Tag: Apple Health

School Services That Can Be Billed to Medicaid

Posted on by Nicol Walsh

Brief Overview:

  • This information is good to know for families of students with Individualized Education Programs (IEPs) and Individualized Family Service Plans (IFSP) when those students have Apple Health (Medicaid/CHIP) for their health insurance.
  • Schools can bill Medicaid for many common IEP and IFSP services. When schools do this, they don’t have to spend special education funds on these services and can use that money to pay for other special education needs.
  • Medicaid billing can be complicated and difficult, and not all schools in WA State do it.
  • Parents can advocate for their student’s school to join the WA State Health Care Authority School-Based Services Program to bill Medicaid and free up money in the special education budget. Parents and caregivers can learn to advocate and resources for that are listed in the article.

Full Article

Individualized services that children receive through their IEP or IFSP may be covered by Medicaid. Medicaid will pay for health-related services in an Individual Education Program (IEP) or Individual Family Service Plan (IFSP) if they are already Medicaid-covered services, if the student qualifies for Medicaid for health insurance.

The Individuals with Disabilities Education Act (IDEA) requires that Medicaid be the primary payer to schools and providers of services included in an IEP or IFSP. (This means that if a school doesn’t use special education funds to pay for these services, Medicaid should be billed before any other insurance or individual.)

Which individualized services will Medicaid pay for?

  • An evaluation to see if a student is eligible for special education (if the student is found eligible)
  • Re-evaluations for special education
  • Nursing/health services
  • Physical Therapy
  • Occupational Therapy
  • Speech Pathology/Audiology
  • Mental Health Care
  • Other health services that schools provide, and Medicaid covers, as long as it’s included in an IEP or IFSP

Will Medicaid pay for services in a 504 plan?

If a student with a 504 plan needs medical services as part of their plan to receive a Free Appropriate Public Education (FAPE), Medicaid will not be the primary payer—but after a school bills any other potential payers (such as private health insurance), a school can bill Medicaid for any remaining costs.

If your student has Medicaid (Apple Health) or CHIP for health insurance, school health services like mental health care, substance use disorder services and monitoring medication can be covered by Medicaid, even if they are not included in a student’s IEP, IFSP, or 504 plan.

If a Local Education Agency (LEA, or school district) runs early childhood programs like Early Head Start, Head Start, or school-based preschool, schools can bill Medicaid for Medicaid-eligible Early and Periodic Screening, Diagnostic and Treatment benefits (EPSDT), even if they are not in a child’s IFSP. This ensures that children in these programs get these essential screening and well-child services.

Why is billing Medicaid important?

When Medicaid pays for services, schools do not have to use special education dollars for those services. Instead, special education dollars can be used for expenses like hiring adequate support staff, adaptive or communication technology, durable mobility supports, and enhanced accessibility supports for inclusive student activities.

How do schools get Medicaid to pay for these services?

Washington State public school districts, educational service districts (ESDs), public charter schools, and tribal schools are all eligible to participate in the School Based Health Services program at Washington State’s Health Care Authority (HCA).

Each school district that wants to bill Medicaid signs a contract with the state Medicaid agency and the Health Care Authority. School districts submit their costs for Medicaid-covered services to the state’s Health Care Authority (HCA), which reimburses their costs while billing Medicaid for those services. School or district staff are responsible to fill out the Medicaid claim forms with the proper billing codes. Staff need to take specific training to do this.

Some schools decide not to bill Medicaid and use special education funds for these services. Why?

Unlike healthcare providers, schools are not set up to bill programs like Medicaid. The billing process can be complicated and time-consuming (for example, the billing guide that HCA provides to schools who want to bill Medicaid is 57 pages long).

In 2023, a new federal law (the Bipartisan Safer Communities Act) required Medicaidto make the billing process easier for schools; in May 2023, the Centers for Medicare and Medicaid Services (CMS) announced new guidance on this topic, which was sent to all states.

The Network for Public Health Law says the law made “important and substantial changes to reimbursement for school-based Medicaid services”. The law requires updates to outdated Medicaid billing guides and gives more help to states and local education agencies (LEAs, or school districts) who want Medicaid to reimburse them for school-based healthcare services. The law also made grants available to states to “implement, enhance or expand school-based programs” for healthcare (HHS) and for programs run by the Department of Education.

One purpose of the new law was to make billing Medicaid simpler and less expensive for schools. A second purpose was to encourage states to allow schools to use Medicaid for more types of healthcare services. The law also provides grants and other funding for mental health services for students.

As of July 2024, the Health Care Authority is still examining the new guidance to see if they want to make changes to the School-Based Health Care Services program.

Parents may think it makes sense to use Medicaid funds rather than special education funds for IEP/IFSP services. This chart from the Health Care Authority lists the schools and districts who have contracted with HCA and get Medicaid reimbursement for school-based health services. (current as of June 2024).

If a school or district is not listed, what are some ways parents can advocate for a school to start billing Medicaid?

  • Ask the school principal or superintendent about the reasons for not billing Medicaid. Ask what would need to change for the district to start Medicaid billing. This information is useful for gathering support from other parents and school personnel, and for getting policymakers to make the change.
  • There are national and statewide organizations that want to expand the use of Medicaid to pay for school-based services for all Medicaid-eligible students, not only students with IFSPs/IEPs. Parents may wish to visit their websites, learn about what they want to change, and contact these organizations for information about advocacy and organizing other parents around this topic.
  • District-wide decisions and policies are often made locally by a district’s administration team, the School Board, or both together. Contact information for district administration will be on the district’s website (and possibly on the school’s website). Contact information for school boards is usually available on a town or city government’s website, and sometimes on the district’s website.
  • Does the school or district have a Special Education PTA? If so, this group of parents and educators may be a good way to find other people interested in this topic. If not, a school’s Parent Teacher Organization (PTO) is also a useful resource. List of WA State Special Education PTAs.
  • When parent advocate groups ask for change, it can be very helpful to offer assistance to help make their request a reality. Can parent volunteers be used in any way to make the change easier? What other creative assistance might be helpful? Discussions with district administration and school boards about “why this won’t work” will let you know where and what type of help is needed.
  • Many organizations which support families, including families whose child or children have disabilities can offer advice or training for parents who want to advocate about the need for services in schools. This list is a starting point—you may find other groups or organizations which are not on the list.

Apple Health for Kids: Medicaid and Children’s Health Insurance Program (CHiP) in Washington State

Posted on by Nicol Walsh

Overview

  • In Washington State, Medicaid, which includes the Children’s Health Insurance Program (CHiP) is called Apple Health. Medicaid and CHIP are medical insurance programs run by the state and funded by the federal government and the state.
  • Children can get free or low-cost health insurance from birth to age 19.
  • A child’s eligibility is based on living in Washington State, and the family level of income. Immigration status does not apply to Apple Health for Kids, and family information will not be shared with immigration officials.
  • There are links in this article to information on Apple Health insurance coverage for parents and caretakers, pregnant individuals, young adults, and children in foster care or who have been in foster care.

Where to apply or find more information about Apple Health for Kids:

Full Article

In Washington State, Medicaid, which includes the Children’s Health Insurance Program (CHiP) is called Apple Health. Medicaid and CHIP are medical insurance programs run by the state and funded by the federal government and the state.

The state agency that runs Apple Health programs is the Health Care Authority. This is the official website to get information about Apple Health programs. For some programs, such as Home and Community-Based Services Waivers (HCBS waivers) the Health Care Authority partners with the Department of Social and Health Services (DSHS). Find out more about HCBS waivers and similar programs at Informing Families.

Apple Health for Kids is free or low-cost health insurance for children from birth to age 19.

It covers the costs of medical, dental, vision (eye) care, hearing care, and behavioral (mental) health.

Medicaid programs, including CHiP, make sure that children get Early and Periodic Screening, Diagnostic, and Treatment services.

These services mean children get regular physical exams, are screened (checked) for any problems with physical and mental health, developmental delays, dental health, hearing, vision, and other tests to find any problems and treat them.

Are complex medical needs covered under Apple Health for Kids?

Yes, the Medically Intensive Children’s Program (MICP) is a Medicaid program for children who need a registered nurse to provide support.  Visit the MICP page at WA State’s Health Care Authority.

Who can get Apple Health for Kids?

  • The child must live in Washington State.
  • The family income must be below a certain amount. Based on the family income level, a child may qualify for either the free Apple Health for Kids (Medicaid), or for Apple Health for Kids with premiums (CHiP).

Important! Children and pregnant individuals may qualify for WA Apple Health coverage regardless of their immigration status.

Information from WashingtonLawHelp.org says:

“All children up to age 19 who have low income are eligible for free medical coverage (“Washington Apple Health”) in Washington State. There are no immigration status requirements for this coverage. Children from families with moderate income can also get coverage. They may have to pay a small monthly premium.

Your children may also be eligible for other programs, including Head Start and other education programs, school meals, and child nutrition programs

It’s generally very safe to apply.  State and federal laws protect the privacy of the information you put on your application. Your information should not be shared with immigration officials.

If you prefer, you can choose to apply for benefits for other family members, such as your children, and not for yourself. You won’t have to give information about your own immigration status, but you may have to give proof of your family’s income.”

Costs of Apple Health for Kids:

People on Apple Health (adults and children) do not pay cost-sharing, co-payments, or deductibles for any service.

There are three premium price levels for Apple Health for Kids:

  • Free (no monthly premiums)
  • Low monthly premium (payment to get the Apple Health Insurance plan)
  • Slightly higher monthly premium

Every year in April, WA State may adjust the amount of income a family can make to qualify for Apple Health for Kids. The premium amounts for Apple Health for Kids with premiums may also change. These changes take inflation and Apple Health program costs into account.

To check if  your family income meets the limits for Apple Health for Kids, go to the WA State Health Care Authority page for Children.

Exception: children of public and school employees who have access to, or are enrolled in health insurance coverage under PEBB or SEBB programs may be eligible for Apple Health for Kids with premiums.

Important to Know:

Apple Health for Kids includes “continuous coverage”. This means a child or youth can stay on Apple Health for Kids even if their family’s income goes above the Apple Health income limits during the continuous coverage period.

This rule applies to free Apple Health for Kids (Medicaid) and Apple Health for Kids with premiums (CHiP). The rule applies to both “with premium” plans.

  • For free Apple Health for Kids: Children birth to age 6 have continuous coverage from when they are enrolled until their 6th birthday.
  • For Apple Health for Kids with premiums, children from birth to age 6 have continuous coverage for 12 months at a time.
  • From age 6 to age 19, all three Apple Health for Kids programs have continuous coverage for 12 months at a time.  

If a child loses their coverage and needs to re-enroll, learn more on the HCA website or by emailing HCA at AskMAGI@hca.wa.gov.

Protections for children’s health insurance: New federal rules for Medicaid and CHiP

The new rules start as of June 1, 2024, but states have some time to make changes to their programs. WA State already follows these rules, but the new rules prevent WA State from doing any of these things in the future.

States will not be allowed to:

  • Require a waiting period before a child can be covered by Medicaid or CHiP health insurance
  • Stop a child’s Medicaid or CHiP health insurance if the family misses premium payments, during the continuous coverage period
  • Make a family pay back the unpaid premiums before a child can re-enroll after their continuous coverage period runs out, or charge an enrollment fee
  • States can’t put a dollar limit on benefits for CHiP. (Medicaid doesn’t allow dollar amount limits). Benefits can be limited in terms of what services are covered, or how often a service can be used. For instance, a state could decide CHiP will only cover a total of 12 visits for physical therapy in one benefit year

Health Coverage for Teens and Young Adults

Teens under age 18 who want or need to get health care coverage without their parents may be eligible for Apple Health under one or more of these conditions:

  • Live separately from parents or guardians and are not claimed by them as a tax dependent
  • Are pregnant
  • Need birth control or STI (sexually transmitted infection) care

To apply, follow these instructions on the Fact Sheet for Apple Health Teen Application Process.

Young adults aged 19 and up may be eligible for Apple Health if they meet income guidelines or have been in foster care. Apply online at Washington Healthplanfinder.

Other WA State Medicaid programs that may help people who care for children, or who are pregnant:

Parents and Caretakers

Pregnant Individuals

Foster Care

Resources:

The Family to Family Health Information Center (F2FHIC)

Helpline at PAVE

Informing Families

Medicaid Basics (article from PAVE)

WashingtonLawHelp.org

Washington State Health Care Authority

Washington State Healthplanfinder

WithinReach

Changes to improve monitoring for quality and improve oversight of HCBS Waiver Programs

New rules

The new rules will apply to § 1915(c) HCBS waivers and §§ 1915(i) state plan services, (j) personal assistance services, and (k) Community First Choice. The new rules will also apply under § 1115 demonstration projects unless specifically waived, and under FFS and managed care delivery systems.

  • Update functional assessments and person-centered plans at least once every 12 months;
  • Establish grievance procedures for Medicaid beneficiaries receiving certain HCBS services in FFS (there are already grievance procedures applicable to managed care);
  • Establish an incident management system to identify, investigate, and resolve critical incidents, including reports of abuse, neglect, and financial exploitation;
  • Provide assurances that payment rates are adequate to ensure a sufficient direct care workforce;
  • Collect and report data to monitor access (e.g., waiting lists, average amount of time between approval for and delivery of HCBS services, percent of authorized hours provided); and
  • Report on core measures in the HCBS Quality Measure Set.

Healthcare in Transition

Posted on by Nicol Walsh

Healthcare transition, like all other aspects of transitioning to adult care and services, can be difficult. However, if teenagers and families plan ahead for healthcare changes that occur when a child becomes an adult, things can go smoothly and be successful. Here are some resources and information for making the health care transition to adult care successful and seamless.

There are two main components for individuals transitioning from pediatric (children’s) to adult health care.

  • New medical providers and systems, including changes in insurance.
  • The young adult’s new responsibility to be in charge of their own health care.

Health Insurance and Providers

For individuals on Medicaid, Medicare, or private health insurance, eligibility, cost, and what services are covered may change.

Washington’s Medicaid option, Apple Health, has different financial requirements for adults than they do for minors. See the chart below for current income requirements for Apple health.

ProgramSingle person2-person house-hold3-person household4-person household5-person household6-person household7-person household
Apple Health for Adults, age 19 through 64 years of age$1,677 monthly$2,268 monthly$2,859
monthly		$3,450
monthly		$4,042
monthly		$4,633
monthly		$5,224
monthly
Current income requirements for Apple Heath
  • To apply or renew for Apple Health, go to the Health Plan Finder website.  Even if an individual is not eligible for fully subsidized healthcare, the Health Plan Finder can reveal some low-priced options. 
  • For young adults on their parents’ private insurance, they will have coverage under their parent’s plan until they are 26, at which time they will need to apply for their own health insurance.  The Health Plan Finder can help you find affordable options, including Apple Health.
  • For individuals under 65 who are receiving Medicare due to a disability, insurance should not change due to the transition to adulthood.

A person’s health insurance may limit the health care providers available. Once you and your family know what type of health insurance you will have, you can select from physicians and other health professionals who accept that insurance. Most medical practices either list what insurances they accept, or you can call the office and ask. Health care insurance plans may also send information on where to find a provider, or you may find it on their website.

Taking on Responsibility for Health Care and Decisions

Healthcare is just one of many new responsibilities that young people take on as they become adults.  Parents can avoid overwhelming a teen with new obligations, beginning with giving younger teens options and increasing tasks to help them adapt to this change.  There are several resources for families and youth to use in this transition:

  • Family to Family has a youth-written curriculum about Transitioning to Adult Doctors for individuals with disabilities that can help teens start their medical transition journeys.
  • Charting the LifeCourse™ was created by families to help individuals and families of all abilities and all ages develop a vision for a good life, including their health care.
  • Got Transition is a comprehensive website about the transition to adult health care, with quizzes, FAQs, and timelines to make it easier to understand.
  • The Center for Transition to Adult Health Care for Youth with Disabilities is a national health care transition resource center. The goal of the center is to empower youth and young adults with intellectual and developmental disabilities (ID/DD) ages 12-26 to direct their own transition from pediatric to adult care with no reduction in quality of care and no gaps in service.

Beyond these resources, the most useful are the young adults, whether you are the parent/caregiver or a transitioning individual. It’s important to recognize that lived experience gives knowledge even in a new situation. There is the knowledge of medical need that may not be in a chart, emotional or behavioral challenges, developing self-determination that supports transition, and other important things only you know.  Next in line are the current medical providers and specialists.  They not only have helped numerous other teens transition to adult healthcare, but they are a part of developing the care plan, a critical resource for transitioning to an unfamiliar doctor or clinic when a young adult may have complex care needs.   Doctors’ office staff are also used to dealing with these issues and may have some good planning advice for families.  Lastly, advice from families who have already helped a child transition to adult care can help to know what to do—and what not to do!  Parent-to-Parent can match parents up with families who have already gone through such transitions with those who seek their knowledge and experience.

5 Tips for Success in Healthcare Transition
Download The Five Tips for Success in Healthcare Transition


Including Health Considerations in the Transition Plan

Parents, Students, and everyone on the IEP team should think about how health and healthcare can affect a student’s goals for college, work and living on their own. PAVE has made a fillable form that you can download when starting to think about this area in transition.

Including Health Considerations in the Transition Plan
Download Including Health Considerations in the Transition Plan

Medicaid Basics

Posted on by Nicol Walsh

A Brief Overview 

  • Medicaid is state-run health care for those with limited income or individuals with chronic or complex health care needs with special circumstances. 
  • Medicaid is available to many families In Washington state who are not eligible for Medicare and are below certain income levels. 
  • Apple Health for children has broader eligibility requirements, meaning that more children in Washington state can be covered for low or no cost. 
  • You can apply for Medicaid through the Washington Health Plan Finder. 
     

Full Article 

Medicaid is a federal health care program that each state manages based on their own states legislative system. It is set up for individuals and families with limited income or special circumstances such as a genetic, medical, or job or accident-related disability. This health care covers physical and mental health and can be low to no-cost. To be eligible for fully subsidized (free) Medicaid you must meet the household income eligibility and not be eligible for Medicare. However, Medicaid for those with Medicare can help with some expenses not covered by Medicare for those with low income. It is available for an individual on classic Medicaid whose parent or guardian has died and whose benefits pass to their child. In the state of Washington, Medicaid is generally known as Apple Health and is administered by the Health Care Authority. 

There are two main types of Medicaid available in the state of Washington: Apple Health (income based), and Classic Medicaid. The day-to-day administration of Apple Health and Classic Medicaid is run by one of five Managed Care Organizations, or MCOs. Apple Health covers individuals up to the age of 6 and eligibility is based on household income. Apple Health has higher income limits for children than adults, meaning that many children in Washington State are eligible for free Apple Health, even when their parents or guardians are not..  If you have Apple Health, you will get healthcare from the providers at one of those MCOs. If you are found (determined) to have a disability or a disabling medical condition and are under the age of 65, you are eligible for Classic Medicaid if you are on Social Security Income or Supplemental Security Income (SSI). This is also considered Apple Health and under one of the 5 MCOs. If an infant, child, or youth through age 21 is in the foster care system they will be covered by Apple Health and will get their healthcare from one specific MCO no matter where they live in the state. 

Determining Eligibility for Apple Health 

Apple Health has different eligibility requirements for children and adults. These differences are listed below, including the maximum monthly household income requirements that families may have to obtain coverage. 

Eligibility for Apple Health for Children: 

  • Children of public employees with access to health insurance coverage under the PEBB or SEBB programs are not eligible for Apple Health for Kids with premiums. 
  • Low-cost coverage (Apple Health with premiums) is only available to children who are uninsured when household income is too high to qualify for free Apple Health (no premiums) 
  • Income requirements for free coverage: (2024) 
 Single Person 2-Person Household 3-Person Household 4-Person Household 5-Person Household 6-Person Household 7-Person Household 
Apple Health for Kids $2613 monthly $3534 monthly $4455 monthly $5375 monthly $6296 monthly $7217 monthly $8138 monthly 
  • Income requirements for Tier I subsidized coverage ($20 monthly per child; $40 family maximum): 
 Single Person 2-Person Household 3-Person Household 4-Person Household 5-Person Household 6-Person Household 7-Person Household 
Apple Health for Kids Tier I $3220 monthly $4355 monthly $5490 monthly $6625 monthly $7761 monthly $8896 monthly $10031 monthly 
  • Income requirements for Tier II subsidized coverage ($30 monthly per child; $60 family maximum): 
 Single Person 2-Person Household 3-Person Household 4-Person Household 5-Person Household 6-Person Household 7-Person Household 
Apple Health for Kids Tier II $3852 monthly $5210 monthly $6568 monthly $7925 monthly $9283 monthly $10641 monthly $11999 monthly 

Eligibility for Apple Health for Adults: 

  • For those aged 19 through 64. 
  • For U.S. citizens or those who meet Medicaid immigration requirements. (Including Washington residents from the Republic of Palau, the Republic of the Marshall Islands, and the Federated States of Micronesia) 
  • For those who are not entitled to Medicare.  
  • Have annual household income at or below the Medicaid standard: 
 Single Person 2-Person Household 3-Person Household 4-Person Household 5-Person Household 6-Person Household 7-Person Household 
Apple Health for Adults $1677 monthly $2268 monthly $2868 monthly $3450 monthly $4042 monthly $4633 monthly $5224 monthly 

How to Apply 

There are a couple of ways to start the process of getting Medicaid or other subsidized health care plans. The Health Insurance Marketplace Calculator provides estimates of health insurance premiums and subsidies for people purchasing insurance on their own in health insurance exchanges or “Marketplaces.” The Washington Health Benefit Exchange can help families and individuals find subsidized health care in their area.  

When ready to apply for coverage from Apple Health: 

  1. Review adult and/or child income eligibility requirements. 
  1. Read the Eligibility Overview to determine if Apple Health is the best fit for you and your family. 
  1. Create an account on Washington Health Plan Finder. 
  1. Collect and enter information into the Washington Health Plan Finder application, WAPlanfinder Mobile App, downloadable paper form, or call the Washington Healthplanfinder Customer Support Center at 1-855-923-4633. 
  1. Review the five Integrated Health Care Plans responsible for Medicaid in Washington, not all of which may be available in your location. 
  1. If you need further help, contact a free Health Plan Navigator. 

To get signed up with Medicaid Classic, go online to Washington Connection and select “Apply Now,” or call 1-877-501-2233. For additional help signing up for Medicaid in Washington, help is available from Parent help 123, which can be contacted at 1-800-322-2588, or PAVE. If, in looking at the information above, you feel that you or the person you care for has lost Medicaid through a mistake or a problem with the system and going through the Washington Connection is not resolving the issue, the Federal Government is asking that you go through Healthcare.gov to get help with re-enrollment.  

WISe Provides Team-Based Services for Washington Youth with Severe Behavioral Health Disorders

Posted on by Nicol Walsh

A Brief Overview

  • WISe behavioral healthcare teams serve children and youth 20 or younger whose conditions are too severe to benefit appropriately from regular visits to a community clinician and/or therapist.
  • To qualify for WISe, the young person must be eligible for Apple Health, which is the public health program for Washington State. WAC 182-505-0210 describes Apple Health eligibility standards.
  • WISe was created as a response to the T.R. et al. lawsuit, settled in 2013.
  • Different agencies manage WISe programs in various regions of the state. The Health Care Authority manages a downloadable list of WISe agencies, organized by county. Families can contact their area agency by calling the phone number on this referral list.
  • Read on for various places families might seek solidarity and support. One option is Family, Youth, and System Partner Round Table (FYSPRT), which is a network of groups that meet to discuss what’s working/not working in behavioral healthcare systems in their communities.

Full Article

Children and youth with intensive needs related to behavioral health may be eligible for services from a statewide program called WISe–Wraparound with Intensive Services. A WISe team includes various clinical and professional staff and certified peers, who may support the emotional needs of family members.  

WISe services are provided in the community—outpatient—for children and youth 20 or younger who are eligible for public insurance, called Apple Health in Washington State. To be assigned to a WISe team, the young person must demonstrate a need for services that are more intensive than what is provided from regular visits to a community clinician and/or therapist.

What does behavioral health mean?

Behavioral health is a broad term describing services for people with conditions based in the brain that impact their behavior. Bipolar disorder, schizophrenia, and substance use disorder (SUD) are examples of severe behavioral health conditions impacting some adults and young people.

Other childhood conditions are many and varied, and not everyone uses the same terms for the same symptoms. The Child Mind Institute is a place for information about childhood symptoms, diagnoses, and options for treatment and support.

Some developmental conditions, such as autism, are considered behavioral health conditions when symptoms have a significant impact on behavior. A person with a complicated behavioral health condition may have impacts in multiple areas and may be given a “dual diagnosis.”

Who is eligible for WISe services?

WISe services are for children and youth until their 21st birthday. WISe is only approved if the patient has used other, less intensive therapies, with little to no improvement.  Once approved for services, a young person may spend time on an “interest list,” receiving limited support, before a full team is formed to serve them.

The young person is evaluated with a Child and Adolescent Needs and Strengths (CANS) intensive mental health screening tool, called the CANS-SCREEN.

Five core areas are evaluated:

  1. Life functioning
  2. Behavioral and emotional needs
  3. Risk behaviors
  4. Caregiver resources and needs
  5. Diagnosis and prognosis

According to the CANS-SCREEN, “The care provider, along with the child/youth and family as well as other stakeholders, gives a number rating to each of these items. These ratings help the provider, child/youth and family understand where intensive or immediate action is most needed, and also where a child/youth has assets that could be a major part of the treatment or service plan.”

WISe requires public health insurance eligibility

In addition to meeting criteria based on their symptoms, a young person must be eligible for Apple Health, which is the name for public health insurance in Washington State. The Washington Administrative Code (WAC 182-505-0210) describes Apple Health eligibility standards for children.

Apple Health is most often administered by Managed Care Organizations (MCOs). In 2022, plans are provided by Amerigroup, Community Health Plan of Washington (CHPW), Coordinated Care, Molina, and United Healthcare. Families can request case management from their MCO to help them navigate and understand healthcare options available to them.

An MCO care coordinator/case manager commonly is the person who refers a young person into WISe, although referrals also can be made by the family, a provider, a county health agency, or someone else with knowledge of the circumstances.

Different agencies manage WISe programs in various regions of the state. The Health Care Authority manages a downloadable list of WISe agencies, organized by county. Families can contact their area agency by calling the phone number on this referral list.

Who is on the WISe team?

Team members include:

  • Natural supports (family, friends, religious leaders…)
  • A Care Coordinator (who oversees clinical aspects of the case)
  • Therapist
  • Professionals (clinicians/prescriber if needed, Child Protective Services, probation officers and others who are relevant)
  • Certified peer support specialist
  • Others upon request (youth peer, school staff…)

The clinical group creates a Team Vision Statement, explaining what they plan to achieve and how they will accomplish it through collaborative work. The family also creates a Vision Statement, showing what strengths they would like to build in their family and what tools they need to make their goals possible.

WISe requires family engagement

The time commitment for WISe is significant. Clinicians engage with the whole household on topics related to school, health, work, relationships, home organization, and more.

WISe publishes data about its service delivery. According to January 2021 Service Intensity Estimates, an average family spends 10 or more hours per week engaged with WISe services. This could be much higher, especially in the beginning. Parents/Caregivers are offered therapy sessions and opportunities to engage with parent peers. 

WISe clinicians are responsible to integrate their work to fit with a family’s schedule, often seeking creative ways to tuck sessions into already busy days. For example, a clinician describes a day when they picked up a child at school and conducted a session in the car while driving the child to their next activity. After work, parent met with the clinician while the adults watched the child swim.

Family experiences with WISe are varied. Some say WISe created a critical turning point that enabled family survival. Others cite high staff turnover as a barrier to ideal therapeutic outcomes. The program is most effective with buy-in from the young person and their caregivers and when services are provided to match family needs and schedules.

Does my child have to agree to WISe services?

WISe is a voluntary program. Families may be able to motivate their child to participate by getting services started through Family Initiated Treatment (FIT). FIT was established as a pathway to treatment for youth 13-17 when Washington passed the Adolescent Behavioral Health Care Access Act in 2019. A parent/caregiver can initiate outpatient services to attempt to get the youth to engage. If after 12 visits (within 3 months) the youth is still unwilling to engage with the treatment, the family must end services. They have the option to engage a different provider to try FIT again.

What if WISe isn’t enough?

The WISe program is the most intensive outpatient program that the state offers. If services don’t seem to be working, the family might check the WISe Service Delivery, Policy, Procedure and Resource Manual to see whether there is more the program could be doing. The family also might check if the child could get additional services from another agency to complement the work with WISe. For example, service providers from a special education program at school or from the Developmental Disabilities Administration (DDA) can collaborate with a WISe team.

If a child needs inpatient services, they may be eligible for a referral into the Children’s Long-term Inpatient Program (CLIP). Children placed on a waiting list for CLIP often receive ongoing services from WISe. PAVE provides an article: Children’s Long-Term Inpatient Program (CLIP) Provides Residential Psychiatric Treatment.

History, Advocacy, and Family Support

WISe was created as a response to the T.R. et al. lawsuit, settled in 2013. The class-action lawsuit named ten plaintiffs who were denied treatment for schizophrenia, depression, bipolar disorder, and other serious psychiatric conditions. Most were institutionalized repeatedly and for extended periods, despite recommendations by therapists and case workers that they return home and receive services in their homes and local communities.

Disability Rights Washington (DRW) provided attorney support for the settlement of the T.R. et al. lawsuit. DRW is monitoring current issues related to children being underserved through WISe and encourages families with concerns to contact attorney Susan Kas: susank@dr-wa.org.

Another result of the legal settlement was a statewide network of stakeholders who meet regularly to discuss what works/doesn’t work within the behavioral health system for youth. That network is called Family, Youth, and System Partner Round Table (FYSPRT). Regional FYSPRTs report to a statewide FYSPRT to share input for system improvement. Regional groups are a hub for family networking and emotional support in addition to serving as a place to engage with community health providers, insurance case managers, and other professionals. Some FYSPRTs have distinct groups for young people to meet and support one another. Many FYSPRT groups use online meeting platforms due to the pandemic.

Another place for families engaged in behavioral health services to network is Washington State Community Connections (WSCC), which sponsors an annual family training weekend, manages an SUD Family Navigator training, and offers a variety of ways for families to share their experiences and support one another. WSCC in 2022 is engaged in work to help build a statewide website to help families navigate behavioral health services across systems. Stay tuned!

Families can get direct support from A Common Voice, a statewide non-profit staffed with Parent Support Specialists who have lived experience parenting a child with challenging behavioral health conditions. The program offers virtual support groups and 1:1 help. A Common Voice is part of the Center of Parent Excellence (COPE), managed by the state’s Health Care Authority. The COPE project website provides a schedule of support group meetings and contact information for regional lead parent support specialists.

An informal place to connect with other families is a Facebook group called Healthy Minds Healthy Futures. Advocates in this group initiated work for an interactive website for parents and are engaged in a push for HB 1800 to expand behavioral health services for minors statewide.

Families wanting to advocate for system change can participate in meetings of the Children and Youth Behavioral Health Work Group (CYBHWG). The work group was created in 2016 by the Legislature (HB 2439) to promote system improvement. CYBHWG supports several advisory groups, including one for Student Behavioral Health and Suicide Prevention. The work groups include representatives from the Legislature, state agencies, health care providers, tribal governments, community health services, and other organizations, as well as parents of children and youth who have received services. Meetings include opportunities for public comment. Meeting schedules and reports are posted on the Health Care Authority (HCA) website.

Parity laws, thoughtful language, stopping stigma

Keep in mind that a healthy mind is part of a healthy body, and U.S. laws protect parity for all illness conditions. Despite those protections, discrimination and stigma are commonly discussed within behavioral healthcare systems. Here are a few tips and considerations to help reduce stigma:

  • All behaviors start in the brain, so an impairment that impacts the brain is going to affect behavior. Some behaviors are not a person’s fault; that’s why they need treatment, support, and services.
  • Specific person-first language can help reduce stigma. For example, instead of calling someone bipolar or schizophrenic, say they are a person with bipolar disorder or schizophrenia.
  • An exception to person-first language is in the autism community, which has collectively agreed to use the term “autistic” to describe someone on the spectrum.
  • Saying that someone has “behavioral health,” or “mental health” does not describe their condition or what they need help with. Everyone has mental health! A better choice is to describe the condition/concern and the need for help: “This youth’s schizophrenia is impacting every aspect of life, and they need a range of services and treatments to recover and move forward with their life plans.”
  • A person who dies from suicide did not commit a crime, so the word “commit” is inappropriate to use when discussing suicide.

For additional information on related topics, including areas where behavioral health impacts school, see PAVE’s article: Mental Health Education and Support at School can be Critical