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Dual SNP Cost-Sharing Update

At WellCare of Georgia (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 we filed with the Centers for Medicaid and Medicare Services (“CMS”).

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 state Medicaid agency for reimbursement.

There are two ways to bill a Medicare crossover claim to Medicaid: Medicare’s Coordination of Benefits Contractor (COBC) can automatically send the claim to Medicaid (called an auto-crossover claim) or the provider can file a crossover claim through the GAMMIS web portal at Providers should bill Medicaid in the same manner in which they bill Medicare. Do not change any codes to match the Medicaid requirements. The Medicaid system has been adapted to Medicare’s coding for crossover claims.

As a reminder, members in WellCare’s DSNP plans are 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 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