MEDICARE MEMBERS: PROTECT YOURSELF AGAINST MEDICARE FRAUD AND IDENTIFY THEFT! THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OFFICE OF INSPECTOR GENERAL IS ALERTING THE PUBLIC ABOUT A FRAUD SCHEME INVOLVING GENETIC TESTING. LEARN HOW TO PROTECT YOURSELF.
Frequently Asked Questions
Someone you allow to act for you, such as a friend or family member.
A percentage of the total cost of the service. These payments may be paid at the doctor’s office or after billing.
A fixed amount that’s your portion to pay for a covered healthcare service, usually paid at the time you get the service.
Cost-sharing is what you pay when you get medications or healthcare services.
The amount you owe for covered healthcare services before your health insurance plan begins to pay. For example, if your deductible is $200 your plan won’t pay anything until you’ve paid $200 for covered services.
Special equipment your doctor may order for you for medical reasons. It can be things like walkers or wheelchairs.
A document you receive as a new member that gives you details about what the plan covers, how much you pay and more.
A statement explaining any treatments or services that you recently received. The EOB usually includes the date(s) of service, provider(s), fees, amounts you may be responsible for and any adjustments.
The list of brand name and generic prescription drugs that a health plan covers for its members.
A drug store that works with the plan to provide services to members at lower rates.
Medications, vitamins and other healthcare items that are available without a prescription.
A health plan option that lets you use doctors and hospitals outside the plan for an additional cost.
A legal form that allows someone else to act for you. You can create a power of attorney for times when you may be unable to make your own health care decisions.
A premium is the amount you pay for your health plan, in order to receive all of your benefits.
A doctor or other healthcare provider who gives, coordinates or helps you access the range of healthcare services you need.
An OK from the plan before a member gets a healthcare service. Your Medicare drug plan may require prior authorization for certain drugs.
Registered Nurses have completed specialized education and training, plus meet licensing requirements for the state that they practice in.
A doctor trained in a specific area of medicine. Your primary doctor might refer you to a specialist.
A Medicare Advantage HMO plan is offered by a private company that contracts with Medicare to provide you with all your Medicare Part A (hospital) and Part B (medical) benefits. It is a health maintenance organization, or HMO. That means it provides care through a network of providers. Care is coordinated through the primary care physician (PCP), who may refer people to specialists as needed. Referrals are generally required to see specialists.
A Medicare Advantage HMO POS also provides care through a network of providers. However, it includes a point of service (POS) feature, which allows members to receive health care services outside of the network with authorization from the plan, although use of providers within the network is encouraged.
A network is a group of doctors and other health care professionals, medical groups, hospitals and other health care facilities that have an agreement with us to deliver covered services to members in our plan. The providers in our network generally bill us directly for care they give you. When you see a network provider, you usually pay only your share of the cost for their services.
We want you to make an informed decision about your Medicare health plan. That’s why we created a glossary.
Yes. However, as long as you are a member of our plan you must use your Wellcare Member ID Medicare card to get covered medical services (with the exception of clinical research studies and hospice services). Keep Wellcare Member ID Medicare card in a safe place in case you need it later. If your Wellcare ID card is damaged, lost or stolen, contact us right away and we will send you a new card.
Of course. You do not lose your Medicare benefits when you join our plan. However, there are limits on when and how often you can change your Medicare Advantage plan. Contact Us to find out more.
You can get service authorizations from you primary care provider (PCP) or from specialists you're referred to.
Our plans are required to cover all services and procedures that are covered by Original Medicare. However, our plans also offer extra benefits not covered by Original Medicare, which may include routine dental, routine hearing, routine vision and prescription drug coverage. Please note that, as a member of our plan, your use/participation in a limited number of services, such as clinical research studies and hospice services, will be paid for directly by Medicare. Becoming a member of our plan does not make you ineligible to receive these services.
You have the right to emergency care, when needed, anywhere in the United States and without pre-approval from us.
An HMO or HMO POS plan is not required to pay for services that are not medically necessary under Medicare. However, Wellcare plans do pay for additional benefits not covered by Original Medicare. If you receive a service that is not covered by our plan, you are responsible for the cost of that service. If you are not sure whether a service is covered, you have the right to call us and ask for an advance decision.
Our plans work just like a traditional health insurance. Just show your Wellcare Member ID card (instead of your Medicare card) at the doctor's office. You may have a co-payment due at that time.
If your doctor or health care provider would like more information about Wellcare, ask him or her to contact us. Our Customer Service representatives are ready to answer questions.
Once you are enrolled, you cannot be disqualified for any medical condition. However, if you move out of our service area or commit fraud, Wellcare reserves the right to disenroll you. All Medicare Advantage plans commit to their members for a full year. Each year, Wellcare decides whether to continue a plan for another year. Even if a Medicare Advantage Plan is discontinued at the end of a benefit year, you will not lose Medicare coverage. If your plan is discontinued, Wellcare must notify you in writing at least 60 days before your coverage ends. The letter will explain your other options for Medicare coverage in your area.
Yes. When you join a Wellcare plan, you must continue to pay your Medicare Part B premium unless it's paid for you by Medicaid or another third party. If you meet certain eligibility requirements for both Medicare and Medicaid, your Part B premium may be covered in full. Some of Wellcare's Plans help by reducing your Medicare Part B premium. The reduction is set up by Medicare and administered through the Social Security Administration (SSA). Depending on how you pay your Medicare Part B premium, your reduction may be credited to your Social Security check or credited on your Medicare Part B premium statement. Reductions may take several months to be issued. However, you will receive a full credit.
Our plans are designed to save you money by offering lower copays and coinsurances when you seek care within our network of providers. An in network PCP will be able to work more directly with your plan to coordinate your care.
Network providers will also save you time by billing our plan for your services. You pay your copays, coinsurance, or deductibles, if applicable, for covered services when you arrive for a visit.
Network PCPs and specialists will work with our plan directly to determine if services are covered, or if they need authorization before you have the service. You can go in for treatment knowing your care is covered.
Yes, a Preferred Provider Organization (PPO) allows members the flexibility to go to doctors, specialists or hospitals that are not in the plan's network list, however they will usually pay a higher cost share. However, out of network providers must be eligible to participate in Medicare and providers that are not in network with your plan are under no obligation to treat our members, except in emergencies.
PPO plans give you the freedom to choose providers and facilities that are not in our network, but there are things to know before choosing an out-of-network provider:
If your provider charges higher for a service than what Medicare allows, you will be responsible for paying that extra amount in addition to the applicable cost-share amounts.
Out-of-network providers are under no obligation to see our members. When you schedule your appointment, make sure they know the insurance you have and are willing to see you.
Some providers have opted out of the Medicare Program. If you receive services from these providers you may be responsible for the full cost of the service or visit, with the exception of emergency care.
Your out-of-network provider may choose not to bill our plan for you and may ask you to pay for services up front. If this happens, you can fill out a claim form and submit it to us with a copy of the bill and any documentation you have about payments you have made. Information on how to file a claim can be found in the Evidence of Coverage online.
Out-of-network providers are not required to get authorization from the plan for your services ahead of time. If you have a service or a visit with an out-of-network provider that is reviewed by the plan after the fact and that service does not meet medical-necessity guidelines, you may be responsible for the full cost of the service. You can ask for a pre-visit coverage decision to confirm the services you are getting are covered and are medically necessary.
PPOs plans provide reimbursement for medically necessary services, regardless if the benefits/services are provided in or out of network. Medical necessity must be established whether the member chooses an in network or out of network provider.
You are not required to choose a PCP on the PPO plan, but we highly recommend you select a primary care physician when you enroll to get the most out of your healthcare. You can pick an in-network or out-of-network PCP, but an in-network PCP will be able to work more directly with your plan to coordinate your care.
Referrals and pre-authorizations for out of network providers are not required, although it is highly encouraged. This applies to services obtained from providers in and out of the member’s state.
PPO members can see any Medicare provider within the US and territories.
Under PPO plans there are two different limits on what you have to pay out-of-pocket for covered medical services:
- In Network Maximum out of pocket: Amount you pay during calendar year for covered Medicare Part A/B services received from in-network providers
- Combined Maximum out of pocket: Amount you pay during calendar year for covered Medicare Part A/B services received from both in-network and out-of-network providers
This will apply if a member goes to an out-of-network provider, regardless if it is within or outside the member's state. If the doctor/provider they visited is a [NAME} participating provider who is outside their state, Out-of-Network cost share will still apply. Additionally, authorization and referral rules do not change whether in or out of state.
Ask your Provider to bill your plan first. However, if you have already paid, you can request reimbursement by filling out a claim form and submitting it to us with a copy of the bill and any documentation you have about payments you have made. Information on how to file a claim can be found in the Evidence of Coverage online.
Yes! Visit our Contact Us page, select your state and give us a call at the number provided. We are happy to help!
365 days from date of service.
30 days (once all required information has been received)
Out of network providers are not required to obtain authorization from the plan prior for your services ahead of time. If you have a service or a visit with an out of network provider that is reviewed by the plan after the fact and that service does not meet medical-necessity guidelines, you may be responsible for the full cost of the service. You can ask for a pre visit coverage decision to confirm the services you are getting are covered and are medically necessary
Visit our Find a Provider page
- Enter your street address, ZIP code or county
- Select your network (the plan that you’re enrolled in)
- Search by name, specialty, and more OR choose a category to search from
With your PPO plan, you have the freedom to choose doctors, specialist and hospitals that are not in network. Your plan does not require a referral to see specialists, but please keep in mind that some specialists may request one. If you would like assistance in confirming if a referral is preferred by your new specialist, please give us a call and we can contact their office to confirm that they are willing to accept our plan for you and to advise them that your plan will not require a referral.
With your PPO plan, you have the freedom to choose doctors, specialist and hospitals that are not in network. Your plan does not require a referral to see specialists, but please keep in mind that some specialists may request one. You can call your PCP office and advise them that even though you have a PPO plan, your specialist is requesting that your PCP fax over a referral order. Alternatively, you can call us and we can assist you with this process.
Members can register for an account by taking the following steps:
- Enter the following information
- First and Last Name
2. Language Preference (English or Spanish)
3. Create a secure password
The Home Page allows you to do any of the following:
- Print a temporary/request a new ID card
- Add your ID card to an Apple Wallet
- Change a primary care provider
- Make a Payment (where applicable)
- Contact a nurse through completing a form, which is submitted to the NurseWise
- A clinical nurse will review the request and respond within 24 hours of the initial request
- Send a secure message to the health plan
- Health Plan Member Services Department staff responds to all requests within one business day
- My Benefits and Cost Sharing
- View plan deductible and out of pocket limits
- Let Us Know (About Your Health) for access to submitting and/or viewing member health assessments
- Reward Program for viewing member rewards account balance and activity
- View important information, including:
- Care Gaps
- Update your contact information