Q: What are Special Needs Plans (SNPs)?
A: SNPs are a type of Medicare Advantage Plan specially designed to focus on the needs of vulnerable targeted populations. There are three general types of SNPs:
- Institutional SNPs (I-SNPs)
- Dual-eligible SNPs (D-SNPs)
- Chronic SNPs (C-SNPs)
Wellcare By 'Ohana Health Plan currently offers only D-SNPs.
Q: Are pharmacy services impacted by the Model of Care?
A: In some cases, D-SNP members may need a review of medications and utilization. If the Case Manager sees a need for additional review, a medical director and/or the Pharmacy department may assist.
Q: If I do not accept Medicaid, may I bill a D-SNP member directly?
A: Not in all cases. Some D-SNP members are held harmless by the state for Medicare Part A and Part B services. These D-SNP members may not be billed for cost sharing, and contracted providers must accept Plan payment in full.
Q: If I accept Medicaid and do not receive any additional payment from Medicaid, may I balance bill the D-SNP member?
A: Not in all cases. CMS requires all plans to develop language for their provider contracts that prohibits balance billing D-SNP members who are held harmless by the state for Medicare Part A and Part B covered services. For these D-SNP members, contracted providers must accept Plan payment in full if they do not receive additional payment from the state Medicaid agency.
Q: How do I submit claims for reimbursement for a D-SNP member if Wellcare and the state have a contract?
A: This varies depending on the arrangement with the state. Please refer to your Provider Manual, Section 14, Dual-Eligible members, to determine the best process for your area.
Q: Why do D-SNP members who lose Medicaid eligibility remain in Wellcare for up to six months?
A: CMS requires all D-SNPs to offer a deeming period - a period of time in which D-SNP members may remain in the plan while they try to regain their Medicaid eligibility. Wellcare by 'Ohana's deeming period is six months.
Please refer to your Provider Manual, Section 14, Dual Eligible Members, for more details.