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Dual SNP Cost-Sharing Update

At WellCare of Florida (WellCare), 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.

While WellCare will not seek to recover overpayments related to this issue, beginning June 1, 2018 WellCare will be administering the coinsurance in accordance with the benefit design filed with the Centers for Medicaid and Medicare Services (CMS).

WellCare has an agreement with the Florida Agency for Health Care Administration (AHCA) to pay the cost share of DSNP members who are cost share protected, and enrolled in a WellCare DSNP.  If we are obligated to pay the DSNP member’s cost share, we will issue a separate evidence of payment to you detailing the Medicaid allowable cost-share amount.

The Balanced Budget Act of 1997 clarified that a state is not obligated to pay providers up to the full amount of Medicare cost sharing if the total payment (including both the Medicare portion and the state’s portion) would exceed the state’s Medicaid rate for that service.  Given the fact that AHCA typically reimburses less than Medicare for the same service, this often means that no cost-share amount is due for WellCare DSNP members.

As a reminder, Federal law, (42 U.S.C. § 1396a(n)(3)(B)), prohibits balance billing of certain dual eligible Medicare beneficiaries. 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 and the information in this communication, you may consult our Medicare Advantage Provider Manual, call Provider Services at 1-855-538-0454 or contact your local WellCare Provider Relations Department.

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Last Updated On: 6/19/2018