PFFS Dual Product

Aug 13, 2007

  1. honestagent
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    honestagent Guru

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    Anybody know if there will be a dual PFFS Open Access Fee for Service plan for duals besides Wellcare?
     
  2. GreenSky
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    GreenSky Guru

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    Actually, WellCare does not have a PFFS plan for duals. They sell the Duet plan that way, but it's just their regular PFFS that pays the same way Medicare pays at at 80%. They do eliminate the deductibles however (I think).

    This benefit is no different than what they have currently. WellCare does add a monthly benefit for OTC crap and in some states better dental. But this is not limited to Dual Eligibles.

    I can find no reason for doctors to accept this plan over Medicare and many reasons why they should not.

    When this plan was presented to me I was told it paid at 100% of Medicare. This would have been a great benefit for everyone because at least in California, Medicaid rarely pays anything over the Medicare allowable. Doctors are working at 80% of the Medicare allowable.

    The regional sales representative even presented it to us incorrectly. She did not understand the actual benefits. It took about 2 months for the "truth" to get to me and at that point I stopped writing their plan.

    I think the Duet Plan can cause more problems than it solves. The only true plans for Medi-Medi is managed care, either HMO or PPO. Unless it's listed as a "Special Needs Plan" (SNP), then it is not a plan specifically for dual eligibles.

    Rick
     
    Last edited: Aug 14, 2007
    GreenSky, Aug 14, 2007
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  3. midwestbroker
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    midwestbroker Guru

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    I have heard of the wellcare plan for duals, but from what I was told, it gives them hearing, dental and vision. All other benefits (medical and rx) are unchanged.

    I know that Humana and Coventry are looking at SNP. Do not know any details about either, but I know they were both looking at them.

    You can enroll a dual in Care Improvement Plus, but it does not change their coverage, but they would have access to nursing care via the phone. Some think that is a good thing, others could care less. They still do have to qualify for the plan though (diabetic, COPD, heart failure, or ESRD).
     
  4. policy doctor
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    It seems like fewer people are expressing themselves correctly, or trying to even understand the English language and use it properly.

    More frustrating when you're at a seminar and they're explaining benefits, or concepts, and use wrong expressions, and semantics.

    Sounds like the Wellcare gal meant their plan pays 100% of whatever Orig Medicare would have paid....meaning, they pay the same amount as O.M. would have paid.

    Or like they say in Georgia, "i;m fixing to leave" and in New York "i'll be by your house" and all mean..." see you real soon!
     
  5. GreenSky
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    GreenSky Guru

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    Actually, she meant 100% of Medicare, not of what Medicare would pay. Both of us understood this and were in agreement. However, both of us were wrong for 2 months.

    Rick
     
    Last edited: Aug 14, 2007
    GreenSky, Aug 14, 2007
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  6. lonestar
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    lonestar New Member

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    Yet another version. The explanation I recieved was that Wellcare pays the 100% of medicare charges for duels. Then Wellcare applied to medicaid for their portion of the payment, therefore eliminating that step for the drs. office
     
    lonestar, Jan 10, 2008
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  7. retread
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    I can't speak to Wellcare's actual claim payments, because I am not contracted with them, but I will say that this explanation is the way it should work. Medicaid is always the payor of last resort, so if Wellcare is coordinated with them and is able to bill them after paying the required Medicare benefits, it appears copacetic.

    Not everything works out as planned on paper. I have run into other plans that are supposedly "co-ordinated" with Medicaid, only to find out that they deny claims. Sometimes this is a problem with the case worker, other times it is because the plan is not set up properly, or does not disclose that the benefits are actually less than full Medicaid benefits.
     
    retread, Jan 10, 2008
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  8. GreenSky
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    The following is correct for California but MAYBE not for other states.

    MediCal (Medicaid in Calif) rarely pays over and above what Medicare pays. Here's why:

    Medicare allowable $100.00
    Medicare Pays $80.00
    MediCal allowable $65.00

    Bill submitted to MediCal. MediCal says "our allowable is $65. You've been paid $80. Thank you very much and see ya!"

    That's why the Duet plan is not any better from the PHYSICIAN'S perspective. The provider knows Medicare will pay but will always have a doubt about a private plan. There is no "WIFM" for the doctor. In addition, because it's a PFFS, the doctor can always tell his patient he won't see them (but will see his neighbor with the same plan).

    Yes, it's beneficial for the member from strictly a benefit perspective. But it NOT a good deal if the person might lose his/her doctor. That is why I did not sell it after finding out it pays the same as Medicare.

    By the way, I don't think a PFFS plan exists that is a SNP. I think that a true SNP by definition is managed care.

    Rick
     
    GreenSky, Jan 10, 2008
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  9. retread
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    I agree. They are marketed as though they were, but in fact are RPPOs, but with an "open" network.
     
    retread, Jan 10, 2008
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  10. JthomasTX
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    JthomasTX New Member

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    Just to add to the conversation.

    Congress passed a bill on 12-20-07, that effectively stops any SNP expansions until DEC. 31 2009. Meaning for the 2010 season.

    So, I bet you will see a few WellCare copycats in the coming year. Since all the true SNP programs can't expand


    I see the point on MediCal reimbursement I have 2 agents out there who have been dealing with provider issues all year. Wellcare and others. Here in TX Medicaid has been picking up the 20% in most cases, so proivider issues have been fewer, but still there.

    The WellCare program gives them Dental, Vision and hearing above and beyond the state program. Some states provide some or all of these services. Idaho being one. However, the WellCare plan is an indemnity dental program. $1000 toward whatever they need, not just fillings, but dentures and cosmetic if they want. $260 toward eyeglasses isn't too shabby either. A lot of members have been combining the state and Duet benefits to get nicer glasses or higher quality dentures.

    The $30 OTC benefit doesn't sound like much, but if your income is under $800per mo. an extra $30 for basic household and personal care items goes a long way. It is ordered from a catalog that has most eveything you would find in a Walgreens. $360 per year use it or lose it.

    I've seen better benefits in some areas, like Houston here.(94 MA plans filed there, can you pick a winner?):radar:

    On the whole, WellCare has been doing quite well. They aren't a home run in some counties, but there is usually another plan you can use to pickup the slack.
     
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