WellCare has more than 23 years of experience in health care, with a majority of that time focused on government health programs. WellCare Private Fee-for-Service (PFFS) plans are an easy option for doctors who have Medicare patients, with these advantages: - PFFS plans are not HMOs or PPOs.
- Referrals or preauthorizations of health care services are not required for medically necessary services.
- No contract is required between WellCare PFFS and the provider.
- Provider reimbursement is based on published Original Medicare rates, reimbursement guidelines and methodologies, less the member's cost-sharing amounts. Medicare Local Coverage Determinations apply.
- Reimbursement for dental, vision and hearing providers for non-Medicare-covered services that are covered by WellCare PFFS is based on WellCare PFFS vendors' usual and customary fees. For information on how to contact these vendors, please see the member's dental/hearing/vision ID card or the WellCare PFFS Quick Reference Contact Guide.
- Wellcare PFFS directly reimburses physicians and other health care professionals for non-dual-eligible members. Reimbursement for dualeligible members will be paid first by Medicare through WellCare PFFS. The difference will be paid by Medicaid, up to the state payment limit.
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Provider Service Center
1-866-235-2770
(TTY/TDD: 1-866-239-6265) Monday–Sunday, 7am to 2am Eastern
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| Some of our plans include dental, hearing, vision and fitness benefits, and Part D coverage. So when you start seeing WellCare PFFS member identification cards, remember-they're a healthy step forward for your patients and your practice. For Provider Service Center, contact 1-866-235-2770 (TTY/TDD: 1-866-239-6265) Monday–Sunday, 7am to 2am Eastern. What is a Private Fee-for-Service (PFFS) Plan?
A Medicare Advantage PFFS plan works differently than a Medicare supplement plan. The federal government approves PFFS plans to be in place of Original Medicare so that people with Medicare have other options. PFFS plans are not a Medicare supplement, (Medigap), Medicare Select or Prescription Drug Plan. In addition, PFFS plans can also offer benefits with predictable member cost sharing on hospital and other physician services. A provider must agree to accept the plan’s terms and conditions of payment prior to providing health care services to members, with the exception of emergencies. If you DO NOT wish to accept WellCare's Terms and Conditions of Payment, then you should not furnish services to a WellCare PFFS member, except for emergency services. If you nonetheless do furnish nonemergency services, you will be subject to these Terms and Conditions whether you wish to agree to them or not. Providers furnishing emergency services will be treated as non-contract providers and reimbursed the payment amounts they would have received under Original Medicare. You can only collect from the member the appropriate WellCare co-payments or coinsurance described in these Terms and Conditions. WellCare PFFS Terms and Conditions of Payment are posted on this Web site. Concert, Sonata, Prelude and Melody are PFFS plans offered by WellCare Health Plans under a contract with the Centers for Medicare and Medicaid Services (CMS) for 2008. Some PFFS plans offer drug coverage. Here's more about these plans. Who is Eligible?
Almost anyone eligible for Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) is eligible to join one of the WellCare PFFS plans as long as he/she lives in the service area. The only eligibility exception includes Medicare beneficiaries with End Stage Renal Disease (ESRD) prior to enrollment. Once enrolled in a WellCare PFFS plan, a member cannot be disenrolled for any medical condition. Additional Information
There are no provider networks, therefore a list of providers is not applicable, however, we have participating providers that includes dental, hearing and vision coverage. Members are not limited to a service area, state or region to obtain their care. Unlike HMOs, a PFFS plan does not require the designation of a Primary Care Physician (PCP). However, WellCare does request that applicants identify their primary providers so that WellCare PFFS plan can mail educational materials about the plan to both members and providers. For product education or information, please contact the Provider Service Center at 1-866-235-2770, (TTY/TDD: 1-866-239-6265) Monday-Sunday, 7 am to 2am Eastern. Marketing Guidelines The Centers for Medicare & Medicaid Services (CMS) has strict Medicare marketing guidelines that are critical for WellCare to maintain. Medicare marketing guidelines apply to WellCare as well as its agents, providers and downstream entities. If you are a provider, please follow the basic rules below. DO | DON’T | Do comply with Medicare Marketing Guidelines as provider specific guidelines define how providers may assist beneficiaries with plan selection, while ensuring plan selection is in the best interests of the beneficiary. | Don’t steer or attempt to steer an undecided potential enrollee toward a plan, or limited number of plans based on the financial interest of the provider. | Do assist a beneficiary in an objective assessment of the beneficiary’s needs and potential plan options that may meet those needs. | Don’t use any affiliation communication materials that describe plans in any way (e.g., benefits, formularies) without prior approval from the plan sponsor. Note: these materials must have CMS-approval prior to distribution. | Do inform beneficiaries where they may obtain information on the full range of plan options by directing beneficiaries to other sources of information, such as the State Health Insurance Assistance Programs, plan toll free information lines, their State Medicaid Office, local Social Security Administration Office, http://www.medicare/gov/ or 1-800-MEDICARE. | Don’t steer or attempt to steer an undecided potential enrollee toward a plan, or limited number of plans based on the financial interest of the provider. | Do work with the plan sponsor to announce affiliations and contractual arrangements to beneficiaries. | Don’t announce affiliations and contractual arrangements to beneficiaries without first working with the plan sponsor. Subsequent announcements must include all provider plan affiliations. |
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