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

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

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


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

Supplemental Security Income (SSI)

A Brief Overview

  • Supplemental Security Income (SSI) is a monthly financial payment made to persons meeting specific eligibility requirements defined by the Social Security Administration (SSA).
  • A person may be eligible for SSI if they are aged, blind or disabled; have limited income and resources; and are a citizen or resident of the United States.
  • SSI is different from Social Security Disability Insurance (SSDI), which is an insurance that workers earn by paying into taxes on their earnings.
  • There is a special rule that allows dependent children of military families serving on overseas assignments to begin or continue receiving SSI benefits while outside of the United States.

Full Article

What Is SSI?

Supplemental Security Income (SSI) is a monthly financial benefit from the Social Security Administration (SSA) to people with limited income and resources who are age 65 or older, blind or disabled.  Blind or disabled children, as well as adults, can get SSI.

Eligibility Requirements

To be eligible for SSI, a person must meet specific eligibility criteria, including:

  • SSA definitions of aged, blind, or disabled
  • Having limited income and resources
  • Citizenship or residency status

Aged Determination

A person who is 65 years of age or older may qualify for SSI as “aged” if they also meet the financial determination.

Blind or Disabled Determination

SSA defines “blind” as seeing at a level of 20/200 or less in the better eye with glasses or contacts, or having a limited field of vision that can only see things at within a 20-degree angle or less in the better eye.  A person with a visual impairment that does not meet the criteria for blindness may still qualify for SSI based on the disability.

An adult or child may qualify for SSI as “disabled” if they have a physical or mental impairment that can be medically diagnosed through clinical and laboratory diagnostic techniques for anatomical, physiological, and psychological irregularities. The condition must cause marked and severe functional limitations, including emotional or learning challenges, that have lasted or are supposed to last for at least 12 months without interruption.

A person aged 18 or older must qualify as an adult, which includes proving they are unable to do substantial gainful activity.  Two (2) months before a child receiving SSI benefits turns 18, SSA will conduct a disability redetermination to determine whether the child meets the adult criteria to continue receiving SSI payments.

Eligibility for disability is determined by a team that includes a disability examiner and a medical or psychological consultant at a state agency known as the Disability Determination Service (DDS).  The team will review medical and financial documents, and determine eligibility based on the documents provided or request more documents be provided.

It is necessary to complete both disability and financial determinations when assessing eligibility. This is because SSI eligibility determination may be used in other programs within your state. 

Limited Income and Resources

SSI is a needs-based program. In order to receive SSI, the applicant must have limited income and resources.

If the applicant has too much income, their application will be denied, and they will be ineligible for SSI payments. A child does not earn income so part of their parent’s income will be attributed to the child. Different sources of income are treated differently and some have greater exclusions than others. When an adult applies on behalf of a child, the parent or guardian’s income is considered “deemed” income to the child. SSA will prorate the adult’s income among the family members to determine the amount applicable to the child.

If you received SSI in another state, be aware that some states have a higher income limit that allows an individual to receive SSI benefits despite being over the federally established income limits. Washington is not a state with a higher income limit and applications submitted in Washington state must meet the federal income limits.

Resources include both money (e.g., cash, bank accounts, Certificates of Deposit, stocks and bonds, investment accounts, life insurance) and property (e.g. vehicles, houses, real estate) that could be sold or converted to cash to pay for food or shelter. There are limits for how much an applicant may have in resources and maintain eligibility for SSI:

  • An individual may have up to $2,000
  • A couple may have up to $3,000
  • When applying on behalf of a child, an adult may have an additional $2,000 in resources and a portion of the adult’s resources may be applied to the child

Some resources are excluded from the eligibility determination, including:

  • Your house and the property you live on
  • The first vehicle (per household)
  • Most personal and household belongings
  • Property that can’t be used or sold for income
  • Up to $100,000 saved in an ABLE account
  • Properly distributed funds from a special needs trust (SNT) on behalf of the individual with a disability

Citizenship or Residency Status

SSI is only available to U.S. citizens and nations residing in the United States or the Northern Mariana Islands, and qualifying non-citizens with certain alien classifications granted by the Department of Homeland Security (DHS).  SSI benefits will stop if a person leaves the U.S. for a full calendar month or at least thirty (30) consecutive days, with the exception of dependent children of active duty servicemembers serving overseas.

Is SSI The Same As SSDI?

Supplemental Security Income (SSI) is not the same thing as Social Security Disability Insurance (SSDI).  SSI is a needs-based public assistance program for children and adults. The eligibility criteria include limited income and resources. SSI payments come from the general funds of the U.S. Treasury from tax revenues.

SSDI is an insurance that workers earn by paying into the Social Security through taxes on their work earnings. It is not affected by income or resources. In order to receive SSDI, the person must have worked and paid from their earnings into the Social Security trust funds in the U.S. Treasury.

How Do I Apply For SSI?

Family to Family Health Information Center (F2FHIC), a program of PAVE, provides technical assistance, information, and training to families of children, youth, and adults with special healthcare needs. The F2F website contains invaluable information and resources to help family members, self-advocates, and professionals navigate complex health systems and public benefits, including SSI. After reviewing F2F’s article about how to apply for SSI, if you have questions and would like to speak with an F2F team member, please submit a Help Request.

Special Consideration For Military Families Overseas

A special rule allows dependent children of military families serving on overseas assignments to begin or continue receiving SSI benefits while outside of the United States. The child must be:

  • is a U.S. citizen
  • living with a parent who is a member of the U.S. Armed Forces assigned to permanent duty ashore outside the United States
  • listed in the Command sponsorship orders.

If the child is receiving SSI benefits before moving overseas with the active duty service member, the benefits will continue based on the rate of the state in which they applied. If the child is born overseas or becomes eligible for SSI while overseas, you can apply for SSI by contacting the Federal Benefits Unit at the nearest U.S. Embassy or Consular Office, or by applying online. For additional support with your application, call SSA at 1-800-772-1213 (TTY 1-800-325-0778).

Once the child turns 18, they will no longer be eligible for SSI until they have been living within the United States for thirty (30) consecutive days and will be subject to the disability redetermination process.

When relocating on military orders overseas, you must report:

  • the servicemember’s expected report date to the duty station overseas
  • the child’s expected date of arrival at the overseas location
  • the mailing address at your new duty station
  • changes in military allowances at your new duty station

Additional Resources

Health Insurance: How a Change in Federal Policy Might Impact Your Family

Families with insurance from the Health Insurance Exchange that was established by the Affordable Care Act (ACA) may be eligible for lower cost insurance because of a rule that changed just in time for the Open Enrollment period that started November 1, 2022.

Open Enrollment ends January 15, 2023. Note that for new coverages to begin on January 1, enrollment must be completed by December 15.

The rule change corrects a problem called the “family glitch,” which created a financial burden for an employee trying to ensure a whole family, not just themselves. The new rule will expand access to affordable coverage for families by using the premium for family coverage ― rather than employee-only coverage ― to determine eligibility for premium tax credits (PTCs). If a person does not have any offer of employer insurance that meets standards for affordability and adequacy, based on calculations that consider the family’s financial picture, they may now be eligible for PTCs to purchase coverage through the marketplace.

In Washington State, information about health insurance plan options is provided at wahealthplanfinder.org. The website supports language access, including sign language, and provides cultural navigators that understand the Indian Health System as well as Medicaid.

For healthcare navigation help by phone, call 1-855-923-4633.

Washington’s Health Plan Finder is also where individuals can sign up for or renew their Apple Health coverage. Washington State is a Medicaid expansion state and provides Medicaid options for a larger portion of adults and children based on income. The state provides an Eligibility Overview for 2022, with information about monthly income limits for families.

Another place for information and help to understand insurance options is parenthelp123, which has navigators who speak English and Spanish: Call 1.800.322.2588.

More information about the “family glitch” legislation can be found at the Center on Budget and Policy or the Common Wealth Fund.

Related Services in School and Beyond can Support a Child’s Development and Learning

A Brief Overview

  • At school, related services help children with disabilities benefit from their special education by providing extra help and support. Options for related services are described in state law (WAC 392-172A-01155).
  • If a child with public health insurance needs specific therapies to meet medical needs, their insurance company is obligated to support those needs. Medical necessity is described in state law (WAC 182-500-0070).
  • Sometimes a service meets educational and medical needs. In those situations, the school might bill Medicaid directly, with parent permission. Families can learn more about School-Based Health Services (SBHS) and ask if their school is participating in this optional program.
  • Washington’s Office of Superintendent of Public Instruction (OSPI) issued guidance in August 2022 to clarify that all parts of a student’s IEP begin with the start of school unless an IEP team has agreed to shift something to meet a student-centered need. Schools may not delay the start of related services for their own reasons related to scheduling or resources.
  • For federal information about the range of options for related services provided by the school, see parentcenterhub.org.

Full Article

Children with disabilities have a range of needs that may be educational, medical, or both. As they grow, develop, and learn, those needs can shift. How family, school, and medical providers respond can impact how much progress the child makes in their emerging skills. This article includes information to help families understand how therapeutic services may be provided at school or elsewhere.

What are related services?

Schools call services that lie outside the scope of traditional teaching “related services.” Another term is “ancillary services.” Related services help children with disabilities benefit from their special education by providing extra help and support.

Therapies for disabilities that impact physical movement or speech are common. Transportation provided through the special education system also is a common related service. Less common in Washington State are in-school mental health services or counseling for behavioral health conditions. Various possibilities are listed in state law (WAC 392-172A-01155). Here are examples from the Washington Administrative Code (WAC):

  • Occupational, Physical, Speech Therapies
  • Counseling
  • Psychological Services
  • Behavioral Services
  • School Social Worker
  • Special Transportation
  • Parent Training

What does parent training mean?

Notice that the final option on this list is parent training. This service might mean the school helps parents understand the special needs of their child or something about their child’s development. Through the related service of parent training, the school can teach family members to help their child practice emerging skills when they’re at home.

Who provides a related service, and who pays?

A related service may be provided by any professional who is trained to assess and/or serve a specific need for a child with a disability condition that affects their learning or development.

When therapeutic services are paid for through medical insurance, they generally must meet a standard of being “medically necessary.” Keep reading for more information about therapeutic services available through the medical system.

Services are provided at school when they are determined to be “educationally necessary.” In those cases, the school district is responsible for payment.

Sometimes a service is both medically and educationally necessary. Sometimes schools seek parent consent to bill the student’s insurance to fund all or part of a related service. Washington State’s Health Care Authority (HCA) manages a program to reimburse schools for services provided to students who are eligible for Apple Health when those services are delivered as part of their Individualized Education Program (IEP).

Tip: See HCA’s website page about School-Based Health Services (SBHS) and consider asking your school if they are participating in this optional program. The guidebook includes information about allowable services. Note that Applied Behavior Analysis (ABA) therapy is explicitly excluded as a reimbursable service through the state’s SBHS program. Most other therapeutic options are reimbursable, including a range of mental health services.

A related service might be part of evaluation

Sometimes a related service is needed to assess a student because school staff do not have the expertise to properly understand a disability condition in order to make service recommendations. “Medical services for diagnostic or evaluation purposes” are written into federal law (IDEA Section 1432) as something an IEP can provide.

Keep in mind that special education evaluations must be comprehensive, in order to identify all of a child’s special education and related service needs, not just those that relate to the IEP eligibility category.

Families can seek an Independent Educational Evaluation (IEE) if they disagree with the methods or conclusions of a school district special education evaluation. PAVE provides an article and sample letter for requesting an IEE.

Related services support FAPE

The federal law that governs special education services is the Individuals with Disabilities Education Act (IDEA). The IDEA makes clear that its list of related services (see below) includes possibilities and options but does not include every related service a student might need. Other therapeutic services might be included in the IEP if they are educationally necessary.

Access and equity are protected by various educational and civil rights laws; anything that helps a student access school-related opportunities can be included as part of a student’s services. Extracurricular activities and school-sponsored sports count.

An IEP is a written commitment for the school to serve a student’s educational needs. Educational needs might be academic, social-emotional, or something else.  They might have to do with how the student functions or adapts to the environment of school.

Educational needs are determined through a comprehensive evaluation and a collaborative process that includes family, school staff, and anyone else with knowledge of the student and their disability-related needs. If an IEP team decides that a service is necessary for the student to access their right to a Free Appropriate Public Education (FAPE), then the school district is responsible to deliver those services.

IDEA does not expressly require that the IEP team include related services personnel. However, if a particular need or related service is discussed in an IEP meeting, it would be appropriate for the provider to attend. IDEA states that, at the discretion of the parent or the public agency, “other individuals who have knowledge or special expertise regarding the child, including related services personnel as appropriate” may be part of a child’s IEP team.

School-based related services might include, but are not limited to:

  • speech-language pathology and audiology services
  • interpreting services
  • psychological services
  • physical and occupational therapy
  • recreation, including therapeutic recreation
  • early identification and assessment of disabilities in children
  • counseling services, including rehabilitation counseling
  • orientation and mobility services for blindness/low vision
  • medical services for diagnostic or evaluation purposes
  • school health services and school nurse services
  • social work services in schools
  • parent counseling and training

The national Center for Parent Information and Resources (parentcenterhub.org) provides additional information about each of these possible related services and what they might look like for a student receiving them as part of an Individualized Education Program (IEP).

IEP services start on Day 1 unless the student needs something different

Washington’s Office of Superintendent of Public Instruction (OSPI) issued guidance in August 2022 to clarify that all parts of a student’s IEP begin with the start of school unless an IEP team has agreed to shift something to meet a student-centered need.

According to OSPI, “School districts are reminded that they cannot arbitrarily determine when special education and related services will begin or schedule them to begin after the start of the school year for some providers.”

OSPI’s guidance references a parent complaint and the state’s decision that schools cannot delay the start of certain services because of provider availability or district scheduling preferences. If it’s in the IEP, then the school is responsible to provide the service on all scheduled days that the student attends school. If services aren’t provided as scheduled by the IEP, then the IEP team can discuss how and when the student will receive compensatory services to make up the missed time.

Families have the right to file a complaint with the state if the school does not fully serve their student’s IEP. One option is the community complaint: PAVE provides a video describing that process. Another option is Due Process. The Procedural Safeguards describe all dispute resolution options that are free for families and protected rights under federal and state laws. 

Options for therapeutic services through the Medicaid system

If a child needs specific therapies to meet medical needs, their insurance company is obligated to support those needs. For children younger than 21 with Medicaid (Apple Health in Washington), medical necessity is determined through assessments that are a protected benefit called Early Screening and Periodic Screening, Diagnostic and Treatment (EPSDT). This screening process is overseen by the National Academy for State Health Policy (NASHP).

For help navigating complex medical issues, families can request case management from their insurance provider. Calling the number on your insurance card and asking if there a form for requesting case management is a way to begin. Sometimes a case manager is automatically assigned if claims become complex and expensive.

Medical criteria are different than school criteria. While school-based services are built to support a student’s educational access, EPSDT determinations are made to support safety and health in the home and community. Here are examples:

  • Physical Therapy (PT) at school might support adapted physical education (PE) or help the student navigate the school building or curriculum. Outside of school, PT can support navigating the home, community, recreational activities, and more.
  • Speech/language services at school are tailored to help the student achieve goals on their Individualized Education Program (IEP) or access their curriculum. Outside of school, speech/language services can expand to support communication for daily living and might be paired with Occupational Therapy (OT), for example, to work on feeding issues, sensory aversions, breathing challenges, alternative communication systems, and more.

Services to support access to school, home, and community might intertwine, and the school district might choose to bill Medicaid for reimbursement, with the family’s signed consent.

TIP: If the school is going to bill insurance, families may want to find out if the insurance company has a reimbursement limit for the service. If the child is getting a similar service in and out of school, care coordination is important to make sure all the services will be paid. Insurance may be willing to pay for more services if it’s clear which are for school-based needs and which are medical. Those details also may be important to note if services are denied and the family wants to appeal the denial through a medical or special education complaint option.

What meets the standard of medical necessity?

The Washington Administrative Code (WAC 182-500-0070) describes medical necessity. If a service is likely to prevent, diagnose, or treat an identified condition that is causing major life impacts, then it may meet the standard. The WAC says medical necessity is:

“…a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction.”

The same WAC goes on to say that all federally funded insurance is obligated to pay for a service if it’s the most reasonable option available to serve the need. That standard is met when:

“There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service.”

The same WAC also explains that a chosen course of treatment might mean a choice to track a condition through observation or offer no treatment. The WAC says:

“For the purposes of this section, ‘course of treatment’ may include mere observation or, where appropriate, no medical treatment at all.” 

A medical specialist, therapist, or pediatrician might assess the child to determine whether a specific service is medically necessary. In some situations, a case manager from the state’s Developmental Disabilities Administration (DDA) may make the determination.

What about private insurance?

Families with insurance through an employer or the healthcare exchange will need to ask their provider for specific information about what therapeutic services are covered. A company’s human resources department is another place to ask about coverages and whether there is a choice of health plan with more allowable options. School-based services may be the only option for some, as medical parity laws do not protect all possible therapeutic services.

Here are a places to get support in understanding your health plan and navigating access to services:

Insurance denials for employer-based plans can be appealed through:

PAVE’s Family to Family (F2F) Health Information Center provides additional information and resources through it’s website, Family Voices of Washington. Click Get Help at wapave.org to request individualized support.

Help for Understanding Health Insurance

Healthcare insurance includes words and abbreviations that can be confusing and hard to remember. This article describes a few key terms to demystify the health insurance world for Washington State families. Washington Healthplanfinder.org is a place to research insurance options statewide, with English and Spanish options.

Managed Care Organization (MCO)

A Managed Care Organization (MCO) is an agency that coordinates medical services and reimburses providers.

State medical insurance in Washington is called Apple Health. Apple Health pays a monthly premium to an MCO that an individual or family chooses to manage preventive, primary, specialty, and other health services. Apple Health also pays for some services directly, through Fee for Service (FFS).

The term “provider” describes any health care professional or facility that provides treatment. Doctors, nurses, mental health professionals, physician assistants, dentists, therapists, behavior specialists, and many other professionals are considered providers.

Clients enrolled in managed care must seek providers who are part of their plan’s network unless there is an emergency or prior authorization is arranged. Prior authorization means the insurance company agrees to pay for a service, treatment, prescription drug, medical equipment, or something else because it is determined to be medically necessary.

The Apple Health system includes five MCOs. Not all plans are available in all areas of Washington State. ​

  • Amerigroup (AMG)
  • Community Health Plan of Washington (CHPW)
  • Coordinated Care of Washington (CCW)
  • Molina Healthcare of Washington, Inc (MHW)
  • United Healthcare Community Plan (UHC)

For complicated circumstances, an MCO may recommend a case manager be assigned to support an individual’s care. Families also have the option to request case management, especially if locating providers is difficult to meet unique or substantial needs.

Health Maintenance Organization (HMO)

A Health Maintenance Organization (HMO) is a type of MCO.  An HMO is an independent system that requires enrollees to seek care within a specific network of hospitals and providers. An HMO plan is based on a network of providers who agree to coordinate care in return for a certain payment rate for their services. 

Preferred Provider Organization (PPO)

A Preferred Provider Organization (PPO) is another type of MCO. A PPO generally will allow individuals to choose their providers and does not limit reimbursement to providers in a specific network. Because of that, a PPO tends to be more expensive than an HMO.

What is the difference between Medicaid and Medicare?

Medicaid is income dependent, and Medicare is not. Both provide government-funded healthcare.

Medicaid is state-managed to provide free or low-cost medical coverage for individuals or families who qualify based on income. Washington’s Medicaid program is Apple Health.

Medicare is a federal health insurance program for individuals age 65 and older and for those with qualifying disabilities. Medicare is not dependent on income.

Copayments, Premiums, and Deductibles

When healthcare is not free, the cost to the family adds up through the copayments, premiums, and deductibles. Here’s what that means:

  • Copayment: a specific fee for a visit or procedure.
  • Premium: payment for the insurance. An individual might have premiums withheld from a paycheck, or an employer might agree to pay all or part of the premium.
  • Deductible: the amount of money an individual must pay each year before insurance payments “kick in.” After a deductible is met, the patient may still make copayments or pay a percentage of the cost, depending on the plan. Supplemental insurance through Medicare is sometimes an option to cover deductible expenses.

What is a Medicaid Waiver?

A Medicaid waiver allows the federal government to waive rules that usually apply to the Medicaid program. The intention is to reimburse for services that would not otherwise be covered by Medicaid. Waivers generally provide local, non-institutional solutions for individuals with disabilities. For example, in-home care paid for through a waiver might support someone to live in the community.

Medicaid.gov provides a Washington Waiver Fact Sheet that outlines waiver programs available in Washington State.

An Illustration of the insurance terms described in this document

Download the illustration as a PDF – Health Illustrative