
For AHE program clients aged 19-20, four other services will be covered:
- Wellness exams;
- Chiropractic care;
- Vision hardware; and
- Orthodontics.
Long-term services and supports are not a covered benefit under AHE.
Management of AHE Program Benefits
The AHE program will be managed by 4 of the 5 Washington state managed care organizations (MCOs), including: Community Health Plan of Washington (CHPW), Coordinated Care of Washington (CCW), Molina Healthcare of Washington (MHW) and UnitedHealthcare Community Plan (UHC). Wellpoint Washington is not participating.
When individuals apply for Apple Health Expansion through Washington Healthplanfinder, they can choose which managed care organization (MCO) they would prefer to be covered under. If an individual does not enroll in a specific MCO, a health plan will be randomly assigned.
Background
Demographic information from the Migration Policy Institute asserts that there is an estimated 246,000 undocumented individuals currently living in Washington state. During the 2022 legislative session, the state legislature directed the Health Care Authority to develop a program to provide Medicaid equivalent health coverage for uninsured undocumented adults, with income up to 138% of the federal poverty level. This measure was passed via budget proviso during the 2023 legislative session with additional funding added in the 2024 legislative session. The combined total authorized for this program is $71.04 million, which HCA’s actuarial firm has estimated will cover 13,000 lives during state fiscal year 2025-2026.
WSHA’s 2024 New Law Implementation Guide
Please visit WSHA’s new law implementation guide online. The Government Affairs team is hard at work preparing resources and information on the high priority bills that passed in 2024 to help members implement the new laws, as well as links to resources such as this bulletin. In addition, you will find the Government Affairs team’s schedule for release of upcoming resources on other laws and additional resources for implementation.
References
SB 5187 – Operating Budget Bill
Health Care Authority: Apple Health Expansion Enrollment Cap Met (6/21/2024)
Health Care Authority: Apple Health Expansion
Health Care Authority: Apple Health Managed Care
Health Care Authority: Apple Health Preferred Drug List
Apple Health Expansion Client Scenarios
Apple Health Expansion Service Area Map
Apple Health Expansion Flyer
ProviderOne Portal
