Dear Health Care Provider or Business Office Manager:

We are proud to offer various health and wellness benefit plans for your Medicare patients, many of whom are also eligible for Medicaid due to limited income. Managing the co-payments for these patients is a unique process, and we at Evercare understand those issues. As you may know, full-benefit dual eligible members and Qualified Medicare Beneficiaries (QMBs) are not responsible for Medicare cost-sharing under Title XIX of the Social Security Act. For those qualified patients, such as dual eligible members in Evercare Plans for People with Limited Incomes, you may bill Evercare and then submit the secondary claim to the member’s Medicaid coverage provider. The combination of payment from Evercare as well as any payment from the Medicaid coverage provider should be considered payment in full. It is our goal to minimize the financial obligation of these members thus allowing your office/facility to avoid costly collection and other administrative activities.

To simplify the administrative process for your office/facility, effective August 1, 2008, Evercare will implement a 30-day cost-sharing grace period for Evercare members covered under Evercare Plans for People with Limited Incomes. This new program is a responseto a requirement by the Centers for Medicare & Medicaid Services (CMS) that states any Special Needs Plans offering a dual eligible plan must provide a cost-sharing grace period so that members who lose their Medicaid eligibility are temporarily given a grace period in which to both re-enroll in their Medicaid benefits and remain free from the financial burden of cost-sharing.

What this means to your office/facility is that Evercare will pay the member’s cost-share for services rendered by your office/facilityduring a 30-day period of time aftera member loses his or her Medicaid eligibility. A brief summary of the process involved is noted below:

  • Submit a primary claim to Evercare and wait for Explanation of Benefits (EOB) to be returned
  • Submit a secondary claim including the Evercare EOB to Medicaid coverage provider
  • If you receive a denial from the Medicaid coverage provider for lack of eligibility, contact the Evercare Customer Service Department at the number noted below.
  • Evercare will confirm the member’s loss of Medicaid coverage, determine if the member is within 30-day cost-sharing grace period (an EOB showing denial of your secondary claim may be required), and re-process your claim for the Evercare cost-share amount, if applicable
  • PLEASE NOTE: Most dual eligible members will regain their Medicaid coverage during the 30-day grace period, so you should not bill the member for future dates of service unless it is again determined that they have lost their coverage.

Should you have any further questions about this CMS-required program, we have included a Frequently Asked Questions document that should answer many of your questions. Also, you may contact the Evercare Customer Service Department at 877-842-3210 (866-622-8054 in Hawaii) if you view member benefits on unitedhealthcareonline.com, 888-666-1353 if you view member benefits on oxhp.com, or 800-542-8789 if you view member benefits on pacificare.com. If you participate in a capitated medical group, please contact your Evercare representative for further information.

Thank you for your continued participation in our health plans and service to our members. We value that relationship and hope that this CMS-required program will be of great value to both the member as well as your office/facility.

Sincerely,

Evercare Provider Relations