At WellCare Health Plans, we value everything you do to deliver quality care to your patients to make sure they have a positive healthcare experience.
We recently determined that for members in our Medicare Dual Special Needs Plans (DSNP) we have been paying 100% of the Medicare allowable reimbursement for professional claims that occur in an institutional place of service. These claims should have been paid by WellCare at 80% of the Medicare allowable because the DSNP member’s benefit has 20% coinsurance.
Beginning May 1, 2018 WellCare will be administering the coinsurance in accordance with the benefit design we filed with the Centers for Medicaid and Medicare Services.
Because members in WellCare’s DSNP plans are Medicare Parts A&B cost share protected, you must submit the cost share portion of the claim for payment to the member’s secondary payer. If that is WellCare, we will generate a secondary claim systematically and reimburse up to the Medicaid allowable.
As a reminder, members in WellCare’s DSNP plans are generally cost share protected, and you should not seek payment of any cost share from the member. In addition, Federal law, (42 U.S.C. § 1396a(n)(3)(B)), provides that no Medicare-enrolled provider may require payment directly from a Qualified Medicare Beneficiary (QMB) for Medicare-covered services. The statute subjects Medicare providers to federal sanctions, including disenrollment from the Medicare program, for violating this provision.
For more information on WellCare’s DSNP plans you may consult our Medicare Advantage Provider Manual, contact or your Provider Relations Representative, or call Provider Services at 1-855-538-0454.
