Meridian Updates to Reimbursement for Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC) for Wellcare Meridian Dual Align (HMO-DSNP) Members

Date: 04/14/26

Historically, Meridian has reimbursed services for Wellcare Meridian Dual Align (HMO-DSNP) members at 80% of the clinic Medicare rate on a Medicare claim and reimbursed the remainder of the Medicare rate on a Medicaid claim.

Based on recent clarification from Illinois HFS, effective October 1, 2025, Meridian has changed this reimbursement method to pay up-to the Medicaid rate on an Wellcare Meridian Dual Align (HMO-DSNP) claim.

Example
Medicare Clinic Rate is $180.51; Medicaid Clinic Rate is $162.52

Medicare Reimbursement
Medicare reimbursement at 80% of Medicare clinic rate = $180.51
Co-insurance amount (20%) = $36.10
Calculated payment of $144.41 ($180.51 minus $36.10)
((Sequestration 2%: $2.89 ($144.41 X .02))
Medicare amount paid to clinic = $141.52

Medicaid Reimbursement
Medicaid rate minus the Medicare calculated payment: $162.52 - $144.41 = $18.11

Please note, sequestration is not part of the Medicaid payment as it is a contractual obligation for Medicare. Medicaid’s cost sharing liability includes only the patient responsibility (deductible, copay, coinsurance) amount(s).

For questions, please contact your Provider Engagement representative.