In April 2023, the Centers for Medicare & Medicaid Services (CMS) approved Washington’s 1115 Waiver request to extend continuous eligibility for any child under six who is enrolled in a free Apple Health (Medicaid) program.
Children under the age of six on free Apple Health will now receive continuous eligibility through their sixth birthday, regardless of changes in household income, if they were eligible in the month of application.
Note: There have been no changes to continuous eligibility for kids over age six on free Apple Health or for those on Apple Health for Kids with premiums, also known as Children Health Insurance Program (CHIP). Coverage for these groups continues to be renewed for 12 months at a time.
What is being done to keep kids covered?
In June 2023, the Health Care Authority (HCA) began work to maintain continuous eligibility for children under the age of six. A manual process is in place to identify eligible children who have lost coverage and reinstate them.
Once the system supports continuous eligibility for kids under age six, children who are active on free Apple Health Kids and meet the eligibility criteria will have their certification period automatically extended through the month they turn six.
When new parents take their infants home from the hospital, they typically have many questions. Is my baby crying too much? Is she nursing enough? Does his poop look normal? During this challenging time, sometimes known as the “fourth trimester,” families need a great deal of support.
To meet this need, the Hospital of University of Pennsylvania (HUP), in partnership with Memora Health, developed a program called “Healing at Home”. The Hospital of the University of Pennsylvania is part of the Institute for Healthcare Improvement (IHI) Eliminating Inequities and Reducing Postpartum Morbidity and Mortality Learning Community. Participants focus on improving clinical and administrative processes to ensure safer and more equitable postpartum care and support for Black mothers and birthing persons.
The Healing at Home program consists of a virtual postpartum assistant, named Penny, which provides automated answers via text message to patients’ questions for the first six weeks after discharge. Penny also administers the Edinburgh Postnatal Depression Scale (EPDS) for screening, and provides blood pressure monitoring for low-risk patients. (High-risk patients participate in a program called Heart Safe Motherhood).
“We launched our program in March of 2020, when COVID-19 was starting when we saw a lot of our parents going home sooner rather than later,” said Laura Scalise, MSN, RN, Nurse Manager at HUP. “We wanted to make sure we could monitor our families that were leaving so soon [after childbirth], provide any connections to support (i.e., lactation referrals), and readily answer the questions they had.”
The country is grappling with a surge in preventable deaths and unaddressed mental health needs, according to the latest edition of the Commonwealth Fund’s Scorecard on State Health System Performance. The report annually ranks states’ health systems based on how well they provide high-quality, accessible, and equitable health care. And for the first time, the scorecard includes measures for evaluating reproductive care and women’s health.
Note: This post was updated on April 4, 2023, to include additional details and a table showing potentially affected preventive services.
On March 30, 2023, a judge in the U.S. District Court in the Northern District of Texas issued a final judgment in a court case challenging the provision of the Affordable Care Act (ACA) that requires most private health plans to cover a range of preventive services without any cost-sharing for their enrollees. Having concluded in September that aspects of the requirement were unconstitutional and violated religious rights, the judge’s remedy in the Braidwood Management v. Becerra imposes new limits on the government’s ability to enforce those requirements nationwide. This Q&A summarizes some of the key issues related to the ruling.
What does the ruling mean for the public?
With about 100 million privately insured people using preventive services required by the ACA to be covered without out-of-pocket costs, the preventive services coverage requirement is the provision of the ACA that affects the broadest number of people, and it has been enormously popular with the public. Because of the ACA requirement, the vast majority of private health plans have to cover a range of preventive services and cannot impose deductibles or copays for them. If the ruling stands, over time, millions of people could end up paying more for preventive care and some may lose access to certain services. However, as sweeping as the ruling is, it does not completely and immediately wipe out preventive services coverage under the ACA.
That’s because the ruling applies specifically to services recommended by the US Preventive Services Taskforce (USPSTF) that were made after 2010 when the ACA was enacted. The ruling would not overturn coverage requirements for vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), women’s preventive health services (such as contraception, well women care and prenatal care, breastfeeding support services, and intimate partner violence screening) recommended by the Health Resources and Services Administration (HRSA), or services for children and young adults recommended by Bright Futures, though the plaintiffs had asked that those be struck down as well and that decision could be appealed. The ruling also only applies to updates to or new USPSTF recommendations issued since March 2010, when the ACA was enacted. It would effectively lock in place coverage requirements based on evidence from 13 years ago.
The ruling separately finds that the mandate to cover pre-exposure prophylaxis (PrEP), a medication taken to prevent HIV, violates the plaintiffs’ religious rights under the Religious Freedom Restoration Act (RFRA). While the RFRA remedy is limited specifically to the plaintiffs, because PrEP was recommended by the USPSTF after 2010, the medication and certain ancillary lab services can now be subject to out-of-pocket costs across all health plans and plans could elect to drop coverage altogether.
Coverage will not necessarily change immediately. Although the ruling is effective immediately, in many cases, health plan contracts are in place for the calendar year, and employers do not typically make changes to coverage or cost midyear. (It may be easier for plans to change formularies to allow for cost-sharing with respect to impacted drugs.)
How prevalent are mental health issues among Medicare beneficiaries?
About one in four Medicare beneficiaries live with mental illness — conditions such as depression, anxiety, schizophrenia, and bipolar disorder — but only 40 percent to 50 percent receive treatment.1 The prevalence of mental illness is about equal among beneficiaries enrolled in traditional Medicare (31%) and those in Medicare Advantage plans (28%), although variation in data sources and measurement make comparisons difficult.2
Mental illness is experienced most by those beneficiaries under age 65 who qualify for Medicare via disability, as well as by low-income beneficiaries dually eligible for Medicare and Medicaid.3 It is also more pervasive in beneficiaries from American Indian/Alaska Native and Hispanic communities relative to other racial and ethnic groups.4
Which mental health services does Medicare cover?
Medicare covers both outpatient and inpatient services as well as prescription drugs to treat mental illness.5 Traditional Medicare and Medicare Advantage plans generally follow the same coverage rules, and some also cover additional services, like grief counseling, or offer other tailored benefits through special needs plans catering to beneficiaries with mental illness.6
Inpatient services. Medicare Part A covers inpatient mental health services in both general hospitals and psychiatric hospitals, but the latter is limited to 190 total days per beneficiary across their lifetime. Traditional Medicare beneficiaries pay a deductible and coinsurance for each benefit period, which, for hospital services, begins on the day of admission and ends after a beneficiary has had no inpatient care for 60 consecutive days. Cost-sharing requirements vary across plans for Medicare Advantage enrollees.
Outpatient services. Medicare Part B covers outpatient mental health services delivered by psychiatrists or other physicians, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, and physician assistants. The services covered include standard services like psychiatric evaluation, individual and group therapy, and medication management. After paying their annual deductible, traditional Medicare beneficiaries pay 20 percent of the Medicare-approved amount for covered services. As with inpatient services, cost-sharing requirements vary across Medicare Advantage plans.
Medication. For traditional Medicare beneficiaries, mental health medications are covered by Medicare Part D. Beneficiaries in a Medicare Advantage plan also may have a Part D prescription drug plan or another drug plan that follows Part D rules. All Medicare drug plans are required to cover antidepressant, anticonvulsant, and antipsychotic medications, as well as a wide range of other psychotropic medications like anti-anxiety drugs. Specific medications covered and out-of-pocket costs vary by drug plan.
About 5 million uninsured people across the country could get coverage through an Affordable Care Act Marketplace health plan with virtually no monthly premium if they enroll soon, a new KFF analysis finds.
In most states, open enrollment runs through January 15, with tax credits available to help eligible low- and middle-income people afford coverage. Those tax credits would offset the full monthly premium for the lowest cost plan or plans for millions of uninsured residents, the analysis finds.
Free or nearly-free premium silver plans with very low deductibles are available to all Marketplace subsidy-eligible enrollees with incomes up to 150% of poverty ($20,385 for individuals or $41,625 for families of four enrolling in 2023). In some cases, there could be a small extra charge – usually no more than a few dollars per month – for non-essential benefits covered by the plan.
In some parts of the country, people with incomes above 150% of poverty can also get free or nearly free silver plans, with somewhat less generous cost-sharing reductions. For example, as can be seen in the interactive map, a 40-year-old making $25,000 per year (184% of poverty) could get a free or nearly free silver plan with a smaller cost-sharing reduction in about 8% of counties, excluding counties where individuals are eligible for Medicaid or Basic Health Program (BHP) plans. Less generous bronze plans with higher deductibles are often available without a premium at even higher incomes.
KFF has an online calculator that estimates the tax credits and premiums available to individuals and families based on their age, income, and location, and maintains more than 300 frequently asked questions about open enrollment, the health insurance marketplaces and the ACA.
For families who have children with complex health care needs, coordinating all the appointments, medications, and therapies can be difficult. When an individual has several doctors and specialists that they regularly see, the help of a care coordinator can be invaluable. A care coordinator, or patient care coordinator, is a health professional employed by an MCO, or managed care organization, to oversee complex care cases. They can help with getting needed appointments, acquiring resources outside of prescriptions, ensuring that medications are easily available and do not have any interactions, and help families have better peace of mind that all of their medical practitioners are on the same page.
Care coordinators are available to many patients, but they are rarely given as an option to overtaxed patients or patients’ parents. Primary care physicians sometimes recommend a care coordinator to help a patient or family, but as they are not familiar with every aspect of a patient’s life and health care, they will often assume that a family does not need a care coordinator when they would be greatly aided by having one. For those with a strong connection to a primary provider, asking them to request a care coordinator for their healthcare can be an efficient way to start the process. While a primary care physician is often the one to initiate the assistance of a care coordinator, is possible for a patient or their family to request care coordination on their own.
The process for requesting a care coordinator is different through different health care systems. The majority of individuals on Medicaid, also known as Apple Health, have their healthcare covered by an MCO. Calling the MCO’s customer service line is often the first step in getting a care coordinator. The phone numbers of the five MCO’s that oversee apple health in Washington state are as follows: Amerigroup at 1-800-600-4441, Community Health Plan of Washington at 1-800-440-1561, Coordinated Care of Washington at 1-877-644-4613, Molina Healthcare of Washington at 1-800-869-7165, and UnitedHealthcare Community Plan at 1-877-542-8997. If you are unsure which MCO is in charge of your healthcare, view our video on Who is in Charge of Your Apple Health Healthcare? If there are problems in getting through to your MCO, you can call the Health Care Authority, that oversees all Washington Medicaid MCOs, at 1-800-562-3022.
For individuals enrolled In Washington State Medicaid, also known as Apple Health, understanding who manages their medical care is not always easy. In almost all cases, the management of care for people with Apple Health is delegated to an MCO, or Managed Care Organization. These are large for-profit organizations that often have a large infrastructure, making it confusing and difficult to find information or direction.
There are five MCO’s under Apple Health in Washington. They are Amerigroup Washington, Community Health Plan of Washington, Coordinated Care of Washington, Molina Healthcare of Washington, and UnitedHealthcare Community Plan. All of these MCOs are available statewide, except UnitedHealthcare Community Plan, with is only available in the western half of the State. For anyone in the foster care system, they are automatically enrolled in Coordinated Care of Washington and this coverage will follow them until they are 21. Health Care Authority has a Service Area Matrix to view what MCOs are available in each county.
Under some circumstances a person on Apple Health will not be put into an MCO. If an individual is American Indian/Alaska Native they can view their options on the Health Care Authority’s American Indians and Alaska Natives page. Other non-MCO Apple Health patients will have a distinct services card that looks the card shown:
For those patients, review the Health Care Authority’s Handbook on Coverage Without a Managed Care Plan for information about how to receive services. It is also possible to call them at 1-800-562-3022.
For those who do not remember which MCO they or their children are signed up with, it might have been done automatically for them when the initial roll out happened in 2014 or when they first became eligible for Apple Health under the ACA. The switch to managed care was fully implemented in 2020. Here are three ways in which to find out which MCO is overseeing an individual’s care:
Review your Provider One Card to see which MCO is listed. Individuals who are on MCO-managed Apple Health will have the name and/or logo of the MCO on the Provider One card, like the example
In this case, UnitedHealthcare is the MCO. The PCP listed is the Primary Care Physician, or a patient’s main doctor, and the PCP phone number listed can be called to schedule visits and ask medical-related questions.
If the provider card is missing, call: 1-800-562-3022 and choose option 1 for self-service, then option 1 for services card. They can help replace the provider card and help enrollees get the services they require.
Call the Health Care Authority Customer Service Line at 1-800-562-3022.
It is important to note that everyone enrolled in Apple Health within one household must be on the same managed care plan. Provider One cards are usually sent out once a year to enrollees and there is a number on the card to call for customer service. Below is the Apple Health managed care plan contact information:
All Apple Health enrollees have the right to change their MCO at any time, with no fee and with no gap in coverage. The shift usually occurs by the 15 of the following month, but the Provider One portal can help if there are challenges. There are several ways to switch plans:
Call the Health Care Authority at 1-800-562-3022 (TRS: 711).
If considering changing to a different MCO, visiting other MCOs websites or calling their information line with some questions can be useful. It is helpful to see what hospitals, urgent care facilities, specialists, and therapists are covered. Not all physicians or medical facilities that take Apple Health are contracted with all MCOs.
Primary care providers (PCPs) serve as most people’s first point of contact with the health care system. These clinicians build relationships with their patients over time and help coordinate care delivered by other health care providers.1 Evidence shows that a strong foundation of primary care yields better health outcomes overall, greater equity in health care access and outcomes, and lower per capita health costs.2
But in the United States, decades of underinvestment and a low provider supply, among other problems, have limited access to effective primary care.3 This brief highlights gaps in the U.S. primary care system by comparing its performance to systems in 10 other high-income countries. We draw on data from the Commonwealth Fund’s 2019 and 2020 international surveys, along with data from the Fund’s 2020 International Profiles of Health Care Systems. (See “How We Conducted This Study” for further details.)
U.S. adults are the least likely to have a regular physician or place of care, or a longstanding relationship with a primary care provider.
Access to home visits or after-hours care is lowest in the U.S.
U.S. primary care providers are the most likely to screen for social service needs.
Half of U.S. primary care physicians report adequate coordination with specialists and hospitals — around the average for the 11 countries studied.