Wellcare By Health Net is assessing their networks to determine differences and working to ensure minimal disruption to members and providers.

Should any of their current providers not participate with the Wellcare By Health Net D-SNP program, members are eligible for continuity of care for 12 months following the transition.

DSNP network.

ONLY if that provider is part of the DSNP Network.

• The services covered only by Medi-Cal are:·         
  • Long Term Care (LTC)·        
  • Community Base Adult Services·        
  • Medi-Cal Covered DME·        
  • Community Supports    
• Asthma Remediation
• Community Transition Services/Nursing Facility Transition Services to a Home  
• Day Habilitation Programs   
• Environmental Accessibility Adaptation (Home Modification)   
• Housing Deposit (up to $6,000)  
• Housing Tenancy and Sustaining Services
• Housing Transition Navigation   
• Medically Tailored Meals    
• Nursing Facility Transition/Diversion to Assisted Living Facilities   
• Personal Care Services and Homemaker Services   
• Recuperative Care   
• Respite Services
• Short-Term Post-Hospitalization Housing
• Sobering Centers
• Transportation

Dual eligible Special Needs Plans (D-SNPs) enroll individuals who are entitled to both Medicare (title XVIII) and medical assistance from a state plan under Medicaid (title XIX). States cover some Medicare costs, depending on the state and the individual’s eligibility. States and health plans may vary in determining their eligibility categories.

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.

Each D-SNP plan may have different requirements.

For Wellcare by Health Net D-SNP plans, 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 (PDF).

If the D-SNP Medicare plan (parent organization) has a Medi-Cal contract,¹ members will be passively transitioned into an exclusively aligned enrollment D-SNP, effective January 1, 2023, and the Department of Health Care Services will reassign their Medi-Cal managed care plan to that parent organization’s Medi-Cal plan. Members will be notified via the current Evidence of Coverage and Annual Notice of Change materials sent in September.

If the D-SNP Medicare plan (parent organization) does not have a Medi-Cal contract in that county,² members will remain in an unaligned D-SNP. Members will be notified via the current Evidence of Coverage and Annual Notice of Change materials sent in September.

¹For Wellcare by Health Net D-SNP, this will occur in Los Angeles, Riverside, San Bernardino and San Diego counties.

²For Wellcare by Health Net D-SNPs, this will occur in Orange County.

³Wellcare by Health Net does not currently (2022) have D-SNP in Santa Clara or San Mateo counties.

The member may be enrolled in a D-SNP look-alike (LAL) plan through December 31, 2022.

If they are not in a D-SNP LAL plan, their Annual Notice of Change will advise of any changes applicable to their benefits/plan for 2023.

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 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 D-SNP members who are in a new exclusively aligned county for 2024 will be automatically enrolled into exclusively aligned D-SNP plan/Medicare Medi-Cal plan effective January 1, 2024, if they do not elect another plan/option to receive their Medicare benefits. 

For Wellcare by Health Net, this will occur in Fresno, Madera, Sacramento, and Tulare counties.

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.

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.

A Medicare Medi-Cal Plan (MMP or Medi-Medi Plan) is a type of Medicare Advantage D-SNP plan. It is for people who have both Medicare and Medi-Cal. It combines Medicare and Medi-Cal benefits and Medicare prescription drug benefits into one plan.

Medi-Medi Plans will coordinate all benefits and services across both programs, including all Medicare and Medi-Cal covered services.

• One care team to coordinate care.
• One health plan to coordinate delivery of services, including medical supplies, transportation, and long-term services and supports.
• One set of benefits and a network of providers, including doctors, hospitals, clinics, labs, pharmacies, and medical equipment suppliers.
• Members may get extra benefits like dental, hearing, or vision coverage, in addition to what Medi-Cal covers (refer to the Member Handbook for the full benefit details).

Wellcare has two Medi-Medi plans: Wellcare By Health Net in the Los Angeles, Sacramento, and Tulare counties, and Wellcare CalViva Health Dual Align in Fresno, Kings, and Madera.

Only Dual Special Needs Plan (D-SNP) members who are in a new exclusive aligned county for 2024 will be automatically enrolled into exclusive aligned D-SNP plan/Medicare Medi-Cal plan effective January 1, 2024, if they do not elect another plan/option to receive their Medicare benefits.

• For Wellcare By Health Net, this will occur in Fresno, Madera, Sacramento, and Tulare counties.
• For D-SNP members in Fresno and Madera counties, their Medi-Cal plans will be assigned to CalViva Health for their Medi-Cal benefit.
• For D-SNP members in Sacramento and Tulare counties, their Medi-Cal plans will be assigned to Health Net for their Medi-Cal benefit.

Members will be notified of 2024 plan changes by mail via the Annual Notification of Change (ANOC) in September 2023 or the standard non-renewal notice sent in October 2023. For non-renewing plans with or without a transition to a new plan, the standard non-renewal notice will be sent to members in October 2023.

The Annual Notification of Change will outline specific changes in benefits between the current year (2023) and the next plan year (2024).

Advise members to ensure their Medicare plan has their current address and phone number so they receive the information.

Health Plans will communicate with you in the normal way they do today when there are changes or updates. 

To date, the Department of Health Care Services and Centers for Medicare & Medicaid Services have advised there will be no change to how they access their Medicare benefits.

Starting January 1, 2023, the Department of Health Care Services will require any new dually eligible beneficiary to enroll in a Medi-Cal managed care plan. For more information, visit the DHCS website.

The member will be assigned a contracted in-network provider (PCP under an affiliated PPG).

Depending on the member’s Medicare plan, the member’s Medi-Cal may be aligned with their Medicare plan under exclusively aligned enrollment if the parent company of the Medicare plan has both Medicare and Medi-Cal in the market. Alignment will only occur upon a new enrollment or plan changes effective 1/1/24 or after in the counties where there is exclusively aligned enrollment [the twelve (12) EAE counties] or there is a Medi-Cal Matching Plan Policy in force. The members will be notified by the state of any changes to their Medi-Cal plans based on their Medicare plans.

No, beneficiaries do not have to wait. They need to be in the Medicare service area AND be a full dual eligible member to join/enroll into the D-SNP plan. This also applies to the Exclusively Aligned Enrollment counties; the alignment of the Medi-Cal plan when the address in the DHCS/Medi-Cal system reflects the county. 

• Medi-Cal is the CA name for the CA Medicaid program
• Qualified based on Low Income or Disability
• Medi-Cal is payer of last resort if the member has multiple coverages
• Application process through Medi-Cal or Covered CA 
• As of 1/1/23, all full duals must enroll into a Medi-Cal Managed Care Health Plan (can choose the health plan). That means if someone is on Medi-Cal FFS and ages into Medicare or qualifies because of disability, they will be assigned to a Medi-Cal Managed Care Plan
• Enrollment/disenrollment is facilitated by the State Enrollment Broker, Health Care Options, via “Choices Form”
• Generally, joining a Medi-Cal plan will not affect beneficiary choice of Medicare Advantage plan or Original Medicare
  • There are specific enrollment policies for specific counties in CA where enrollment into a Medicare Advantage plan will impact the Medi-Cal plan the member is assigned to such as the Exclusive Aligned Enrollment Policy and the Matching Plan Policy
• Medicare providers do not need to be in the Medi-Cal plan network to continue to provide Medicare covered services/benefits. See here for more details
• Each county can have a different “model" (PDF) determining the health plan options

• Make sure they are full scope Medi-Cal with NO share of cost (SOC)
• Ensure the beneficiary’s doctors, specialists, facilities, etc. are in the network (this is the # 1 reason someone disenrolls from the plan)
• Ensure their residential address with the State/Medi-Cal matches their address they are providing on the DSNP application
• Complete the Health Risk Assessment (HRA).  This provides the plan with critical and current health issues and social needs so we can ensure

Through their Medi-Cal Managed Care Plan (MCP)

1. Long Term Care (LTC)
2. Community Bases Adult Services (CBAS) aka adult day health care
3. Medi-Cal Covered DME (incontinence supplies)
4. Community Supports (CS); these may vary by health plan and county.  If the member is with Health Net or CalViva Health for their Medi-Cal MCP, the list of Community Supports can be found here
5. Transportation; unlimited

 Though Medi-Cal Fee for Service (FFS) aka Medi-Cal carved-out services

1. In-Home Support Services (IHSS)
2. Medi-Cal Dental (basic dental)
3. Specialty Mental Health & Substance Use Disorder Services; county contacts here
4. Multipurpose Senior Services Program (MSSP)
5. Medi-Cal Rx
6. Home and Community-Based Waiver Programs (HCBS)

• For 2024, Wellcare’s DSNP dental coverage is intended to supplement the Medi-Cal covered dental services and covers services which are NOT covered by Medi-Cal dental program

• They will need to see a dentist who is in the applicable Medi-Cal Dental program
• They will present their BIC card (the one with the poppies on it) to that dentist office
• The dentist will bill Medi-Cal dental for the services covered under the Medi-Cal dental program

The Medi-Cal Dental covers: 

• Exams (Covered benefit once every 6 months)
• Emergency Service
• X-Rays
• Teeth Cleaning
• Fluoride Varnish
• Deep Cleaning- Scaling and Root Planing
• Fillings
• Tooth Remova
• Root CanalsCrowns *
• Partial Dentures
• Full Dentures
• Denture Reline
• Sedation
• See the Medi-Cal Dental Handbook for all details

• Each member is assigned to a dentist who takes BOTH Medi-Cal FFS Dental & Delta Dental upon enrollment (no dentist choice on the enrollment form/Acsend; network search only)
• Each member receives a Delta Dental ID card & Letter advising of the Dentist assignment
• The letter received gives instructions on how to change dentists, if necessary.  The best way is to call our call center using Wellcare custom phone line.  Then the member can also get questions answered at the same time.   (855) 643-8515 (Delta Wellcare Line)
• Two (2) claims are needed- one to Medi-cal for Medi-Cal covered services, and a 2nd to Delta for the DSNP plan covered services.  The claims will NOT crossover between the Medi-Cal dental program and the DSNP plan

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

• It is the annual review to determine beneficiary eligibility for the Medi-Cal program.  This process was put on hold in early 2020 - Q2 2023 due to the Covid-19 Public Health Emergency (PHE)
• For Wellcare, you must be a full dual eligible beneficiary to be in our DSNP Plan.  If a DSNP member loses their Medi-Cal Eligibility because they no longer qualify for full scope Medi-Cal, they will be placed in six (6) month “deeming period” to allow them more time to regain their Medi-Cal eligibility.  A series of three (3) notices are sent throughout the deeming period advising them they need to regain their Medi-Cal eligibility to stay on the DSNP plan and if they do not regain their Medi-Cal eligibility, they will be involuntarily disenrolled from the plan (with an SEP to join another plan).

• DSNP Plans may have different or additional benefits aimed at a dual eligible beneficiary that a traditional Medicare Plan or a “look alike” plan may not
• DSNP plans are required to coordinate all care for their member under the State Medicaid Agency Contract (SMAC) regardless of the Medi-Cal plan the member is in (aligned/matched or not)
• DSNP plans have a Model of Care (MOC) which requires concentrated efforts to improve the care of their membership; reportable to the National Committee for Quality Assurance (NCQA)
• Traditional Medicare Plan or a “look alike” plans are not required to coordinate anything for the member so the member may come to you, their broker, for support on coordination.

• Wellcare did have a look alike plan, but as part of the 2021 Medicare Advantage and Part D Final Rule (CMS-4190-F1 (PDF)), the Centers for Medicare and Medicaid Services (CMS) finalized new contracting limitations for D-SNP LAL plans at 42 CFR § 422.514(d) and (e): any non-D-SNP Medicare Advantage Part D plan with 80% or more full Medicaid members (full duals) will not be renewed for the 2023 plan year. The health plans who have the Look Alike plans for 2024 probably have less than 80% of the total enrollees in the non-SNP plans, which is below the threshold set by CMS. This allows certain health plans to retain and sell Look Alike plans. However, CMS reviews the plan’s January membership every year and will not renew a contract with the plan that is not a SNP and has the enrollment consisting of 80 percent or more of total enrollees in the non-SNP plans. By doing so, CMS is looking to eliminate the Look Alike plans from the market. 

It is a part of the federal regulations (PDF) from 2021. Starting in 2021, if CMS identifies a plan as a look alike, they were sent a notice to transition those members in the look like plan to the D-NSP plan. Since then, CMS has been reviewing the January membership each year, and CMS will not renew or enter into a contract for an MA plan that is not a SNP and has the enrollment consisting of 80 percent or more of total enrollees in the non-SNP plans.

We believe the D-SNP plan is a better choice because member receives care coordination regardless of the Medi-Cal plan the member is in, which allows for a minimal member abrasion. The “Look Alike” plan is not required to coordinate anything for the members, so the member may come to you, brokers/producers and their medical providers, for support on care coordination.

Another benefit of being enrolled in a D-SNP over a Look Alike plan is prevention of balance billing. Balance billing is when a beneficiary is billed for the 20 percent of co-insurance not covered by traditional Medicare or FFS. DHCS prohibits Medicare providers to bill dual eligible beneficiaries for Medicare cost sharing, which means the members cannot be charged for co-pays, co-insurance, or deductibles.