Dual Eligible Question

[Bill_Kiray]

Just as an aside, I've seen more problems with Dual Eligibles being enrolled into "regular" MA plans than anything else. That will almost always lead to a situation where a member goes to see a provider that bills them more than they would pay under Original Medicare and Medicaid. Once that happens, not only will the member dump the case (resulting in a chargeback, most often a rapid) but will put in a complaint.

Be careful the scenarios in which you do this, it often leads to more problems for you than you need.

 

[SportsNut]

Just as an aside, I've seen more problems with Dual Eligibles being enrolled into "regular" MA plans than anything else. That will almost always lead to a situation where a member goes to see a provider that bills them more than they would pay under Original Medicare and Medicaid. Once that happens, not only will the member dump the case (resulting in a chargeback, most often a rapid) but will put in a complaint.

Be careful the scenarios in which you do this, it often leads to more problems for you than you need.

Curious Bill, what carries / products have you seen this with, where an agent placed them into a "regular MA" product vs. what other type of MAP product...? I know UHC has a product specifically designed for duals, it is called EverCare. I'm not sure exactly what the main diff is in that product vs the std product line... but in the Sum of Benefits section it specifically lists how the benefits will be paid if the insured is Medi-Medi, which makes it nice when folks look at the product and see they will pay 0. But of course this product is also an HMO, so you then run into PCP issues again. (potentially).

 

[Bill_Kiray]

Curious Bill, what carries / products have you seen this with, where an agent placed them into a "regular MA" product vs. what other type of MAP product...? I know UHC has a product specifically designed for duals, it is called EverCare. I'm not sure exactly what the main diff is in that product vs the std product line... but in the Sum of Benefits section it specifically lists how the benefits will be paid if the insured is Medi-Medi, which makes it nice when folks look at the product and see they will pay 0. But of course this product is also an HMO, so you then run into PCP issues again. (potentially).

When a Dual Eligible is enrolled into a Dual SNP, the carrier coordinates benefits with Medicaid. This happens even when the provider who is under contract is not a Medicaid provider. Examples of this type of product would be UnitedHealthcare Dual Complete (formerly Evercare, Americhoice, Unison, etc.), Bravo Select, HealthSpring TotalCare, Highmark SecurityBlue Care, etc.

When a Dual Elgible is enrolled into a non-SNP (like AARP MedicareComplete), and they see a provider who is in their network but doesn't participate with Medicaid, it can be extremely difficult to get Medicaid to reimburse the cost sharing.

 

[SportsNut]

When a Dual Eligible is enrolled into a Dual SNP, the carrier coordinates benefits with Medicaid. This happens even when the provider who is under contract is not a Medicaid provider. Examples of this type of product would be UnitedHealthcare Dual Complete (formerly Evercare, Americhoice, Unison, etc.), Bravo Select, HealthSpring TotalCare, Highmark SecurityBlue Care, etc.

When a Dual Elgible is enrolled into a non-SNP (like AARP MedicareComplete), and they see a provider who is in their network but doesn't participate with Medicaid, it can be extremely difficult to get Medicaid to reimburse the cost sharing.

Specifically, do you know how Anthems Senior Advantage Value performs when used with dual eligibles...? They say it works great, but have no specific experience with it in this manner... lots otherwise though. Their appl asks about M'caid and has a spot to include the M'caid number...

Isn't the UHC Deal Compl still and HMO...? So all the docs that they plan to see must accept the HMO, correct...? That is where I have seen weakness... that the docs don't accept the HMO, so no coverage. It seems to me that the dual eligible thing would work better with a PPO; more docs and everyone takes it, no matter whether in or out of network. Your thoughts on that statement...?

 

[Josh]

SportsNut: You should check with the billing offices, but generally whether or not it's an HMO it doesn't matter. If Medicare denies the claim, for whatever reason, Medicaid picks up the bill, whether there is a 20% balance, a copay, or the entire bill needs to get paid, it generally makes zero difference to the beneficiary.

 

[pbbaseball]

hmmm... i do a lot of LIS on traditional MA plans, but haven't ever done a medicaid into a non SNP plan... figured they would be balance billed the copays.. interesting

 

[Josh]

I did it with Aetna a bunch along with some other carriers. The plan usually loves it because Medicaid eats the claims and the client loves it because they have access to more doctors and get some extras, but usually they just like feeling like they got to buy something (if we're being honest with ourselves).

Back to Aetna, I wrote a ton of business for them they didn't have to pay claims on because it was all Medicaid folks and their PCP was actually a clinic that basically only to Medicaid, so the patient had no difference in service and Aetna took a pile of good risk. I'm not sure how much that made up for me sticking them with $160k worth of cancer treatments a client needed, but I'm sure it helped.

 

[jmarkk1]

I did it with Aetna a bunch along with some other carriers. The plan usually loves it because Medicaid eats the claims and the client loves it because they have access to more doctors and get some extras, but usually they just like feeling like they got to buy something (if we're being honest with ourselves).

Back to Aetna, I wrote a ton of business for them they didn't have to pay claims on because it was all Medicaid folks and their PCP was actually a clinic that basically only to Medicaid, so the patient had no difference in service and Aetna took a pile of good risk. I'm not sure how much that made up for me sticking them with $160k worth of cancer treatments a client needed, but I'm sure it helped.

So basically the thing to watch out for is if client goes to provider that doesn't accept medicaid? regardless if provider is out of network?

If client keeps going to medicaid provider, even if they are out of network, medicaid pays as usual? (I'm referring to a scenario where they are offered a PPO plan that has out of network coverage....not an HMO only plan)

 

[Josh]

That's exactly it. You can check with billing offices to ask them, usually they know how to handle it and if not, it's always nice for them to have a heads up.

Just to reiterate the point, out of network, in network, or out of network with a ppo, it all works the same. Ignore the Medicare for a moment, Medicaid pays for everything. If they have Medicare then it's one more entity to bill and the billing office has more work to do and the office might make more money than on Medicaid alone, but at the end of the day Medicaid providers can't balance bill their patients, regardless of the Medicare status.

If you can follow the above, it'll put you leagues ahead of most Medicare Advantage agents in dealing with duals.

 

[Mark from WI]

We had an interesting discussion about Dual Eligible Marketing on SIMA this morning. Join SIMA for free to see the dialog. Lots of agents weighed in on some pretty good tips. I would post the link but I would need permission from each member involved in the conversation.