Tag: medicaid

Medicaid Waiver Benefits for Military Families 

Posted on by Barb Koumjian

When considering medical benefits for family members with special needs, military families often overlook Medicaid, a health benefits program established by federal law. Medicaid covers basic and long-term health care services for eligible children, pregnant women, parents with dependent children, adults aged 65 or older, and individuals with disabilities.

Eligible dependents of military families can benefit from BOTH TRICARE and Medicaid. Since TRICARE and Medicaid are both entitlement programs established by federal law, Congress has established a hierarchy of benefits between the two programs so eligible military family members receive the maximum range of benefits.  When a military family member is dually enrolled in TRICARE and Medicaid, TRICARE is the primary payee and Medicaid covers remaining costs.

Medicaid’s financial eligibility is determined by low-income limits and the number of members in a family. The income limits and coverage vary by the State administering the Medicaid program.  In most states, a person who is eligible for Medicaid is automatically eligible for Social Security Income (SSI). In some states, the application for SSI includes Medicaid, while in others there is a separate application process. Learn more about SSI.   The Division of Disability Determination Services (DDDS) in Washington State is responsible for assessing blindness and disability for SSI and Medicaid eligibility.

State waiver programs vary in eligibility criteria and coverage. The federal Medicaid website contains information Medicaid programs in each state, as well as state waiver programs. Waivers allow the state to decide how to spend federal Medicaid funding. For more information about mandatory benefits states must provide under Medicaid, read this Military OneSource article.

In many states, there are waiting lists for Medicaid waiver programs, and it may take years for an applicant to begin receiving services under the waiver. However, waiting lists are not always first-come, first-served. They can be based on the type and severity of disability, or on availability of providers and services. Each state runs its own Medicaid program, and benefits do not automatically transfer from one state to the next. Military families must reapply to get benefits anytime they PCS to another state.

Recognizing the challenge this presents for highly mobile military families, 37 states have developed policies specific to military families. Military waiver benefits in most of these states, including Washington, allow active duty military families to enroll in a waiver program and remain on the waitlist in their state of legal residence if they move but plan to return to that state. In Florida, there is no waitlist for Medicaid waivers if the active duty military family member was receiving waiver services in the previous state. Families are responsible for keeping their Case Manager informed as to their current location. Changes in status must be reported promptly to the Case Manager. This Military OneSource article provides more information about how to access military waiver benefits. 

When a service member leaves the military and TRICARE benefits change, Medicaid can provide services similar to those of TRICARE Extended Care Health Option (ECHO). Apply for Medicaid benefits for your child in the state in which you will be living after retirement or separation and apply before any transitional period for medical benefits starts. This will help prevent or minimize gaps in services and supports for the military family member with special needs.

Contact your regional TRICARE contractor to answer questions about receiving Medicaid benefits while on TRICARE.

Additional Resources

Supplemental Security Income (SSI)

Posted on by Nicol Walsh

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

Your Apple Health: What you need to know about the Public Health Emergency

Posted on by Nicol Walsh

A Brief Overview

  • Changes to Medicaid after the Public Health Emergency
  • What to do to keep personal/family information current
  • Find out what might change with your current coverage

Full Article

Did you know? During the Covid-19 Public Health Emergency, WA State changed some rules about Apple Health (Medicaid). If you or a family member had Medicaid for health insurance, you did not have to renew every year. If you paid a premium for Medicaid health insurance, premium payments stopped during the Public Health Emergency. Some people received temporary health insurance coverage if they qualified for other benefits.

The PHE ended March 31, 2023, and now:

  • Beginning April 2023, you must renew your Apple Health/Medicaid insurance
  • If you usually paid a premium, premiums are starting up again
  • You may need a new eligibility review

If you do not renew, do not complete a required eligibility review or if you do not pay a premium when it is due, you may lose your health insurance coverage for you or your family member.

What to do:

  • Update your contact information with your insurance provider so your provider can send you important information about renewal, eligibility reviews and premiums
  • Renew your insurance when your provider tells you
  • Premiums for certain Apple Health/Medicaid insurance plans are starting again (Apple Health for Kids with premiums/Children’s Health Insurance Program, Apple Health for Workers with Disabilities (HWD). Watch your mail or email for notices or premium bills from your provider

If you are on one of these Apple Health/Medicaid plans, call:

  • Amerigroup: 1-800-600-4441
  • Community Health Plan of Washington: 1-800-440-1561
  • Coordinated Care: 1-877-644-4613
  • Molina:1-800-869-7165
  • UnitedHealthcare: 1-877-542-8997

If you usually get notices from WA State Health Care Authority email askmedicaid@hca.wa.gov with your name, date of birth, and updated contact information.

If you usually get notices from Washington Healthplanfinder:

  • Log in to your Washington Healthplanfinder account at wahealthplanfinder.org
  • Call Washington Healthplanfinder at 1-855-923-4633

If you are age 65 and older, have blindness or a disability, get Medicare, and get healthcare coverage through Department of Social and Health Services (DSHS):

  • Update contact information at waconnection.org or call 1-877-501-2233 or
  • Visit your local Community Service Office

References:

 Washington State Health Care Authority End of the Public Health Emergency Communications Toolkit

Apple health updates For more information: go to wapave.org and type the words Apple Health in the search bar.

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

Children’s Long-Term Inpatient Program (CLIP) Provides Residential Psychiatric Treatment

Posted on by Nicol Walsh

A Brief Overview

  • CLIP serves children ages 5-17 by providing mental-health treatment and school in a secure, residential facility. Read on for more information about CLIP eligibility and how to initiate a referral.
  • Young people placed in CLIP could not recover adequately with the most intensive outpatient services available, which in Washington are provided through Wraparound with Intensive Services (WISe).
  • Family caregivers of young people with intensive behavioral health needs can request support from A Common Voice, staffed by lead parent support specialists. Find their contact information on the Center of Parent Excellence (COPE) page of the Health Care Authority’s website.

Full Article

Families have few options to help a child with a psychiatric illness that makes in-home, community-based care unworkable. Local hospitals are designed to provide crisis care and generally do not keep a patient for mental health treatment and recovery beyond a few days or weeks. Sometimes those short hospitalizations are not long enough for lasting stability.

One choice for children 5-17 is the Children’s Long-Term Inpatient Program (CLIP), which provides intensive mental health services and school in a secure residential setting. A CLIP stay is usually about 6 months long. Eligibility for CLIP ends on the child’s 18th birthday.

Most CLIP referrals are for children with Medicaid—public health insurance, which is called Apple Health in Washington State. Families with private health insurance have access to CLIP but may be referred first to private facilities for long-term, inpatient care. Medicaid is the payer of last resort.

Who is Eligible for CLIP?

  • Youth ages 5 to 18
  • Legal residents of Washington State
  • Youth diagnosed with a severe psychiatric disorder
  • Youth at risk to themselves or others or gravely disabled due to a psychiatric condition
  • Youth who are not successfully treated through community-based mental health resources

Families are involved and children get school at CLIP

Parents/legal guardians engage with the treatment team while a child is at CLIP. The goal is to help the child stabilize and provide the family with skills and tools for a successful return to the home, school and community.

Children attend school while at CLIP. Teachers at the residential facility manage the student’s Individualized Education Program (IEP), or Section 504 plan, and help with transitions from and back into the student’s local school.

CLIP referrals may be voluntary or involuntary

Parents and legal guardians can refer children to CLIP. The first step is to know whether the referral is voluntary or involuntary. Parents can volunteer their children younger than 13 for residential treatment. Youth 13 and older must voluntarily go to CLIP unless they meet criteria for involuntary commitment.

The Revised Code of Washington (RCW 71.34.010) establishes that an adolescent 13-18 may be committed for up to 180 days of involuntary inpatient psychiatric treatment if commitment criteria are met. Residential placement at CLIP is one way to carry out a commitment order, which may be based on a standard of imminent threat (to self or others) or grave disability/severe psychiatric deterioration. Seattle Children’s Hospital provides a Guide to the Involuntary Treatment Act (ITA).

To refer a child or youth to CLIP for voluntary admission, the parent, legal guardian, or youth may get help by following a CLIP administration menu that starts with the name of the child’s heath plan. A child’s mental health provider or social worker also can support a CLIP application.

The family can request a hearing with a regional committee, which may then refer the case to the CLIP Administration for final approval. Sometimes a child is put on a waiting list for an available bed.

CLIP is a step up from WISe

Young people placed in CLIP have a record of being unable to access an appropriate level of care within their community. That usually means failure to recover with services from our state’s most intensive outpatient option for children and youth, which is Wraparound with Intensive Services (WISe).

The WISe program was begun as part of the settlement of a class-action lawsuit, TR v Dreyfus, in which a federal court found that Washington wasn’t providing adequate mental-health services to youth. WISe teams provide a wide range of therapies and supports with a goal to keep the young person out of the hospital.

Families engaged in WISe and/or CLIP services are encouraged to participate in their regional Family, Youth, and System Partner Roundtable (FYSPRT), which provides a place to share resources, solidarity, and feedback about the behavioral health system. See PAVE’s article: Families and Youth Have a Voice on Mental Health Matters Through FYSPRT.

Organize and prepare for a CLIP application process

Families need an organized set of medical and school paperwork to complete CLIP applications. Refer to PAVE’s article about document management for guidance about how to create a care notebook or other filing system for this and other purposes.

The regional CLIP committee includes care providers from managed care organizations and other agencies that may provide additional support and resources to the family, regardless of whether a CLIP referral is recommended. Generally, the committee determines that all community-care options have been exhausted before recommending a more restrictive placement through CLIP. The team will also make a recommendation based on whether the child is likely to benefit from the therapeutic program, which is mental health based and may not be a good fit for an individual with a severe form of developmental or intellectual disability.

Where is CLIP located?

The largest CLIP facility is the Child Study and Treatment Center (CSTC) in Lakewood, adjacent to Western State Hospital. CSTC provides about 60 beds in cottages that house children in groups by age and other factors. Additional options with fewer beds include:

  • Tacoma, The Pearl Street Center
  • Spokane, the Tamarack Center
  • Yakima, Two Rivers Landing

Further Resources

Washington’s Health Care Authority (HCA) has additional information about WISe, CLIP, early signs of psychosis, and Family Initiated Treatment (FIT).  If a person 15-40 is newly experiencing psychosis, Washington offers a wraparound-style program called New Journeys (website link includes access to a referral form).

Help for Understanding Health Insurance

Posted on by Nicol Walsh

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

Technology Provides Options for Medical Care from a Distance

Posted on by Nicol Walsh

A Brief Overview

  • During the coronavirus pandemic and statewide stay-home orders, some providers are offering online appointments. This article includes information about access to telehealth and how to prepare for a virtual visit.
  • Federal privacy laws have been relaxed during the shutdown to allow more opportunities for on-screen healthcare. Washington’s telemedicine parity law was updated by the 2015 legislature. Those updates went into effect in 2017 (SSB 5175).
  • Generally, military families with TRICARE and families with state insurance, Apple Health, have coverage for medically necessary services provided through telemedicine.
  • A 6-minute video tutorial from the Hawaii Department of Health provides information about what to expect during a telehealth session.
  • Washington’s Department of Social and Health Services (DSHS) is providing free cell phones and minutes to low-income families through a federal program called Lifeline. State-specific information about this option is available from the Health Care Authority.
  • See Links to Support Families during the Coronavirus Crisis for additional resources.

Full Article

Families staying home during the coronavirus pandemic need new ways to access medical care. Onscreen appointments—telehealth, telemedicine, teleintervention, telepsychiatry—meet some needs.

The U.S. Department of Health and Human Services (hhs.gov) in early March 2020 relaxed legal requirements related to confidentiality in order to support the delivery of telehealth services while families shelter in place. Roger Severino, director of the Office for Civil Rights (OCR), issued the following statement: “We are empowering medical providers to serve patients wherever they are during this national public health emergency. We are especially concerned about reaching those most at risk, including older persons and persons with disabilities.”

The federal guidance refers to confidentiality rules under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The HHS website states that OCR will use discretion and relax compliance under HIPAA if services are delivered in good faith:

“During the COVID-19 national emergency, which also constitutes a nationwide public health emergency, covered health care providers subject to the HIPAA Rules may seek to communicate with patients, and provide telehealth services, through remote communications technologies.  Some of these technologies, and the manner in which they are used by HIPAA-covered health care providers, may not fully comply with the requirements of the HIPAA Rules.”

Washington State has grown telehealth since 2015

Even before social distancing requirements, virtual appointments for diagnoses and treatments that don’t require direct physical examination have gained popularity. Before COVID-19 took hold, Washington’s 2020 legislature passed HB 2728 to support further development of children’s behavioral health services delivered through telemedicine.

In order to meet needs in some rural communities and underserved fields, such as psychiatry, Washington’s telemedicine parity law was updated by the 2015 legislature. Those updates went into effect in 2017 (SSB 5175).

The law enables providers to seek reimbursement for most services provided virtually if those same services would be covered by insurance if they were delivered in person. The law defines telemedicine as “the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment.”

Telephone (“audio only”) services or provider guidance by facsimile (FAX) or email may not be covered. Families can check with their insurance carrier to make sure an appointment would be covered if video could fail during the appointment or is unavailable because of a technology complication.

Generally, telemedicine is covered by insurance if:

  • The payor would cover the service if it was provided in-person, and the service can reasonably be provided without direct contact.
  • The health care service is medically necessary.
  • The service is recognized as an essential health benefit under the federal Patient Protection and Affordable Care Act

Individual providers create their own policies about whether they provide services electronically, and the parity law doesn’t guarantee equal reimbursement. Washington is part of the Interstate Medical Licensure Compact, making it easier for providers to get licensed in multiple states and provide services to a broader clientele, including through telemedicine.

Families with Medicaid in Washington State, which is called Apple Health, can find information related to telehealth from the Health Care Authority. In keeping with federal guidance, Medicaid in general is reimbursing telehealth services at the same rate they would reimburse in-person services during the pandemic.

TRICARE expands options for military families, including ABA

TRICARE provides coverage for medically necessary telemedicine visits from providers who offer that service. Preventive health screenings, psychiatric care and medication consultations are examples of appointments that are most easily held virtually. Depending on the TRICARE plan, an authorization or referral may be needed.

In addition, TRICARE is extending telehealth for families who access Applied Behavior Analysis (ABA) and are enrolled in the Autism Care Demonstration (ACD) March 31- May 31, 2020. This temporary extension includes ABA support to parents/caregivers, and the services don’t require the child to be present at the telehealth appointment.

How do I prepare for a telemedicine appointment?

Before services are rendered, providers are required to seek informed consent from patients and/or legal guardians and to provide information about how the technology works and how privacy is protected. Electronic signatures are generally acceptable, particularly as the state requires social distancing. The Washington State Department of Social and Health Services (DSHS) provides a downloadable guidebook about telehealth. 

Prepare for a routine check-up like you would if you were visiting the clinic: Write down questions and concerns, including any changes related to health or medication. A visual tutorial, created by the Department of Health in Hawaii, walks through the different types of telehealth and what someone might expect.

If you suspect COVID-19, carefully document symptoms. The Centers for Disease Control (CDC) provide a COVID-19 screening tool. Be sure to note anything about the illness or its possible treatment that might be affected by a disability condition.

If testing is prescribed, a drive-through testing site may be suggested. The Americans with Disabilities Act (ADA) affords individuals the right to accommodations when accessing what is publicly available. The Northwest ADA Center provides guidance about drive-through testing, specifically addressing topics related to blindness, deafness or wheelchair access, for example. Prepare for the telehealth appointment with any questions related to drive-through testing and disability, if that topic might come up.

What if I don’t have internet or a cell phone?

Families who do not have internet at home may be able to get service for free or low cost because of the pandemic. Some internet providers offer free internet for a limited time, based on income. Internet Essentials from Comcast and Charter Communications are examples. Their services are based on income, and students with free and reduced lunches are among those who may qualify.

Washington’s  Department of Social and Health Services (DSHS) is providing free cell phones and minutes to low-income families through a federal program called Lifeline. State-specific information about this option is available from the Health Care Authority.

How can I plan for an in-person doctor visit or emergency?

Children with complex medical needs may still need an in-person doctor visit for some conditions. General guidance is to call ahead if there is concern that anyone in the family might be ill so medical staff can take precautions to protect everyone from exposure to illness. In many locations, individuals are screened and checked for fever before they enter the facility.

For a medical emergency, prepare to offer first-responders clear information about the nature of the emergency. If a member of your household has a chronic condition that may create an urgent care situation, prepare a handout with basic information in advance. PAVE’s article about a Care Notebook might help. Because personal protective equipment (masks, gloves, gowns) are in short supply, responders will send minimal staff for less urgent circumstances. If the situation is clearly life or death, a larger team may suit up with personal protective equipment in order to help.

Many dental offices have closed, although some may remain open for emergency procedures. Call ahead: Schedules and policies are changing rapidly.

Caregivers of children with complex needs face additional challenges

Being the caregiver for a child with significant medical needs adds additional layers to current circumstances. Here are questions some will face:

  • Is my child’s medical need worth the risk of exposure to a hospital setting?
  • What are the short-term and long-term considerations in changing the plan for care during this time of national crisis?

The answers obviously are personal and different for every family’s circumstances.

While facing tough choices and uncertain times, your self-care is critical, and PAVE offers an article with ideas just for you. Of course, start with the basics: breathe with intention, nourish your body and seek points of fun and connection each day. Staying connected to a child’s care team can help, so you’re already in touch if there’s an emergent medical situation.

PAVE’s Family-to-Family Health Information Center continues to provide information for families and caregivers of children with disabilities and special healthcare needs in Washington State. Fill out a Helpline Request Form at wapave.org for individualized assistance.

New Immigration Rules: Public Services May Impact Eligibility for U.S. Residency

Posted on by Nicol Walsh

On Feb. 24, 2020, U.S. Citizenship and Immigration Services (USCIS) implemented new rules nationwide that impact immigrants who wish to become permanent or long-term residents. Since the policy change, some benefits that families receive may count against them if they apply for residency.

Called Inadmissibility on Public Charge Grounds, the new rule prohibits permanent residency if an individual relies on or is likely to rely on public resources for housing, food or healthcare assistance. The changes were implemented in response to a Supreme Court ruling.

Previously, persons may have been eligible for residency if they did not primarily depend on government funds. According to the USCIS, the new rule requires that a potential resident will not depend on government funds at all.  A person applying for residency must demonstrate current and potential income. Non-residents already in the United States may be impacted if they continue to access government resources and wish to stay or make their residency status permanent.

What programs are included?

  • Medicaid for adults over 21 (expectations are made for emergencies, pregnant women, and those who have given birth in the last 60 days)
  • Supplemental Security Income (SSI)
  • General Assistance programs from government agencies that give cash support or income maintenance
  • Supplemental Nutrition Assistance Program (SNAP or Food Stamps)
  • Housing Assistance, including public housing, Section 8, and Temporary Assistance for Needy Families (TANF) cash benefits

Benefits Excluded from Public Charge

  • Emergency medical assistance
  • Children’s Health Insurance Program (CHIP)
  • Medicaid for children under 21
  • Disaster relief
  • State, local, or tribal programs (other than cash assistance)
  • Community-based programs, such as soup kitchens, crisis counseling and intervention, and short-term shelter
  • Temporary Assistance for Needy Families (TANF) non-cash benefits
  • Supplemental Nutrition for Women Infants and Children (WIC)
  • School Breakfast and Lunch programs
  • Low Income Home Energy Assistance Program (LIHEAP)
  • Transportation vouchers or services
  • Pell Grants and student loans
  • Childcare services
  • Head Start
  • Job training programs

Who is Affected?

Most individuals seeking permanent residency with a Green Card are affected.  Use of public benefits may also damage a non-resident’s attempt to extend temporary residency in the U.S.

Individuals who may be exempt or eligible for a waiver

  • Refugees
  • Asylum applicants
  • Refugees and asylees applying for adjustment to permanent resident status
  • Amerasian Immigrants
  • Individuals granted relief under the Cuban Adjustment Act (CAA), Nicaraguan and Central American Relief Act (NACARA), or Haitian Refugee Immigration Fairness Act (HRIFA)
  • Individuals applying for a T or U Visa
  • Individuals with a T or U Visa who are trying to become a permanent resident with a Green Card
  • Applicants for Temporary Protected Status (TPS)
  • Certain applicants under the LIFE Act Provisions

Are there any exceptions?

The USCIS has announced that “inadmissibility based on the public charge ground is determined by the totality of the circumstances.” While use of public charge funds will count against individuals applying for residency, they are not the sole factor in the government’s decision to approve or deny residency requests. Here are additional resources:

American Immigration Lawyers Association: Public Charge Changes at USCIS, DOJ, and DOS

Public Charge Fact Sheet

Reuters: “U.S. Supreme Court lets hardline Trump immigration policy take effect”

U.S. Citizenship and Immigration Services: Public Charge