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Dual SNP Cost-Sharing Update

At ‘Ohana Health Plan, 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 ‘Ohana at 80% of the Medicare allowable because the DSNP member’s benefit has 20% coinsurance.

DSNP members in Hawai`i are cost share protected and are not responsible for co-pays or coinsurance. ‘Ohana has an agreement with the State of Hawai`i’s Department of Human Services, Med-QUEST Division (MQD) to pay the entire cost share of DSNP members who are enrolled in the ‘Ohana DSNP.  If the Medicaid allowable amount is greater than the Medicare allowable amount we are obligated to pay all of the DSNP member’s cost share up to the Medicaid allowable amount. We will issue a separate evidence of payment to you detailing the Medicaid allowable cost-share amount.

Our records indicate that you have provided professional services in an institutional place of service to a DSNP member in the past 6 months.  Beginning May 1, 2018 ‘Ohana will be administering the coinsurance in accordance with the benefit design filed with the Centers for Medicaid and Medicare Services (CMS).

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 Medicaid typically reimburses less than Medicare for the same service, this often means no cost-share amount will be paid for ‘Ohana DSNP claims.

As a reminder, Federal law, (42 U.S.C. § 1396a(n)(3)(B)), prohibits balance billing of 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 ‘Ohana’s DSNP plans and the information in this communication, you may consult our Medicare Advantage Provider Manual, call Customer Service at 1-888-846-4262 or contact your ‘Ohana Provider Relations Representative.


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Last Updated On: 6/19/2018