Medicare Advantage dual eligibility with Medi-Cal
Special Needs Plans
May 30, 2015
This guidance is generally applicable for all health insurance companies that offer Medicare Advantage Special Needs Plans for dual eligible beneficiaries.
Dual Eligibles (Duals) are individuals who are entitled to benefits from both the federal Medicare and state-run Medicaid programs. For members enrolled in an Anthem Blue Cross Special Needs Plan (D-SNP), the D-SNP will take the place of Medicare as the primary payer and Medicaid will remain the secondary payer. In order to receive coverage, our D-SNP members must utilize Anthem Blue Cross providers for Medicare-covered services (doctors, hospitals, etc.).
Coordination of Benefits
Sales does not have a responsibility to assist with coordination of benefits. If a member reaches out to you for assistance, you may refer them to Customer Service, to the appropriate provider, back to the State or to the Care Management team. The Plan is required to assist the member with care coordination — i.e., to help them navigate the healthcare continuum, bridging the gap in coordinating what is available to them on the Medicaid side.
The Medicare plan pays for services provided as the primary payor and then the State or Medicaid plan pays their portion as secondary. The member should always present both ID cards to the provider at the time of service. When that is done, coordination of benefits happens behind the scenes and the member does not need to be involved. You may let the member know that coordination of benefits will work the way their Medicare plan works now. The difference is that they will receive additional services under the D-SNP.
D-SNP provider contracts prohibit balance billing the patient. What is balance billing?
Sending bills from hospitals and physicians for the balance due for medical services provided is called “balance billing.” This balance due represents the difference between the contractual amount Medicare paid on the claim as the primary insurance carrier (Medicare allowance) and the amount that Medicaid paid as the secondary carrier. The practice of balance billing for D-SNP members is prohibited. Medicare and Medicaid coordinate benefits. The member is not responsible for any balance remaining unpaid.
If a provider accepts both our plan and Medicaid, we would pay our portion based on the plan benefits and the provider would then balance bill Medicaid. If the member would get balance billed, they should contact our Customer Service team at the phone number listed on the back or their ID card.
It’s important for the member to know or ask whether a doctor accepts Medicaid. If the member accesses care from a Medicare-only provider for a Medicaid service, the claim will be denied as “not a covered service” and will not be covered under cost-share protection.
Can providers not accepting Medicaid refuse to accept our D-SNP members?
No – the providers are not allowed contractually to refuse our D-SNP members. In addition, providers cannot contractually balance bill the member if they don’t have a Medicaid number. Providers are not allowed to balance bill D-SNP members in our products. They are federally/state protected from cost-sharing. However, if a provider doesn’t accept Medicaid, they will likely not be reimbursed by the state.
How do members find a D-SNP network provider?
Members should visit the Member Portal and choose “Find a Doctor.” Follow the instructions to search by Plan network.
The online provider listing will include flags/indicators for those providers who accept Medicaid. Information is also available through the On Line Store and in the printed directory.