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Lindsey Holden, EBS in Portage County, assisted a client in obtaining QMB. The client's spouse received an inheritance that caused her to lose SSI, Medicaid, and QMB. However, the main portion of the inheritance was real property in the spouse's name, only. This meant that the client could be eligible for MAPP, but because she did not qualify for premium-free Part A, she would be responsible for Part A and Part B premiums without QMB. The client's spouse intended to sell the property eventually, but was hesitant to do so that quickly. When Lindsey explained that she could become QMB eligible if the property was listed for sale, they contacted a realtor (a relative) who listed the property for them. Lindsey was able to show IM that the property was unavailable under MEH 16.2.2, and with assertive follow-through, the client's QMB was processed.
11/30/2023
Story #128
Marianne Johnson, EBS for Bayfield County, heard from the daughter of a nursing home resident who was facing a divestment penalty amounting to more than $41,000 for selling a parcel of land at less than fair market value. Marianne worked with the daughter and her local Information and Assistance specialist to submit documentation for an undue hardship waiver. The waiver was granted and the family was greatly relieved to have one less looming bill to worry about.
Monetary Impact = $41,000
10/31/2023
Story #122
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
Michelle Fellom, EBS in Chippewa County, recently helped a married couple avoid losing MAPP eligibility due to difficulties providing verification related to life insurance policies. Income Maintenance records were still showing their policies as available assets even though the policies had been cancelled years ago. With no home internet access and no family to help out, the couple was struggling to provide verification acceptable to the Consortium. Michelle tried calling the insurance company with the customers on the line, but the company refused to issue anything in writing to confirm the status of the policies. After a failed attempt at a four-way call with Consortium staff and the insurance company, Michelle eventually succeeded at getting the customers, the Consortium, and the insurance company on the line at the same time. With the verification requirement finally satisfied, the couple got to breathe a sigh of relief that their MAPP coverage would continue uninterrupted.
8/31/2023
Story #99
Mikayla Sorge, EBS of Wood County, helped a client keep his Medicare Savings Program benefit. During the Public Health Emergency, the client had been receiving MAPP and QMB. During the PHE, he had cashed out a pension and reported it to IM timely. During the PHE unwinding, he received notice that his renewal was scheduled for May 2024. This meant that he should continue to receive MAPP and QMB through this time. However, the client received a notice that due to his pension, he was now only eligible for SLMB+, and because a person cannot have SLMB+ and MAPP at the same time, he would need to choose one or the other. This was incorrect, however, because his benefits should remain unchanged until his renewal date. Mikayla contacted IM and was able to resolve the issue quickly without needing to escalate it with the ForwardHealth Partners Inbox.
7/27/2023
Story #97
Jenae Belmas, EBS of Marathon County, assisted a client through the Medicaid ALJ hearing process to finally get QMB backdating for her. The client came to Jenae in September 2022, because she became a lawful permanent resident (green card holder) and had reached her five continuous years of residency in the US. This means that she was now eligible for several benefits and wanted assistance enrolling. The client was going to be a dual eligible (Medicaid and Medicare), but she was going to have to pay a premium for Part A. However, as a dual eligible, she was eligible for QMB, which would cover premiums for both Part A and B. Jenae helped the client apply, knowing that the next step was contacting SSA and applying for “conditional enrollment" into Medicare, meaning, her Parts A and B would only begin when her QMB started, so that she wouldn't be on the hook for premium payments. Despite following all correct procedures, this did not happen. After many months of back and forth between IM and SSA, and an Administrative Law Judge hearing in June 2023, the ALJ determined that SSA had not acted timely and that QMB should be backdated according to her original application and eligibility date. An added layer was that this client did not speak English, so Jenae patiently steered this case forward while also working with the client's family members and interpreters.
6/29/2023
Story #96
Terri Esselman, EBS of Clark County, helped a client obtain Prior Authorization from Medicaid for partial dentures. The client's original dentist received the necessary prior authorization, but due to a series of staffing changes at her provider, the client was not made aware of the approval nor was the procedure scheduled. The prior authorization then lapsed (it was only effective for one year), and under the new dentist it was now being denied. The client came to Terri for help. It took months to get the provider and dentist to provide necessary records. Ultimately, the client requested a Fair Hearing. Terri's BSSA submitted a summary brief and a form signed by the new dentist, and Medicaid agreed to issue a new prior authorization without the need for a hearing. This client was having difficulty eating, had lost a significant amount of weight, and had stopped leaving the house due to her self-consciousness of her missing teeth. Terri's advocacy will make a tremendous difference in her life.
5/31/2023
Story #79
Nyna Frelich, EBS in Brown County, was successful in helping a 69-year-old woman save
thousands of dollars in medical bills. The client came to Nyna in December of 2022
for help with medical bills from a hospitalization the month prior. This client only
had Medicare Part A. She had several prescriptions that she could not afford after the
hospitalization and very high out-of-pocket medical expenses.
First, during OEP, Nyna helped her enroll into a Medicare Part D prescription drug
plan to use in the new year. Nyna also helped the client apply for EBD Medicaid with a
deductible. This client's deductible was about $4,500. Nyna helped the client submit
medical expenses to Economic Support (ES), but they did not apply the medical expenses
to her deductible in the correct order according to the MEH.
The way ES entered the medical expenses meant she would have had to pay the majority
of the deductible out-of-pocket, whereas if ES entered the expenses in the correct order,
she would not have. Nyna asked ES to reenter the order of the medical expenses, but they
refused. With the help of her BSSA, Nyna filed a fair hearing and typed an argument including
MEH references for how the medical expense should be entered to meet the deductible. ES
corrected the case before it went to hearing. Because ES reentered the order of the medical
expenses, the client's hospital bill remained unpaid by Medicaid. However, the client was
able to apply for financial assistance for those bills. Since the hospital was willing to
write off some of her medical expenses, the other medical providers were also willing to
write off her medical expenses. We were able to get much of the deductible amount written
off with financial assistance, and get the remainder covered by Medicaid.
In January, Nyna used the GEP to help the client apply for Part B and helped her enroll
into a MA plan. She is now fully covered with Medicare and will have Medicaid continuous
coverage through August 2023 due to the PHE. She will also have full LIS/extra help through
the 2024 calendar year. By working with Nyna, this client was able to save thousands of
dollars on past medical bills and become fully covered for any future medical expenses as well.
Monetary Impact = $4,500
5/31/2023
Story #77
Kenton Zink, EBS in Dane County, recently met with a farmer who had lost QMB eligibility and had fallen behind on Medicare premiums. He had also received confusing letters telling him that he had lost BadgerCare coverage even though he continued to be eligible under Public Health Emergency rules. Amidst all the concern and confusion over his health insurance coverage, the client had been delaying reconstructive oral surgery to help repair damage from cancer treatments. Kenton worked with the Medicaid Buy-In Analyst to reestablish premium payments through the Medicare Savings Programs, helped reassure the client that his BadgerCare coverage remained in place so he could proceed with reconstructive care, and helped the client get approved for MAPP so that he will have reliable secondary coverage when his BadgerCare eligibility ends.
2/28/2023
Story #63
Pam Fuchs, EBS in Sauk County, helped a client who mysteriously lost QMB early in the pandemic. The client applied for benefits in February 2020, and she was confirmed eligible for QMB in March 2020, which meant that QMB began on April 1, 2020. However, the client's QMB benefits ended as of April 30, 2020, despite the federal rules that required states to maintain continuous coverage for people enrolled in Medicaid programs. Because the client had not paid her Part B premiums, she was disenrolled from Part B. Pam emailed the ForwardHealth Partners Inbox, and after following up several times, she learned that the client's QMB benefits should not have ended. The client was reenrolled in QMB as of May 1, 2020, which meant that she would be reenrolled in Part B as of that date, and the state would pay her retroactive Part B premiums.
5/1/2020
Story #62
Jodi Kautzer, EBS in Calumet County, assisted a 61-year-old client with her recently deceased husband's outstanding medical bills of almost $12,000. Jodi was doing a benefits checkup for the client when she mentioned that she was feeling stressed about her recently deceased husband's medical bills that were about to go into collections. Jodi contacted her BSSA first to see if it was okay to help in this instance since EBS are typically not able to work with the estates of clients who are deceased. Jodi's BSSA gave permission to assist in this limited circumstance. Jodi discovered that the spouse was eligible for Medicaid at the time services were rendered, but the provider had not billed Medicaid. Instead, the provider was just going to send the bill to collections. Jodi worked the medical provider to verify Medicaid eligibility and advocated to have the outstanding bills correctly billed to Medicaid. Almost $12,000 in medical bills ended up being covered in full.
Monetary Impact = $12,000
2/22/2023
Story #60
In July, Megan Girardy, EBS in Jackson County, met with a man who had recently entered into home hospice after surviving four years with stage four prostate cancer. They discussed the process of applying for disability benefits and began filing for early retirement benefits. The local SSA field office representative proved very helpful and began the process of filing for survivor benefits and designating the client's wife as representative payee for their two children. Megan helped the client complete a compassionate allowance request in August. At each visit along the way, they spent time discussing family, going through old photos, sharing hunting stories, and learning about his family's history. When the client passed away in late October, Megan was invited by the family to come to their home to assist with the notification process. After she arrived, his wife showed Megan that she had received notice that benefits were approved with a back payment award of more than $18,000, which the family later used to cover funeral expenses. Megan received a hand-written thank you note with the client's signature, an invitation to his celebration of life, and an open pass to his hunting cabin to continue sharing stories with his family.
Monetary Impact = $18,000
10/31/2022
Story #43
Kenton Zink, EBS in Dane County, helped a client get nursing home care covered by Medicaid. The client was covered by MAPP when she went into the nursing home. She initially elected hospice benefits but later revoked the hospice election when her condition improved. She then returned to full benefit coverage under MAPP. However, rather than bill Medicaid for the remainder of her stay, the nursing home billed the client directly, threatened collections, and even pursued her family members for payment. When questioned why the claim had not been submitted to Medicaid, it turned out that the nursing home billing office mistakenly thought that it was not allowed to bill Medicaid due to specific procedural requirements. Medicaid requires a nursing home to submit a level of care request when a resident revokes a hospice election and continues to reside in the nursing home. The billing staff thought that a level of care request could only be submitted for a person enrolled in long-term care Medicaid. With some advocacy from Kenton, the nursing home agreed to submit the claim to MAPP and the entire stay was covered, saving the client from more than $30,000 of debt.
Monetary Impact = $30,000
11/30/2022
Story #41
Tiffany Scully, EBS in Dane County, also assisted a 63-year-old client with a good cause late appeal for an SSDI appeal. (Note: EBS typically do not help with SSDI appeals, but Tiffany got permission from her BSSA to assist in this narrow circumstance). The client was referred to the EBS Program by a nurse practitioner at a local cancer treatment clinic who tried to assist him with a phone appointment to apply for disability, but they were unable to get through to the claims rep due to phone issues and missed their scheduled appointment. When Tiffany and the client contacted the Madison SSA FO to reschedule, the claims rep informed them that the record showed the client already applied for SSDI in August 2021, based on a history of seizures. His claim was denied in March 2022. The client did not recall ever applying for SSDI, even though the forms had been signed by him, and he never received the denial notice. Tiffany explained that while the original claim was still pending, in November 2021, the client had been diagnosed with metastatic melanoma. During the call with SSA, the claims rep consulted with the FO manager who recommended submitting a good cause late appeal rather than a new disability application. With the client's permission, Tiffany consulted with the nurse practitioner at the cancer clinic who confirmed that the client met and exceeded the criteria under the compassionate allowance listing for skin malignant melanoma with metastases. After consulting with her program attorney, Tiffany met with the client and completed the necessary forms to request the good cause appeal, then faxed everything to the Madison FO and indicated that it was a TERI case. After making numerous calls to the FO over the course of two months requesting an update on when the claim would be sent to the DDB, Tiffany utilized the escalation process, and the area work incentives coordinator ensured that this process was completed. Within a few days of receiving the claim, the DDB issued a favorable decision which the area work incentives coordinator communicated to the EBS. The client is very pleased as his monthly Social Security benefit increased significantly under SSDI. Prior to the appeal, he had been receiving early retirement benefits, and, after paying his rent each month, he had less than $200 remaining for his other living expenses, making it difficult to make ends meet.
10/30/2022
Story #38
Nyna Frelich, EBS in Brown County, recently helped a client get approved for Family Care, allowing the family to keep all of their assets without having to spend any down, thereby saving the family over $150,000. The couple's countable assets were around $160k, so they would have to spend down to half. However, Nyna discovered that the couple's long-term care insurance policy had been paying for care and, that after the asset assessment, if they continued with the application for Medicaid, any amount the LTC insurance policy paid out (about $100k) would be disregarded pursuant to MEH 35.1. Essentially, they wouldn't have to spend down anymore because the $100k exemption already put them below the asset limit. This made it so that the client could get Family Care services right away without spending down any more than necessary.
Monetary Impact = $150,000
9/30/2022
Story #33
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
Emily Reuter, EBS in Grant County, recently won a Medicaid fair hearing about a case involving a divestment. The client's husband had advanced dementia, and although she had been providing nearly all of his care in their home, his condition had worsened, and she was unable to provide 24-hour care herself. The ADRC helped with the Family Care application, but the client had sold the couple's home to their grandson a few months before because they could not afford to keep paying the mortgage. The client explained that she was worried that if they lost their home to foreclosure, they would have nowhere to live. The couple was paying rent to their grandson to continue living there. The sale price of the home was equal to the outstanding balance on the mortgage, which was a little less than the assessed value. Income Maintenance, however, used the current Zestimate on Zillow to set the fair market value for the house, turning what should've been a $12,000 divestment penalty into a $111,000 divestment! IM then denied a subsequent undue hardship waiver request, saying that the grandson could just give the house back. Emily helped the clients request a fair hearing to dispute IM's determination of the fair market value of the house and argue that the sale was not done to qualify for Medicaid. The administrative law judge agreed that IM's use of the Zestimate was inappropriate and that the sale of the house was an allowed divestment because it was not done with the intent to qualify for Medicare. Thanks to Emily's hard work and advocacy, the client's husband is now getting the care he needs!
Monetary Impact = $100,000
8/31/2022
Story #24
Mindy Shrader, EBS in Sauk County, recently received a favorable decision from SSA on an appeal of a client’s Medicare start date. The client was QMB eligible, and Mindy helped the client request conditional enrollment into Part A in April 2021. Her QMB enrollment started June 1, 2021. Unfortunately, SSA ignored the conditional enrollment request, and started the client’s Medicare before her QMB started, even though the client did not have a SEP and was not in a Medicare enrollment period. The client is not eligible for premium-free Part A, so this left her with a very large premium bill. When SSA was unable to fix this, Mindy helped the client request reconsideration. After many months in the processing center, the client received an updated Medicare card with the correct start dates and a letter explaining that she no longer owed any Medicare premiums.
Monetary Impact = $510
5/31/2022
Story #14
Jessica Flores, EBS in Door County, recently worked to informally resolve a case involving Medicaid patient liability. The client had Intuitional Medicaid since mid-2020. In April 2022, he received his first bill from the nursing home for multiple months of his patient liability costs. This was alarming to his wife and his daughter, who is also his POA, because they had not received notice. They tried contacting the consortium but were unable to get the issue resolved. The EBS worked to find that due to workarounds and out-of-the-norm COVID-19 processing, the CARES system never kicked a letter out to the member, and therefore, he was never notified of his patient liability obligations properly. The EBS contacted the IM worker assigned to this member’s case and they discussed options that he may have. Since the error was caused by agency processing, IM agreed to manually override his liability billing for January-April 2022. This resulted in saving him over $6,700.
Monetary Impact = $6,700
5/31/2022
Story #13