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Provider Digest | Volume 168

Date: 04/30/25

Update on Wellcare Skilled Home Health and Post-Acute Facility Network Services

On April 1, 2025, Wellcare By Health Net (Wellcare),Wellcare By Trillium Advantage (Wellcare), tango, and WellSky announced the expansion of our partnership to Oregon, effective July 1, 2025. You can review the full details of our original announcement in the Update on Wellcare Skilled Home Health and Post-Acute Facility Network Services notification (PDF). We are sharing this information again as a helpful reference as we approach July 1, 2025, to ensure our provider partners have the information they need to enable a coordinated transition and a positive experience.

The tango – WellSky solution brings a first of its kind partnership to the market to use the leading technology and services capabilities of WellSky and the skilled home health enablement expertise of tango to deliver a fully integrated proactive post-acute care program that streamlines and coordinates a cohesive provider and member experience across the post-acute continuum.

The agreement signifies the appointment of tango – WellSky as the delegated manager for Wellcare's skilled home health and post-acute care benefits related to skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals. This expanded partnership is specific to Wellcare’s Medicare Advantage members.

The expanded partnership encompasses several key components that aim to enhance the quality and delivery of skilled home health and post-acute care for Wellcare’s members:

  1. Referral Coordination and Authorization Management for Post-Acute Facilities:
    • Efficient management of referrals, referral coordination, and authorizations.
  2. Network Development and Management for Skilled Home Health:
    • Developing, contracting, maintaining, and credentialing a robust network of skilled home health care providers.
  3. Claims Payment for Skilled Home Health:
    • Timely and accurate claims payment for the services provided for skilled home health.
  4. Wellcare will continue to directly contract and pay claims for Post-Acute Facilities

To learn more, please view the Update on Wellcare Skilled Home Health and Post-Acute Facility Network Services notification (PDF).

If you have any questions, please contact your assigned Wellcare Provider Engagement Representative:

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Reminder: OHA Appointment Access Requirements for Trillium Medicaid Providers

To ensure access to care and improved health outcomes, Trillium Medicaid providers are contractually obligated to comply with the Oregon Health Authority access requirements. Please review the below access requirements and contact your dedicated Provider Engagement Representative if you have any questions.

OHA Appointment Access Requirements

Providers shall make Covered Services available 24 hours a day, seven (7) days a week. For after-hours care, Providers are to have an on-call physician/nurse or a messaging system advising members how to seek after-hours care.
 
All Providers are required to prioritize timely access for prioritized population members:

  • Pregnant women
  • Children ages birth through (5) years

Physical Health (Primary Care and Specialists) Appointment Access Standards

 Appointment Type & Access Standard

  • Emergency: Immediate or referred to an emergency department depending on the member’s condition
  • Urgent: Within 72 hours or as indicated in initial screening and in accordance with OAR 410-141-3840 (48 hours NCQA)
  • Well Care (Routine): Within 4 weeks, or as otherwise required by applicable care coordination rules including OAR 410-141-3860- 410-141-3870

Behavioral Health (Non-Specialty/Non-Priority Populations) Appointment Access Standards

 Appointment Type & Access Standard

  • Urgent Care: Within 24 hours
  • Routine Care: Assessment within seven (7) days of the request, with a second appointment occurring as clinically appropriate.

Specialty Behavioral Health (Priority Populations) Appointment Access Standards

Priority access order for entry per OAR 309-019-0135:

  1. Individuals who are pregnant and using substances intravenously
  2. Individuals who are pregnant
  3. Individuals who are using substances intravenously; and
  4. Individuals or families with dependent children.

* If a timeframe cannot be met due to lack of capacity, the member must be placed on a waitlist and provided interim services within 72 hours of being put on a waitlist. Interim services must be provided.

Appointment Type & Access Standard

  • Urgent Care: Within 24 hours
  • Opioid use disorder: Assessment and entry within 72 hours
  • Medication assisted treatment: As quickly as possible, not to exceed 72 hours for assessment and entry
  • IV drug users including heroin: Immediate assessment and entry. Admission for treatment in a residential level of care is required within fourteen (14) days of request, or, if interim series are necessary due to capacity restrictions, admission must commence within 120 days from placement on a waitlist
  • Children with serious emotional disturbance (as defined in OAR 410-141-3500): Any limits that the Authority may specify in the contract or in sub regulatory guidance
  • Pregnant women, veterans and their families, women with children, unpaid caregivers, families, and children ages birth through five years, individuals with HIV/AIDS or tuberculosis, individuals at the risk of first episode psychosis and the I/DD population: Immediate assessment and entry. If interim services are necessary due to capacity restrictions, treatment at appropriate level of care must commence within 120 days from placement on a waitlist

* For additional information, see OAR 410-141-3840, OAR 410-141-3860, OAR 410-141-3870, and OAR 309-019-0135.

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