Wellcare by Health Net D-SNP network.

Only if that provider is also contract on our D-SNP Network.

Yes, members new to a D-SNP plan are eligible for continuity of care for 12 months from enrollment if certain circumstances are met.

Advise the member to utilize the Provider Search tool to look up participating providers within the D-SNP network, which can save the member of the out of network provider cost. You can also advise the member to contact the health plan by using the Member Services phone number on the back of their ID card for a provider search or PCP assignment.

• For D-SNP members in Fresno, Kings, and Madera counties, call 833-236-2366
• For D-SNP members in all the other counties, call 800-431-9007

The Medi-Cal benefit includes: Long Term Care (LTC), Community Based Adult Services (CBAS), Community Supports, Durable Medical Equipment (DME), and Medi-Cal covered transportation.
The Community Resource/Supports may include, but is not limited to, the following services:

• Housing Transition Navigation Services (homeless, or about to become)
• Housing Deposits
• Housing Tenancy and Sustaining Services
• Short-Term Post Hospitalization Housing
• Recuperative Care (medical respite)
• Respite Services
• Day Rehabilitation
• Nursing Facility Transition/Diversion to Assisted Living Facilities
• Community Transition Services/Nursing Facility Transitions to a Home
• Personal Care and Homemaker Services
• Environmental Accessibility Adaptations (home modifications)
• Meals/Medically Tailored Meals
• Sobering Centers
• Asthma Remediation
  

Member can access the Medi-Cal covered benefits in any of these ways below:

• Members can contact the Member Services number in the back of the card to get more information and get access to their covered Medi-Cal benefits.
  • For D-SNP members in Fresno, Kings, and Madera counties, call 833-236-2366
  • For D-SNP members in all the other counties, call 800-431-9007
• Members can use the findhelp platform to submit referrals to request Community Support benefits.

Inform the member to contact the health plan by using the phone number on the back of their ID card for any Medicare and Medi-Cal benefits related questions.

• For D-SNP members in Fresno, Kings, and Madera counties, call 833-236-2366
• For D-SNP members in all the other counties, call 800-431-9007

Inform the member to contact Member Services for support.

• For D-SNP members in Fresno, Kings, and Madera counties, call 833-236-2366
• For D-SNP members in all the other counties, call 800-431-9007

The member can contact Member Services phone number on the back of their ID card for support.

• For D-SNP members in Fresno, Kings, and Madera counties, call 833-236-2366
• For D-SNP members in all the other counties, call 800-431-9007

Yes, the incontinence supplies are covered through their Medi-Cal plan.

If the member has Health Net Medi-Cal, CalViva Health Medi-Cal, or Community Health Plan of Imperial Valley (CHPIV) Medi-Cal, the provider office first needs to submit the incontinence supply prescription to the Participating Provider Group and obtain a denial. Once the Medicare denial letter is received, fax the documentation to one of the contracted DME vendors, J&B Medical Supply Company LLC or Byram. The documentation should include member demographics, Medi-Cal ID number, prescription for incontinence supplies, copy of the Medicare denial, and quantity and types of needed supplies.

If the member has a different Medi-Cal plan in Orange, San Bernardino, Riverside, San Diego, Placer, Kern, or San Francisco, submit a referral using the Provider Portal. The list of covered incontinence medical supplies is available in the Provider Ops Manual.

Contact our Care Management team by calling 833-340-0083 or sending an email to centenecmescalationsmedicare@centene.com for help.

Yes, our D-SNP plan covers 80% and the remaining 20% must be billed to Medi-Cal Rx by the pharmacy.

The member should contact the Member Services using the number in the back of ID card if they are charged with a copay. D-SNP members are not responsible for copays.

Dual eligible Special Needs Plans (D-SNPs) enroll individuals who have Medicare and Medicaid (Medi-Cal).
Wellcare By Health Net has D-SNP plans in Amador, Imperial, San Joaquin, Stanislaus, Calaveras, Tuolumne, Fresno, Kings, Madera, Los Angeles, Sacramento, and Tulare. And Kern, Placer, San Francisco, Orange, Riverside, San Bernardino, San Diego are categorized as “no-sell” counties.

A dual eligible beneficiary should join a D-SNP because it provides a more streamlined, hassle-free experience in navigating through benefits. This is because the plan provides care coordination services designed to help arrange services on the member's behalf, and often offers extra benefits beyond what beneficiaries can get from original Medicare and Medi-Cal.

A D-SNP plan is required to coordinate all Medicare and Medi-Cal benefits through a formal Model of Care (MOC), which includes personalized care plans, care coordination, and support services to improve health outcomes.
In contrast, a D-SNP Look-Alike plan may appear similar in coverage but is not officially recognized as a special needs plan and is not required to coordinate care between Medicare and Medi-Cal. As a result, members must manage their care on their own, which can lead them to rely more heavily on agents or brokers for support.

For Wellcare by Health Net D-SNPs, enrollees must be Full Benefit Dual Eligible, Qualified Medicare Beneficiary Plus and Specified Low-Income Medicare Beneficiary Plus.
Definitions of all types of Qualified Medicare Beneficiary programs are available on the Centers for Medicare & Medicaid Services Medicare-Medicaid Coordination Office website.
Wellcare certified agents also have access to an online eligibility tool (through ASCEND) that allows them to check a member’s Medicare Savings Program and Extra Help level.

Current D-SNP members will remain enrolled in the Wellcare By Health Net D-SNP plan even though their Medi-Cal managed care assignment is a different health plan. The D-SNP contractor, Wellcare By Health Net, is responsible to coordinate all Medicare and Medi-Cal covered services regardless of who is the Medi-Cal Health Plan.

No, only full benefit dual eligible beneficiaries will be able to enroll into an exclusively aligned enrollment D-SNP if there is one offered in their county of residence.

EAE DSNP and regular non-EAE DSNP

• Wellcare Dual Liberty (HMO D-SNP) - H3561- 001 – Kern, Placer and San Francisco
• Wellcare Dual Liberty (HMO D-SNP) - H3561- 009 – Orange, Riverside, San Bernadino and San Diego
  

Wellcare Dual Liberty (HMO D-SNP) - H3561- 001 – Tuolumne and Calaveras counties

Exclusive aligned enrollment occurs when both contracts, D-SNP and Medi-Cal, are held or administered by the same parent organization/company and alignment of this enrollment is facilitated.

This approach ensures coordinated care with integrated benefits, including a single member ID card, one care team, and one health plan managing all services—from medical appointments and supplies to transportation and long-term support. Members also have access to one comprehensive network of providers and may receive additional benefits such as dental, hearing, or vision coverage, as outlined in the Member Handbook. This makes it feel and function like one plan to the member.

Enrollment automatically changes a member’s Medi-Cal plan to the same parent organization’s plan, with the state/DHCS handling the switch.

Wellcare By Health Net’s parent company is Centene, Inc. For Centene plans in California, the exclusively aligned enrollment D-SNP plans are:

• Wellcare Dual Align – Wellcare By Health Net D-SNP with a Health Net Medi-Cal plan in Los Angeles, Sacramento, and Tulare.
• Wellcare CalViva Health Dual Align* – Wellcare By Health Net D-SNP with a CalViva Health Medi-Cal plan in Fresno, Kings, and Madera counties.

Members must choose a PCP and a medical group from our Wellcare by Health Net D-SNP network.

Enrollment in the exclusively aligned enrollment D-SNP will trigger the Department of Health Care Services to reassign the member's Medi-Cal plan to the same parent organization.

These plans will be available through various health plans in multiple counties throughout California.

Example:

1. Mr. Smith is a full dual beneficiary with Medicare fee-for-services and Plan A for his Medi-Cal managed care plan.

2. Mr. Smith applies for enrollment into Plan B’s exclusively aligned enrollment D-SNP to take advantage of care coordination and benefits. Mr. Smith can choose a primary care physician/participating physician group within Plan B’s provider network on his exclusively aligned enrollment D-SNP application.

3. When approved by the Centers for Medicare & Medicaid Services, Mr. Smith's Medi-Cal managed care plan will change automatically to Plan B's Medi-Cal managed care plan. 

Only if one is offered in the service area where the beneficiary lives. Medicare.gov can help identify plans available in the ZIP Code of the beneficiary.

Enrollment in the exclusively aligned enrollment D-SNP will trigger the Department of Health Care Services to reassign the member's Medi-Cal plan to the same parent organization.

These plans will be available through various health plans in multiple counties throughout California.

Example:

1. Mr. Smith is a full dual beneficiary with Medicare fee-for-services and Plan A for his Medi-Cal managed care plan.

2. Mr. Smith applies for enrollment into Plan B’s exclusively aligned enrollment D-SNP to take advantage of care coordination and benefits. Mr. Smith can choose a primary care physician/participating physician group within Plan B’s provider network on his exclusively aligned enrollment D-SNP application.

3. When approved by the Centers for Medicare & Medicaid Services, Mr. Smith's Medi-Cal managed care plan will change automatically to Plan B's Medi-Cal managed care plan. 

Only if one is offered in the service area where the beneficiary lives. Medicare website can help identify plans available in the Zip Code of the beneficiary.

Because the Medicare and Medi-Cal services are administered by the same parent organization, the two plans make it feel and function like one plan to the member.

This approach ensures coordinated care with integrated benefits, including a single member ID card, one care team, and one health plan managing all services—from medical appointments and supplies to transportation and long-term support. Members also have access to one comprehensive network of providers and may receive additional benefits such as dental, hearing, or vision coverage, as outlined in the Member Handbook.

Refer the member to check the member’s plan benefit material and evidence of coverage (EOC) for the covered hearing benefits.

Members can contact Member Services for assistance.

• For D-SNP members in Fresno, Kings, and Madera counties, call 833-236-2366
• For D-SNP members in all the other counties, call 800-431-9007
  

Refer the member to check the member’s plan benefit material and evidence of coverage (EOC) for the covered hearing benefits.

• Medi-Cal will cover up to $100 after Medicare allowance is exhausted.

Members can contact Member Services for assistance.

• For D-SNP members in Fresno, Kings, and Madera counties, call 833-236-2366
• For D-SNP members in all the other counties, call 800-431-9007
  

Members can contact the transportation vendor directly using the phone number listed on their ID card. Or they can also call Member Services for assistance.

• For D-SNP members in Fresno, Kings, and Madera counties, call 833-236-2366
• For D-SNP members in all the other counties, call 800-431-9007

There is no trip limit when you combine the Medicare and Medi-Cal benefits.

If the member has transportation benefits through their Medicare Advantage/D-SNP plan, those must be exhausted before accessing the unlimited transportation benefits through their Medi-Cal managed care plan.

Whether the member is using the Medicare or Medi-Cal transportation benefit, they can access the higher mode of transportation by calling the Member Service for assistance.

• For D-SNP members in Fresno, Kings, and Madera counties, call 833-236-2366
• For D-SNP members in all the other counties, call 800-431-9007

If a member still has transportation benefit through their Medicare Advantage/D-SNP plan, request for a higher mode of transportation when calling the transportation vendor.

If a member has exhausted the Medicare Advantage/D-SNP plan and need a higher mode of transportation, a Physician Certification Statement (PCS) form is required to be filled out by the physician/provider office and faxed to Care Ride Unit (CRU) team’s fax number at 833-701-0051.  

Delta Dental of California.

Refer to Wellcare D-SNP Plan Benefit Material. D-SNP members have access to Medi-Cal dental benefits.

The services covered by Medi-Cal Dental may include:

• Dental exams (every 12 months)
• X-rays
• Teeth cleaning (every 12 months)
• Scaling and root planing
• Fluoride varnish (every 12 months)
• Fillings
• Crowns
• Root canals
• Partial and full dentures
• Denture relines
• Tooth removal
• Emergency services

For specific coverages, refer the member to check the benefits in the Smile California website.

For Medi-Cal covered services, member needs to see a dentist in Medi-Cal network. For DSNP covered dental services, member needs to see a dentist in DSNP Delta Dental provider network. Each D-SNP member is assigned to a dentist who takes both Medi-Cal FFS Dental and Delta Dental upon enrollment.

Yes, the members can continue to see their Med-Cal dentists for Medi-Cal covered dental services.

Only if that dentist is on the Delta Dental Medi-Medi Network.

The member needs to see dentists who accept the Medi-Cal dental plan. If the member has the Medi-Cal Fee for Service, they can look up the dentist in the Smile California website.

If the member has the dental managed care plan, they need to see dentists who accepts the Medi-Cal Dental Managed Care Plan they are enrolled with. They can look up the dentist in the Dental Managed Care websites.

Delta Dental Dentists who the members are assigned to are in the Medi-Cal Dental Fee For Service network so the member can access both their Medi-Cal and D-SNP dental benefits through the Delta Dental dentists

Upon enrollment, each member receives a Delta Dental ID card & Letter advising of the dentist assignment.

The letter received upon enrollment gives instructions on how to change to a different Delta Dental dentists, if necessary. The best way is to call our call center using Delta Dental's dedicated Wellcare custom phone line at 855-643-8515.

All dentists contracted under the Delta Dental Medi-Medi network are verified to be participating in the Medi-Cal dental Fee for Service network.

There is NO "primary" payer! The members have two plans with different benefits that do not coordinate with each other.

Yes, as long as the dentist is on the Delta Dental and Medi-Cal networks.

Care coordination is the organization of a member’s care across multiple health care providers to ensure the member receives safe, effective and appropriate care.

A care coordinator collaborates with the member, the Health Plan, and the member's healthcare providers to ensure the member receives the necessary care. They work with the member to create a care plan and identify the team members responsible for delivering, coordinating, and overseeing the member's healthcare.

The member can call the Care Management toll-free line at 833-340-0083 to get connected with the Care Management team.

Or the member can call Member Services who will help the member contact a care coordinator or with help changing a care coordinator.

• For D-SNP members in Fresno, Kings, and Madera counties, call 833-236-2366
• For D-SNP members in all the other counties, call 800-431-9007
  

The member can call the Care Management toll-free line at 833-340-0083 to get connected with the Care Management team.

Or the member can call Member Services who will help the member contact a care coordinator or with help changing a care coordinator.

• For D-SNP members in Fresno, Kings, and Madera counties, call  833-236-2366
• For D-SNP members in all the other counties, call 800-431-9007

Yes, Members may self-refer by calling the Care Management toll-free line at 833-340-0083.

The Centers for Medicare & Medicaid Services (CMS) is focusing on aligning the D-SNP and Medi-Cal/Medicaid Plan under the same parent organization for ease of care coordination.

• No quarterly Duals SEP effective January 1, 2025
• Two new monthly SEPs effective January 1, 2025
  • SEP # 1 (Duals disenrollment) – Low Income Subsidy (LIS)/Dual Eligible (DE) members may enroll into Prescription Drug Plan (PDP) standalone disenrolling them from an MA or D-SNP plan; returning to original Medicare/FFS.
  • SEP # 2 (Integrated care) – LIS/Dual Eligible (DE) members may move/enroll into an integrated D-SNP plan. Here are the counties that Wellcare has the integrated D-SNP plans: Fresno, Kings, Madera, Los Angeles, Sacramento, and Tulare.
    

CalViva Health is a Medi-Cal Managed Care Plan not affiliated with or owned by Centene. They are the Local Initiative Health Plan for Medi-Cal managed care in Fresno, Kings, and Madera counties (Central Valley). CalViva Health is a full-service health plan contracting with DHCS to provide Medi-Cal Covered Services to Medi-Cal managed care enrollees under the Two-Plan model in all zip codes in Fresno, Kings, and Madera counties. CalViva Health contracts with Health Net Community Solutions, Inc. on a capitated basis to provide and arrange for Medi-Cal Covered Services in all Zip Codes in Fresno, Kings, and Madera counties.

To meet the goals of the CalAIM Program, CA Medi-Cal plans will be required to also have a Medicare Advantage D-SNP Plan. CalViva Health only has the Medi-Cal contract with the state and does not have any Medicare contracts with CMS. Since Health Net’s parent organization, Centene, has a Medicare Contract, CalViva Health and Wellcare By Health Net have partnered to provide an Exclusive Aligned Enrollment D-SNP plan in Fresno, Kings and Madera counties.

The member can contact their broker, Member Services or 800-MEDICARE (800-633-4227).

• For D-SNP members in Fresno, Kings, and Madera counties, call 833-236-2366
• For D-SNP members in all the other counties, call 800-431-9007

If a D-SNP member loses their Medicaid/Medi-Cal eligibility, they can remain on the D-SNP for a period of time (called "deeming period") giving them opportunity to regain their Medicaid/Medi-Cal eligibility. If they do not regain their Medicaid/Medi-Cal eligibility, they are involuntarily disenrolled from the D-SNP plan. Wellcare By Health Net members have a 6-month deeming period.

For dual eligible beneficiaries who choose to enroll in a Medicare Advantage (MA) plan in those counties, their Medi-Cal plan must align with their MA plan choice, if there is a Medi-Cal plan affiliated with their MA plan. The Medi-Cal matching plan policy does not change or impact a beneficiary's MA plan choice.
Please refer to the DHCS website’s "Medi-Cal ‘Matching Plan Policy’ for Dual Eligible Beneficiaries."

The member needs to advise the D-SNP plan so that the health plan can coordinate with the ECM provider.

Members will be notified of the new plan year changes by mail via the Annual Notification of Changes (ANOC) in September and/or the standard non-renewal notice sent in October.
The Annual Notification of Change will outline specific changes in benefits between the current year and the next plan year.
Advise your members to ensure their Medicare plan has their current address and phone number so they receive the information.

Producers will receive communications throughout the year as needed. Producers are encouraged to access the D-SNP Resources for Producers page online for the most current resources and updates, as the page is updated regularly. They are also strongly encouraged to stay in contact with the local Medicare Broker Sales Team (Regional Agency Managers) to receive updates on major industry changes, training events, and additional sales opportunities with Wellcare.