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Angie Pietroske, EBS in Kewaunee County, was successful in assisting an 87-year-old woman to get back into her 5-star Medicare Advantage plan that worked well for her. During OEP of 2022, Angie had helped this client enroll in an Advantage Plan that worked well for the client and gave her the flexibility to go in and out of network with no change in cost. However, the client, who is in early stages of dementia, received a call from an agent from another company who switched her to a different plan. Angie worked with Alyssa Kulpa to file a complaint through the CTM to undo the enrollment and get her back in her plan retroactively. After less than a week, the CTM was resolved, and the client was back in her old plan.
10/31/2023
Story #117
Pam Fuchs, EBS in Sauk County, helped a client successfully request retroactive enrollment into her preferred Advantage plan after an agent contacted the client on Facebook and then showed up at her home to enroll her in a Special Needs Plan for dual eligibles (D-SNP) without her consent. The agent even told the client that he “deals with the ADRC." When the client realized that none of her providers were in the D-SNP's network and that she would not have coverage for an upcoming surgery, she called the ADRC Director to complain. The ADRC Director assured the client that the agent was not affiliated with the ADRC and referred her to Pam for assistance, while doing some detective work on her own to learn the agent's name and agency address (and that the local police department had heard about him doing this in the past!). Pam worked with Alyssa Kulpa to file a CTM complaint, which was resolved within 24 hours.
8/30/2023
Story #109
Pierce County EBS, Jane White, was contacted by a client who had fallen behind on premium payments for her Medicare cost plan for the months of January, February, and March. She paid her premiums for all three months on the last day of March but did not make her April premium payment at that time. In mid-May, the client received a letter from her plan stating that because she had not yet made her April premium payment she would be retroactively disenrolled effective back to May 1. The client had important medical appointments coming up toward the end of May and was concerned about having to pay traditional Medicare coinsurance. Jane contacted her program attorney who researched involuntary disenrollment requirements for Medicare cost plans. While it appeared that the plan was probably following Medicare rules, it also appeared that the client might be able to reinstate her enrollment for good cause. Jane worked with the client and representatives from the plan to explain the circumstances and the entitlement to good cause reinstatement. Plan representatives reviewed the information and decided that the client met the good cause conditions to allow reinstatement, and that the disenrollment should not have happened in the first place once she had paid up her past due premiums. As a result, the client avoided a gap in coverage and the extra costs that would have come with being disenrolled into traditional Medicare.
5/31/2023
Story #78
Emily Reuter helped another client untangle a complicated Part D enrollment mess. The client had been disenrolled from his Part D plan when another beneficiary with the same first and last name chose a new plan during the 2022 fall Open Enrollment Period. Medicare and both plans had mixed the two beneficiaries up even though they had different middle names and Medicare ID numbers! The CTM took over a month to resolve, as Medicare and the plans were still confused about the situation, but the client was eventually reenrolled into his plan.
5/31/2023
Story #74
In November, Laura Killian, EBS in Douglas County, helped a client enrolled in QMB submit a request to disenroll from her Medicare Advantage plan. Even though the client submitted the disenrollment request during the Annual Election Period, the plan denied the request on the grounds that she was not allowed to use the Special Enrollment Period for Dual-Eligible Individuals during the fourth quarter of the year. Requiring the client to wait until January to submit a new disenrollment request would have meant extra months of premiums that the client could not afford. Laura contacted the plan and CMS to discuss the situation and the plan ultimately agreed that the disenrollment request would be treated as an AEP election request and would become effective as of December 31.
1/31/2023
Story #59
Mary Rheinschmidt, EBS in Lincoln County, helped a client reduce her divestment penalty period by 104 days! The client came to Mary to apply for LTC Medicaid. It was first discovered that her long-term burial insurance was not checked as irrevocable, so the client was over the asset limit. Mary quickly helped resolve this with the funeral home and submit the documentation to the Consortium. The next issue was the client had made numerous loans to family members within the lookback period. All of the loans were verbal, and only some had been paid back in full. Mary helped gather all of the client's bank statements, copies of checks, and client's notes for the past five years, and painstakingly reviewed them with her supervising attorney. Mary also helped the client request some additional repayments by the family members, further reducing the total divested amount. IM had originally assessed a divestment penalty period of 168 days, but with Mary's detailed work, they were able to reduce the penalty period to 64 days. Because the client had her functional screen in June, her penalty period had already been served, and her Family Care started in August. The family was thrilled.
8/31/2022
Story #26