D-SNP Frequently Asked Questions for Providers

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. Applies to ALL D-SNP plans including:
    • Non EAE D-SNP – Wellcare Dual Liberty – Amador, Imperial, San Joaquin, Stanislaus, Tuolumne, Calaveras
    • EAE D-SNP – WellCare Dual Align & Wellcare CalViva Health Dual Align – Los Angeles, Tulare, Sacramento, Fresno, Kings, Madera
  • SEP # 2 (Integrated care) – LIS/Dual Eligible (DE) members may move/enroll into an integrated D-SNP plan IF they are already enrolled or are in the process of enrolling into the same parent organization’s Medi-Cal plan. Applies ONLY to EAE D-SNP products/plans including:
    • EAE D-SNP – WellCare Dual Align & Wellcare CalViva health Dual Align – Los Angeles, Tulare, Sacramento, Fresno, Kings, Madera

• 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

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

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.

No. You do not need to be contracted with Health Net or CalViva Health Medi-Cal to provide Medicare covered services to our D-SNP members. You would only need to be contracted with CalViva Health or Health Net Medi-Cal if you are providing Medi-Cal covered services not covered by Medicare (such as LTC or CBAS).

Use your existing Provider Services contact number.

D-SNP network.

Only if that provider is part of the D-SNP Network.

Members new to a D-SNP plan are eligible for continuity of care for 12 months from enrollment if certain circumstances are met. Please see the Provider Operations Manual.

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 may have different requirements.

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.

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.

Under exclusively alignment enrollment, members enroll in a dual eligible special needs plan (D-SNP) for Medicare benefits and in an Medi-Cal Managed Care Plan for Medi-Cal benefits, which are both operated by the same parent organization for better care coordination and integration.

Exclusively aligned enrollment D-SNPs offer an integrated approach to care and care coordination. The matching Medicare D-SNP and Medi-Cal plans will work together to deliver all covered benefits to their members. And as all members in the plan are also enrolled in the matching managed care plan, they can receive integrated member materials, such as one integrated member ID card.

Enrollment into the exclusively aligned enrollment D-SNP will result in the member’s Medi-Cal plan changing to the same parent organization’s Medi-Cal managed care plan. The Medi-Cal plan is changed automatically by the state/DHCS, who will send a notification in the mail to the member advising them of the auto assignment.

Wellcare By Health Net's parent organization 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.

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.

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 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).

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 for 2024.

If a dual eligible beneficiary joins the Wellcare By Health Net D-SNP plan in Fresno, Kings, and Madera counties, they will be automatically assigned to CalViva Health for their Medi-Cal Managed Care Plan.

D-SNP matching plan counties

The 17 counties with the Medi-Cal matching plan policy in 2024 are:

• Alameda, Contra Costa, Fresno, Kern, Kings, Los Angeles, Madera, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Mateo, Santa Clara, Stanislaus, and Tulare.

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

Also remind the member that any referral for services which require an approval will generate a written response to them. And if denied, the member will be provided with their appeal rights.

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

Also remind the member that any referral for services which requires an approval will generate a written response to them. And if denied, the member will be provided with their appeal rights.

If the member is aligned with us through Health Net Medi-Cal, CalViva Health Medi-Cal or Community Health Plan of Imperial Valley (CHPIV), the following resources are available.

Please see the following Medi-Cal information in the Provider Library:

CalAIM Resources for Providers

For Wellcare By Health Net D-SNP members enrolled in Health Net Medi-Cal or CHPIV; search and submit a referral for Community Supports.

For Wellcare By Health Net D-SNP members enrolled in CalViva Health, search and submit a referral for Community Supports at the CalViva findhelp tool.

Research the findhelp platform, which can provide the member with the Community Supports, and help the member get connected to the services. You can also submit a request for care coordination to Wellcare By Health Net using the referral form (PDF).

The Public Programs team will help our members connect to these Community Supports via help_referral@healthnet.com.

All providers are identified in the provider directory under "Other Facilities" Members can self-refer to the Community Support service.

The Community Resource/Supports may include, but is not limited to, the following services:

1. Housing Transition Navigation Services (homeless, or about to become)
2. Housing Deposits
3. Housing Tenancy and Sustaining Services
4. Short-Term Post Hospitalization Housing
5. Recuperative Care (medical respite)
6. Respite Services
7. Day Rehabilitation
8. Nursing Facility Transition/Diversion to Assisted Living Facilities
9. Community Transition Services/Nursing Facility Transitions to a Home
10. Personal Care and Homemaker Services
11. Environmental Accessibility Adaptations (home modifications)
12. Meals/Medically Tailored Meals
13. Sobering Centers
14. Asthma Remediation

The member can call their Case Manager and Member Services for assistance.

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 works with the member, the Health Plan and the member's care providers to make sure the member gets the health care that is needed. The care coordinator works with the member to put together a care plan and determines who is on the care team to deliver, meet and manage the member's health care.

Providers can access their Provider Portal account, call the Wellness Case Management/Care Coordination Team at 833-340-0083 (Monday-Friday 5:00 a.m.-5:00 p.m. Pacific time), or email CenteneCMEscalationsMedicare@centene.com.

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

Providers may call the Wellcare Care Management Referral Line, or complete and fax a request to the number on the Quick Reference Guide. Members may self-refer by calling the Care Management toll-free line or the Nurse Advice Line after hours or on weekends.

ECM is a whole person, interdisciplinary approach to care that addresses the clinical and non-clinical needs of members with the most complex medical and social needs. ECM is designed to be delivered by community-based ECM providers that are contracted with managed care health plans. Member care management, as well as coordination across Medicare and Medi-Cal benefits, is a primary function of D-SNPs.

D-SNP Plans will work with ECM providers, as needed, to transition a member from ECM to D-SNP Care Management once the member graduates from ECM as part of the continuity of care.

As of January 1, 2024, all D-SNPs must provide sufficient care management ("ECM-like care management") exclusively through their D-SNP plan.

There is significant overlap across the D-SNP model of care and ECM requirements which could result in duplication and confusion for members and care teams if a member receives care management from both programs. For more information on ECM and how it differs from D-SNP, refer to the DHCS CalAIM policy guide and the ECM policy guide.

Inform the member that they can contact Member Services for support but, if they are still having trouble scheduling an appointment with the County Behavioral Health Services, they can contact the ombudsman:

Medi-Cal Managed Care Ombudsman: 888-452-8609

Inform the member that they can contact the Health Plan's Member Services department for support. Representatives are trained to coordinate the transportation benefits between Medicare and the Medi-Cal benefits. The member can also call the transportation telephone number on the back of their member ID card. 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.

You can reach out on the member's behalf or ask the member to reach out to help_referral@healthnet.com to access incontinence supplies or DME. The email is triaged by the Public Programs team and will support access to incontinence supplies.

Have the member reach out to the County Department of Social Services directly. Alternatively, if they need help with the application, the Public Programs team can help. Have them reach out to help_referral@healthnet.com.

Have the member reach out to the CBAS center directly. If they need help finding or identifying a CBAS center, help them reach out to help_referral@healthnet.com. The Public Programs team will support access to the CBAS program.

Yes, but only when they are covered by both Medicare and Medi-Cal Rx. Diabetic supplies including meters, test strips and lancets are fully covered when a member presents both their D-SNP member ID card and their state of California Medi-Cal card at the pharmacy since their supplies are covered 80% from Medicare and 20% from the Medi-Cal Rx program. Please remind the member to present their state of California Medi-Cal card, not their Medi-Cal managed plan ID card while at the pharmacy.

• Blood Glucose Test Strips
  • OneTouch Ultra (Box 100)
  • OneTouch Verio Test Strips (Box 100)
• Glucometers
  • OneTouch Ultra 2 Meter
  • OneTouch Verio Flex Meter System
  • OneTouch Verio Reflect Meter System
• Continuous Glucose Monitoring
  • Dexcom G6
  • Dexcom G7
  • FreeStyle Libre 2
  • FreeStyle Libre 3
  • FreeStyle Libre14 Day

To prevent a member being charged a copayment, please ensure they are prescribed the referenced brands for coverage. The pharmacy must bill both Express Scripts and Magellan for Medi-Cal Rx claims. If a pharmacy needs assistance with balance billing, they must call Medi-Cal Rx at 800-977-2273.

If a member needs a brand not covered by Medical RX, the provider/pharmacy needs to submit a request to Medi-Cal RX to make an exception.

D-SNP members have the flexibility to visit any dentist within Delta Dental’s Medi-Medi network. This network comprises dentists who are part of both the Medi-Cal and Delta Dental’s Medi-Medi networks. This guarantees that members enrolled in this plan can conveniently receive all their care from a single dentist. For more information, refer to the Delta Dental website.

For 2025, Wellcare's D-SNP dental coverage is intended to supplement the Medi-Cal covered dental services and covers services which are NOT covered by Medi-Cal dental program.

Visit Delta Dental Provider Tools to verify patient eligibility and benefits. Additionally, each patient must receive a comprehensive written treatment plan. The accepted plan must be signed by the patient or their guardian and the treating dentist and submitted to Delta Dental for estimate and prior authorization.

• 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

Medi-Cal Dental covers the following:

• Exams (Covered benefit once every 6 months)
• Emergency Service
• X-Rays
• Teeth Cleaning
• Fluoride Varnish
• Deep Cleaning- Scaling and Root Planning
• Fillings
• Tooth Removal
• Root Canals
• Crowns (Crowns on molars or premolars [back teeth] may be covered in some cases)
• 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/Ascend; 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 Delta Dental's dedicated Wellcare custom phone line. Then the member can also get questions answered at the same time: 855-643-8515 (Delta Dental's dedicated Wellcare Line)

You can access the Wellcare D-SNP Dental Evidence of Coverage (EOC) and Summary of Benefits (SOB) or contact Delta Dental directly at 855-643-8515 for more information.

No, they can still provide the Wellcare D-SNP covered dental services to the Wellcare D-SNP member.

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

Two (2) claims are needed – One to Medi-Cal for Medi-Cal covered services, and a second claim to Delta for the D-SNP plan covered services.

Visit the Delta Dental website to learn more about how to be a part of the Delta Dental Medicare network.

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

Refer to the non-participating provider section for additional guidance. For additional information, providers are encouraged to access the Provider Operations Manual.

Please refer to the DHCS website’s "Medi-Cal ‘Matching Plan Policy’ for Dual Eligible Beneficiaries."

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.

Members will be notified of 2025 plan changes by mail via the Annual Notification of Changes (ANOC) in September 2024 and/or the standard non-renewal notice sent in October 2024.

The Annual Notification of Change will outline specific changes in benefits between the current year (2024) and the next plan year (2025).

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