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I met with a consumer who was on several medications and wanted to compare his current Part D plan with other plans for 2025. The premium for his current plan was going up and removing four of his medications from thier formulary. The Medicare.gov Planfinder tool estimated that if he stayed with his current plan, his cost would be over $200,000 between the pharmacy and premium in 2025. After we ran the Medicare.gov plan options and double-checked the plan's formulary on thier website, we were able to find a plan that covered all but one of his medications. He selected this new plan, and it will cost him around $5,000 in 2025, and this includes the one medication outside of the formulary. He was pleased to find a plan to cover so many of his medications.
Monetary Impact = $195,000
11/15/2024
Story #133
Amanda Higgins, EBS in Dodge County, recently helped a client who was initially referred to her for help with insurance issues. The client is not eligible for premium-free Part A and had a Marketplace plan with a high deductible. Moreover, she was facing bills of over $90,000 after receiving out-of-network care for a stroke. Amanda helped the client apply for financial assistance, which resulted in a significant percentage of the bills being written off. Amanda then helped the client set up a payment plan for the remainder of the amount owed. In addition, Amanda counseled the client about choosing a 2024 Marketplace plan that would be a better fit for her care needs, and the client met with an agent to enroll in a plan for next year. Finally, although the client was over the asset limit for Medicaid, thanks to Amanda's assistance, the client is now receiving $171/month in FoodShare.
11/30/2023
Story #130
Jenae Belmas, EBS in Marathon County, helped a client obtain Medicare Part B benefits. Earlier this summer, the client was released from incarceration and immediately went to SSA to restart his Social Security retirement payments and his Medicare Part B. The SSA worker, however, told him he had to wait until the GEP in January, 2024. The client assumed he was receiving correct information from SSA, and did not seek Jenae's assistance until he was having problems getting a Medicare Advantage Plan in place. Jenae helped the client point out to SSA that it should have used the new Special Enrollment Period for recently incarcerated individuals. SSA kept telling the client it was in the process of reinstating his Part B, but each time Jenae checked in, his status had not changed. Finally, the client had a medical emergency and would not get treatment because he feared his lack of health coverage. Jenae contacted her supervising attorney, who escalated the issue to the highest levels at SSA. It ultimately took six months and vigorous advocacy, but the client finally got the benefits he was entitled to so he could receive the care he needed.
11/30/2023
Story #129
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
Jennie Bowers in St. Croix County helped a client with a successful appeal following the denial of a medical procedure. Her client had had prostate cancer and had developed some severe and unpleasant side effects from the medications used to treat the condition. The client worked with his doctor for over a year to try and come up with alternate, non-surgical ways of treating the problems, but was unsuccessful. He had excess skin that had swelled up near his prostate area causing painful urination, difficulty maintaining cleanliness, and painful walking (due to rubbing). Ultimately, his doctors determined surgery was necessary to correct the problem. Medicare initially denied part of the surgical procedure as being “cosmetic." However, by obtaining medical records showing the client's many trips to the doctor regarding the problem as well as his many unsuccessful attempts at treating the issue using less invasive techniques, Jennie was able to demonstrate to Medicare that this surgery was entirely medically necessary for treatment of his pain and condition. The client agreed to let Jennie send in pictures of the condition (taken by his doctor) along with the appeal so that the reviewers could see the scope of the problems that the client had been dealing with. As they say, a picture is worth a thousand words! Upon seeing the pictures and reading the appeal, Medicare agreed that the surgery was not cosmetic, and approved coverage for the remaining $5,000 balance.
Monetary Impact: $5,000
10/31/2023
Story #127
Jessica Smith, EBS in Eau Claire County, helped a client successfully appeal the denial of her gastrointestinal testing. The client was 76 years old and experiencing symptoms initially diagnosed as mild food poisoning and expected to pass within a day or so. However, when her symptoms did not improve after a couple of days and actually worsened, she returned to her doctor's office and insisted on additional testing. Good thing the client was persistent because she actually tested positive for C difficile toxin, commonly known as “C-diff." The client received a phone call from an epidemiologist at Mayo Hospital in Rochester, Minnesota with instructions about starting a strong antibiotic regimen immediately due to the serious implications of the infection. Medicare denied the test as unnecessary; however, upon investigating the facts, Jessica found out that the client had met three of the five conditions in the Medicare Local Coverage Determination (LCD), even though it was only necessary to have met one of those five conditions in order for Medicare to cover the test. Jessica obtained a copy of the patient's medical records regarding the need for the test and sent in the appeal. Medicare agreed that the test was warranted and paid for the $816 claim. And since the client also had a supplement, she did not owe anything for the test after it was covered by Medicare.
Monetary Impact: $816
10/31/20232
Story #126
Mary Velcich, EBS in Green County, recently helped a client with a Medicare Coordination of Benefits and Recovery case. The client had been involved in a car accident and received treatment for her injuries. Although her car insurance paid up to the policy coverage limit for medical expenses, the client needed additional care. Medicare believed that it had paid nearly $27,000 in conditional payments. Mary helped the client submit documentation showing that the car insurance could not pay any additional amount for her care and that all of the money from the insurance company had been paid directly to the hospital. Although the Benefits Coordination & Recovery Center sent another notice insisting that the client received a settlement because of the accident, Mary resubmitted the documentation from the insurance company, and the client finally received a notice saying that the issue had been resolved and that she did not owe Medicare any money.
Monetary Impact: $27,000
10/31/2023
Story #125
Karen Nichols, EBS for Burnett County, was recently contacted by a client who had received Medicare Summary Notices (MSNs) stating that certain claims were being denied based on records of an insurance payment stemming from a car accident that happened more than ten years ago. The Medicare Benefits Coordination & Recovery Center (BCRC) insisted on documentation from the insurance company showing that the case was closed, but when the client contacted the insurance company, she was told that the company did not keep records that long. Karen helped the client follow up with the insurance company and convinced them to send a letter to the BCRC. The insurance settlement is now cleared off the client's record, paving the way for Medicare coverage of claims exceeding $200,000.
Monetary Impact: $200,000
10/31/2023
Story #121
Kathryn Noll-Arias, EBS in Winnebago County, recently had two successful SNF appeals. The second client, an 84-year-old man, suffered a fall at home and fractured his left hip and left clavicle. After hospitalization, he was transferred to a SNF for rehabilitation. About four weeks later, the client's MA plan issued a denial for further SNF services; however, the client had not met his rehab goals and was not yet safe to return home. He continued to receive daily skilled therapies for another two weeks, and then his therapy was cut down to three days per week. Kathryn assisted the client with an appeal and after an ALJ hearing, the client got the additional two weeks covered.
10/31/2023
Story #120
Kathryn Noll-Arias, EBS in Winnebago County, recently had two successful SNF appeals. The first client, an 88-year-old man was in the hospital for meningitis and an infected hematoma from a fall. He was diagnosed with Methicillin-Sensitive Staphylococcus aureus (MSSA) and was started on an IV antibiotic. He was discharged to a SNF for rehabilitation and skilled nursing care for his wound and IV antibiotic. When his therapies were reduced from five days per week to three, the SNF issued a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) stating that Original Medicare would no longer cover his SNF stay. However, the client was still at a skilled level of care for his IV antibiotic. Kathryn assisted the client with appealing and after an ALJ hearing, received a fully favorable decision covering the client's entire stay at the SNF.
10/31/2023
Story #119
Jennifer Trasser, EBS in Outagamie County, assisted a 78-year-old woman to get her entire skilled nursing facility (SNF) stay fully covered. The client had a total knee replacement and was then discharged to the SNF for daily skilled rehabilitation. After only one week, the client's Medicare Advantage (MA) plan issued a denial stating that her SNF stay would no longer be covered; however, the client had not progressed enough at that point to be able to safely return home. She continued to get daily skilled therapies for an additional 10 days, made progress, and then was safe to return home. Jennifer assisted the client with the appeal and at the hearing, the client's MA plan agreed to full coverage of the client's stay at the SNF.
10/31/2023
Story #118
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
Ashley Greene, EBS in Crawford County, recently helped a client with a successful Medicare reconsideration. The client underwent surgery to remove skin growths that were interfering with his breathing and vision. Although Medicare paid the facility fee, the claim for the physician's services were denied. Ashley helped the client request a redetermination, which was unfavorable. Ashley then helped the client obtain additional records from his providers, including a letter from the doctor who performed the surgery as well as before and after pictures. This time, the decision was favorable!
9/29/2023
Story #116
Kathy Schultz, EBS of Langlade County, helped a client eliminate her Medicare Part D Late Enrollment Penalty. The client was assessed a Part D LEP because it did not have the information regarding her SeniorCare coverage. The client's friend had tried to help her appeal, but thought the Part D LEP was assessed because she was late on her Part D premium payments (which she was not). After receiving a denial, they came to Kathy, who helped her submit another appeal with the correct proof of SeniorCare coverage dates. C2C Solutions, however, gave this appeal a new number and denied due to it being past the appeal deadline. Kathy worked with her BSSA to draft a good cause late appeal based on the client's diligent work trying to resolve the issue since January. C2C Solutions ultimately agreed, and nine months later her LEP was removed.
9/29/2023
Story #112
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
Kathy Cummings, EBS in Columbia County, recently helped a client obtain coverage for a skilled nursing facility (SNF) stay after an Advantage plan denial. The client was expected to need 12 weeks of daily physical therapy and occupational therapy after a fall at home left her with a broken leg and ankle, but her Advantage plan denied coverage after only three weeks. As a result, the client discharged home from the SNF after only six weeks. Kathy worked with the client's family to obtain medical records and prepare for an ALJ hearing. The morning of the hearing, the client's family received a letter from the plan stating that the client's entire SNF stay would be covered!
Monetary Impact =
8/31/2023
Story #108
Mindy Shrader also helped a client receive a fully favorable Medicare appeal of a Skilled Nursing Facility (SNF) coverage denial. The client needed daily occupational therapy, physical therapy, and wound care after a surgery for a broken leg so that he could return home and begin chemotherapy. However, his Medicare Advantage Plan terminated coverage after only 16 days. Mindy helped the client's family obtain medical records and prepare for the ALJ hearing, which took place in February. However, when they had not received a decision in May, the BSSA called the ALJ's assistant, who said that the hearing decision had already been mailed but that she would fax a copy of the decision. When the decision still had not arrived weeks later, Mindy helped the client's family work with Sen. Baldwin's office to obtain a copy of the decision, which finally arrived via mail to the BSSA's office with a July postmark. The decision was fully favorable, giving the client an additional two-and-a-half weeks of coverage, and the client's family was thrilled!
Monetary Impact =
8/31/2023
Story #107
Jerri Sokol, EBS of Iron County, helped a client resolve a Medicare billing error totaling near $430. The client had received a blood test that tested for multiple upper respiratory conditions. When the client received his Medicare Summary Notice (MSN), the reasons for denial were confusing, and it was coded with a GY-modifier, which means statutorily not covered by Medicare. Researching the National and Local Coverage Determinations (NCDs and LCDs) showed that this type of test needed a specific modifier, and not the GY-modifier. Jerri helped the client contact the provider and ask them to re-bill using the correct billing code, and they waived the bill in full.
Monetary Impact = $430
8/31/2023
Story #105
Gail Sauerman, EBS of Taylor County, helped a client receive a favorable Medicare decision totaling over $2,500. The client had received a Rhinophyma reduction procedure due to soft tissue collapsing his airway and making it difficult to breathe. Medicare, however, denied the claim, determining the nature of the procedure was cosmetic. The client had been diligently trying to get coverage, but was having no success. Gail gathered the critical medical documentation to prove why the client's procedure was medically necessary and helped him submit a good-cause late appeal due to his ongoing efforts to resolve the matter on his own. As a result of this appeal, Medicare paid the claim in full.
Monetary Impact = $2,500
8/31/2023
Story #102
Mary Rheinschmidt also helped a client reduce her medication bill substantially. The client came to Mary because she'd been charged roughly $18,000 EACH for two Stelara injections. The injections had previously been covered; she was used to paying roughly $1,500 out-of-pocket. However, a Medicare regulation change meant that Stelara injections were no longer covered. The change went into effect in Wisconsin in October, 2021 and she received an injection in November. She was understandably shocked to receive a bill for over $18,000 afterwards. The client was due for another injection in February, 2022, and the provider assured her it would be covered this time. The client, however, received yet another denial and a bill for $18,000. Mary left absolutely no stone unturned to help get coverage for the bills. This included filing multiple appeals with Medicare, requesting patient assistance, and helping the clients contact their legislators. In fact, Mary spoke to a worker from Tom Tiffany's office on behalf of the clients about the issue. Shortly after, Mary learned that the provider agreed to drop the $36,000 charge to just $9,000. At this time, it is unclear if the Congressional inquiry prompted the reversal, or whether the provider waived a portion of the bill, used patient assistance funds, or some other remedy. What we do know is that Mary worked for over a year on this case to get a just result, and the clients were thrilled to have the bill reduced to a more manageable amount.
Monetary Impact = $27,000
8/30/2023
Story #101
Mary Rheinschmidt, EBS of Lincoln County, helped a client receive reimbursement for a Skilled Nursing Facility (SNF) denial by an Advantage Plan. The client had entered the SNF after hip replacement surgery and his doctors recommended he receive at least four weeks of physical and occupational therapy at a skilled nursing facility. Security Health Plan, however, denied coverage after just 16 days. The client ended up needing 25 days in the SNF before he could safely go home. Mary worked with the client to gather all necessary medical documentation for the appeal, which was taken to the ALJ hearing stage. The day of the hearing, Security Health Plan agreed to pay the denied days – a total of over $2,600.
Monetary Impact = $2,600
8/31/2023
Story #100
Karen Nichols, EBS for Burnett County, met with a client who was having problems with billing for hip replacement surgery. Her Medicare Advantage plan was insisting that the procedure needed to be billed as inpatient surgery, but the surgery center was insisting that it could only bill the procedure as outpatient because it was a Critical Access Hospital. The hospital had appealed the denial to the plan, but the client had never directly appealed for herself. Karen contacted the plan and was told that the plan would allow the client to submit an appeal even though the deadline had passed. Karen contacted her program attorney who helped research the procedure and discovered that Medicare rules allowed this type of hip surgery to be billed either as inpatient or outpatient. Karen then helped the client write up and submit an appeal letter. With clarification that the surgery could be billed as outpatient, the plan reversed its denial and agreed to cover the charges. That decision reduced the client's bill from more than $37,000 down to $97.
Monetary Impact = $36,000
7/27/2023
Story #98
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
Jodi Kautzer, EBS in Calumet County, assisted a 67-year-old woman in getting a refund of over $720 for registered dietitian sessions that should have been covered by her Medicare Advantage (MA) plan. The client called her MA plan and was told that she would have up to six sessions covered by a particular provider. However, the provider submitted the claim incorrectly, and the claims were denied. The provider collected the money from the client and was less than helpful in assisting with resubmitting the claims. Jodi worked with the client for months to appeal to the MA plan and get the MA plan to work with the provider to get the sessions covered. The client received a refund check in the mail for the services that she was promised.
Monetary Impact = $720
7/28/2023
Story #95
Tiffany also assisted a 66-year-old client who was referred in May because she was terminated from her job and was unable to afford the high cost of Trulicity, a new drug her doctor prescribed for her diabetes. The client was enrolled in SeniorCare Level 2B but did not have funds to pay the $850 deductible. Because of her loss of income, Tiffany helped her successfully apply for the Qualified Medicare Beneficiary (QMB) Program in May, and her benefits became effective June 1st. Meanwhile, Tiffany also assisted her with an application for Social Security retirement benefits. Due to this new source of income, her QMB enrollment will only last for one month. However, as a result of having been enrolled in the QMB program, she will have full Extra Help/Low-Income Subsidy (LIS) for the rest of the year. The client was finally able to fill her prescription and she paid the $10.35 co-pay under LIS. Fortunately, she was offered a job which starts next month. The client is very pleased with the assistance she received from Tiffany during a very stressful time in her life.
Monetary Impact = $850
6/1/2023
Story #88
Tiffany Scully, EBS in Dane County, was successful in assisting a 75-year-old client with enrollment in Medicare Part B without a late enrollment penalty (LEP), using the Special Enrollment Period (SEP) related to loss of employer group health plan (EGHP) coverage. The client was covered under her spouse's EGHP since she turned 65. After her spouse retired in September 2022, she applied for Part B, but her application was denied by SSA because they said she did not show proof of active employer coverage from March 2013 to the present. The client sent SSA a completed Request for Employment Information form, but the employer's representative indicated that their records only went back to 2017. The original business the spouse worked for had changed names several times and was purchased by a larger company in 2017. When Tiffany and the client contacted the insurance company for the EGHP, they also could not provide proof of coverage prior to 2017. According to SSA POMS HI 00805.295 (Evidence of GHP or LGHP Coverage Based on Current Employment Status), when the employer, GHP or LGHP cannot provide all evidence of coverage based on employment status, the applicant can submit other documentation. Based on this, Tiffany helped the client submit a new Medicare Part B application along with a statement of claimant (Form SSA 795) explaining the situation as well as the additional evidence the client was able to locate, which included W2s, paystubs showing deductions for health insurance with a spousal surcharge, and tax forms 1095-C (Employer-Provided Health Insurance Offer and Coverage). This was all faxed to the Madison SSA Field Office on one of the last days of the client's 8-month SEP. She had just become aware of the EBS Program, after months of trying to address this issue on her own. She cried tears of joy when she found out that her Part B enrollment was processed and there was no LEP!
6/29/2023
Story #87
Jennifer helped a client get a dental bill issue resolved. The client has a Medicare Advantage (MA) plan with some dental coverage. She went to a dentist for some covered dental work and was told she would have no co-pay for the services. At the appointment, however, she was told she would have a $400 co-pay. Then, she received another bill for $800. Jennifer helped this client connect with her MA plan who helped advocate for the client with the dentist. The MA plan opened up a fraud case against the dental provider who promptly returned all payments to the client.
Monetary Impact = $1,200
6/29/2023
Story #84
Jennifer had another successful case outcome where she assisted a client in getting thousands of dollars in medical bills covered under Medicare. The client, a 71-year-old man, has Original Medicare and had a worker's compensation issue ten years prior that had since been closed. This client's claims kept getting denied by Medicare because Medicare had his worker's comp insurance listed as a primary payer. The client and his doctor had both tried resolving the issue with Medicare and they both also submitted several appeals of these denied claims. The appeals were denied, and the next step was to request an administrative law judge (ALJ) hearing. Before doing that, however, Jennifer tried once more to resolve the issue with the BCRC and asked the provider to resubmit the claims. The claims were approved and paid, and the issue was fully resolved for this client.
Monetary Impact = $1,000
Story #83
Jennifer also recently received a fully favorable decision for a Skilled Nursing Facility (SNF) appeal. The client, a 74-year-old woman, had suffered a stroke and was subsequently admitted to a SNF for rehabilitation and daily skilled cares on her Percutaneous Endoscopic Gastrostomy (PEG) tube. The client's Medicare Advantage (MA) plan denied further SNF coverage after about three weeks in the SNF. Even though the client had stopped receiving daily skilled physical, occupational, and speech therapies, she still required daily skilled cares on her PEG tube and was not yet safe to return home. At the hearing, the beneficiary's MA plan tried arguing that the client's PEG tube did not qualify for Medicare SNF coverage because it was a chronic condition that the beneficiary was expected to have for life. This, however, was not anywhere in the Medicare regulations. After the hearing, the client received a fully favorable decision stating that she was eligible for Medicare SNF coverage for the full 100 days allowed by Medicare and her MA plan.
6/29/2023
Story #82
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
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
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
Bethany Schneider, EBS in Dunn County, recently assisted a client who was delayed in getting his Medicare started. The client had applied for his Medicare A and B to start on January 1, 2023; however, he received a letter from SSA indicating that “due to a unique systems issue" his Medicare enrollment had been delayed. The client had no other health insurance coverage and had a large outstanding bill from a provider that Medicare should have covered. Bethany was ultimately able to help get his Medicare A and B started and backdated to January 1, but that left him without any wraparound coverage or drug coverage. Bethany and the client called his chosen Advantage plan and asked them to enroll him in backdated coverage with the plan (per guidance from CMS), but the plan refused. Ultimately, a CTM complaint had to be filed against the Advantage plan to force it to enroll him into the plan retroactively as of January 1. The very next day CMS resolved the CTM complaint in the client's favor and retroactively enrolled in him the Advantage plan with drug coverage so that the client could get his needed medications and his outstanding provider bills covered.
4/28/2023
Story #72
Leda Welke Judd, EBS in Eau Claire County successfully helped a client with an out-of-network Part D drug reimbursement. Leda had helped answer the client's questions when she initially started on Medicare, so the client returned to her when she was having problems. The client had had surgery over the summer of 2022, and the insulin she received while in the hospital was not covered by Medicare A and B. Her bill for the insulin was $360. The client had tried calling her Part D plan on her own at first to ask about coverage, but she was told that since she had switched plans during open enrollment period, the item could not be covered. However, Leda knew that was wrong, so she helped the client call the plan back together and the plan agreed to send out the Out-of-Network Reimbursement form for the Part D plan. Together, Leda and the client completed the form and sent it in. The client received $291 reimbursement back from the plan for the coverage of the insulin. The client was thrilled and wrote a letter to Leda detailing her appreciation.
Monetary Impact = $291
4/28/2023
Story #71
Dane County EBS Tiffany Scully received a successful outcome for an 84-year-old client who was paying a 60% late enrollment penalty for Medicare Part B beginning July 2021. The client reported that he had group health plan coverage through his spouse's former employment at a large health organization; however, he did not recall the effective dates of the coverage, and he became overwhelmed at the thought of trying to contact anyone at the company to obtain this information. Due to his wife's dementia, she was unable to assist him with this process. Fortunately, Tiffany and the client got connected to a helpful benefit analyst at the employer who completed the CMS L564 form which was then submitted to SSA in August 2021. After numerous follow up calls to the local field office, the client received a notice of decision from SSA in February 2023, stating that their original decision was amended, and his premium surcharge was reduced from 60% to 20%. The client will receive a refund from SSA for the late enrollment penalties he was charged, but did not owe, back to July 2021. He is very grateful for Tiffany's support and persistence in navigating through this process with him.
2/23/2023
Story #69
Mindy Shrader, EBS in Sauk County, recently received a fully favorable Medicare appeal of Skilled Nursing Facility (SNF) coverage. The client was a 71-year-old man admitted to the SNF for rehab after surgery to treat a broken leg. After nine days in the SNF, his Medicare Advantage Plan terminated coverage even though he was not yet ready to return home, and his providers believed that daily skilled services were still medically necessary. With the help of her BSSA, Mindy helped the client's family with an ALJ hearing and received a fully favorable result that gave the client an extra month of coverage.
4/28/2023
Story #67
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
Angie Pietroske, EBS in Kewaunee County, helped a client resolve her Part D plan issue through a CTM complaint with Alyssa Kulpa's help. Angie met with this client during AEP and helped her select a Part D plan. The planfinder showed that her pharmacy was in-network for the plan selected. However, when the client went to the pharmacy she learned that it was not in network for her plan. Unfortunately, this was the only pharmacy within reasonable driving distance for this client, not to mention the fact that it's a pharmacy the client knows and trusts. Alyssa helped Angie submit a CTM complaint due to the planfinder error to get the client into a plan that has her pharmacy in-network. Within four days, the CTM complaint was resolved, and the client was switched into a plan that works for her.
2/28/2023
Story #61
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
Terri Esselman, EBS of Clark County, helped a client obtain QMB. The client had already been determined disabled, received SSDI, and was enrolled in Medicare Part A. She had delayed Medicare Part B due to costs. When the client met with Terri regarding her recent ESRD diagnosis, Terri recognized that the client would be eligible for QMB, which would help her get her Medicare Part B premiums paid. Terri helped the client call IM to apply for QMB, however, IM would not process the application because it could not see the client's enrollment in Medicare. IM explained the client would need proof from SSA to process the application. Terri helped the client contact SSA, who explained that the client was enrolled in Medicare, but that she had outstanding Part B premiums owed (even though the client hadn't enrolled in Part B). SSA said it could do nothing regarding the data exchange with IM. After much back-and-forth between IM and SSA (including using the SSA escalation protocol, the Medicare Buy-In Specialist, and the supervising attorney), SSA provided the proof of conditional enrollment into Part B and IM admitted agency error for not screening the client for QMB earlier.
Monetary Impact = $
2/28/2023
Story #57
Joanne Welsh, EBS in Richland County, helped a client successfully appeal his Part D late enrollment penalty. The client had been on SeniorCare for a number of years but had not filled out the plan's paperwork correctly to report the creditable drug coverage. Joanne helped the client appeal to C2C Solutions, which found that the client was not required to pay a late enrollment penalty.
2/28/2023
Story #55
Pam Fuchs, EBS in Sauk County, helped two clients successfully appeal their Income-Related Monthly Adjustment Amounts (IRMAAs). The clients had sold businesses when they retired, which resulted in significant capital gains income in 2021. Pam helped the clients explain that they had stopped working and that their current income was much lower than reflected by their 2021 tax returns. SSA agreed and removed the IRMAAs!
2/28/2023
Story #53
Pam Fuchs, EBS in Sauk County, also helped a client with a Medicare coordination of benefits and recovery case. The client had been injured in a car accident before undergoing treatment and surgery for a hernia. Unfortunately, Medicare determined that over $1,000 worth of claims related to the client's hernia surgery were conditionally paid. Pam helped the client show that these claims were not related to the car accident, and the Benefits Coordination & Recovery Center agreed!
Monetary Impact = $1,000
1/25/2023
Story #48
Joanne Welsh, EBS in Richland County, helped a client successfully dispute over $6,000 worth of claims that Medicare had determined were conditionally paid. The client had recently undergone hip replacement surgery and shoulder surgery. Unfortunately, Medicare determined that the claims related to his hip and shoulder treatment were related to an old workers' compensation claim involving an ankle injury. Joanne helped the client clarify that the claims listed on the Payment Summary Form were completely unrelated to his workers' compensation case, and the Benefits Coordination & Recovery Center agreed!
Monetary Impact = $6,000
1/25/2023
Story #47
Jessica Knippel, EBS in Manitowoc County, helped a couple who each had a late enrollment penalty with their respective Part D plans. The husband and wife, who are 70 and 69 years old respectively, both had SeniorCare for drug coverage for many years. They recently enrolled in Part D plans during open enrollment with two different companies. Neither company accepted SeniorCare as creditable drug coverage and assessed each spouse a late enrollment penalty. Jessica helped both spouses appeal the late enrollment penalties and quickly received favorable results on both.
11/30/2022
Story #45
Leanne Grover, EBS in Barron County, helped a client successfully appeal a denial for air ambulance services. The man was vacationing in New Mexico when he had a medical emergency that required specialized surgical care. He was flown from a small local hospital to a larger facility in downtown Albuquerque. Medicare denied coverage for the air ambulance because he had not been taken to the nearest alternative hospital. Leanne was able to get letters from each of two closer hospitals stating that they would not have been able to provide the level of care the patient needed. The claim was approved at the redetermination level to cover air ambulance costs exceeding $99,000!
Monetary Impact = $99,000
11/30/2022
Story #42
Leilani Amundson, EBS in Dane County, recently received a fully favorable Medicare appeal of Skilled Nursing Facility (SNF) coverage. Leilani's client is a 72-year-old man who had to have an amputation of his leg above the knee. After surgery, he was moved to a SNF for rehab. After about two weeks in the SNF, his Medicare Advantage Plan terminated coverage; however, he was not yet ready to return home—he had not made enough progress in therapy, nor were his home modifications completed. He remained in the SNF an additional nine days receiving daily skilled therapies all while his family scrambled to complete home modifications. Those extra nine days left this client with a bill of over $3,000 for the uncovered room and board. With the help of her BSSA, Leilani assisted the client with an ALJ hearing and received a fully favorable result.
Monetary Impact = $3,000
10/30/2022
Story #39
Tiffany Scully, EBS in Dane County, recently assisted a 63-year-old client on SSDI with enrollment into Medicare Part B with retroactive coverage beginning July 1, 2022. The client had Medicare Part A and a retiree health plan beginning in May 2016, and he rejected Part B because he did not think he needed it. Unfortunately, his retiree plan did not realize that they should have been paying secondary to Medicare Part B for several years and did not notify him until the end of 2021 that he needed to enroll in Part B. The client then submitted a Part B application in January 2022 during the GEP; however, after hearing from his retiree insurance company that everything was “taken care of" he interpreted this to mean that he no longer needed Part B. Concerned about the cost of Part B, he subsequently contacted SSA in February to withdraw his application. He did not understand what the insurance company explained to him, and they later reiterated that he still needed to enroll in Part B. The client has a history of cancer and other medical conditions. He told Tiffany that because of this coordination of benefits issue he has had medical bills go into collections and he has delayed medical care until next year, because he thought the earliest he could get Part B coverage was February 1, 2023. To resolve this issue, Tiffany assisted the client with contacting the Madison SSA FO and confirmed that his Part B application was never processed and SSA never received a signed request for termination of SMI from him. Because of this, Tiffany advocated that SSA process the application, in accordance with the POMS, with coverage retroactive to July 1, 2022. Several days after contacting SSA, Tiffany called Medicare SHIP and confirmed that the client's record was updated, and he now has Part B effective July 1. The client reports feeling a huge sense of relief and no longer needs to postpone necessary medical appointments due to financial concerns.
Monetary Impact = $
10/30/2022
Story #37
Mindy Shrader, EBS in Sauk County, helped a client get reenrolled in Part B after she was somehow disenrolled during the process of switching from Railroad Retirement Medicare on her late husband's record to Medicare via the Social Security Administration based on her own work record. The client didn't realize that her Part B coverage ended until she was at the pharmacy trying to fill prescriptions and learned that her Advantage plan disenrolled her. Mindy helped the client request equitable relief, and when the case stalled in the processing center, Mindy reached out to Elida Elizondo at SSA to see if she could move the case along. After that, SSA granted the equitable relief request, and the client's Part B was reinstated.
10/30/2022
Story #35
Leilani Amundson, EBS in Dane County, recently helped a client get her Medicare Part B retroactively reinstated. The client turned 65 and signed up for Medicare. She had thought that her financial planner set up the automatic withdrawal for her premium payments, however they did not. She received a notice dated April 2022 that her Medicare would be ending, and she wouldn't be able to reenroll until the general enrollment period (GEP). However, she didn't see this notice until several months later due to illness. She immediately went to the local SSA office and paid the balance of over $4,000 (including IRMAA), but there was still an issue. Leilani called the SHIP hotline who noted that her payment did not reflect the additional 40 cents on the bill and confirmed her check didn't correctly spell out the cents even though it was written in the numeric box. This was the only issue anyone could pinpoint. Leilani was able to reach an SSA representative who agreed to an appeal for equitable relief, took her telephonic signature, and got a screenshot of her payment of .40 The SSA worker then submitted his approval and recommendation for expedited reinstatement for Medicare to restart as of June of 2022.
9/30/2022
Story #34
Alice Ackerman, EBS in Monroe County, helped a client request equitable relief with respect to her Medicare Part B enrollment after she was unable to reach SSA by phone this past March and April. Alice helped the client contact SSA and provide proof that she had employer insurance from active employment. When the field office said they hadn't received instructions for handling these cases, Alice provided them with a copy of the SSA Emergency Message on equitable relief for beneficiaries unable to contact SSA because of technical issues with the agency's phone lines. The client's Part B enrollment was finally processed as requested!
9/30/2022
Story #29
Mindy helped a client who was dealing with some ambulance billing issues. The client had received ambulance bills from three separate dates of service. However, the ambulance provider had not bothered to bill her Advantage plan for two of those dates. The one claim that had been submitted was submitted late, and the explanation of benefits clearly said that, because of the late submission, the client was not responsible for the bill. With Mindy's help, a demand bill letter was sent to the ambulance provider asking them to submit the remaining claims and reminding them that, as a Medicare-enrolled provider, federal law required them to file claims for services provided to Medicare beneficiaries. The ambulance provider submitted the remaining two claims to the Advantage plan, and the services were covered. In addition, the provider agreed to stop billing the client for the claim that was submitted late. This saved the client over $3,000!
Monetary Impact = $3,000
9/30/2022
Story #28
Mindy Shrader, EBS in Sauk County, recently helped a client successfully request reconsideration of an SSDI overpayment of more than $60,000. The client is a farmer and had received a crop insurance payment one spring when it was too wet to plant. Because the crop insurance payment was taxable income, he reported it on his taxes, which made his adjusted gross income look very high for the year. SSA assumed that the income was from work and determined that he was no longer eligible for SSDI. In addition, SSA terminated his Medicare enrollment. Mindy helped the client submit a copy of his tax return to SSA to show that the income was not from substantial gainful activity. She also requested that SSA provide critical payments while the reconsideration was pending so that the client could afford his living expenses. Not only was the reconsideration successful, but the client received more than $10,000 in backpay, and his Medicare was reinstated.
Monetary Impact = $60,000
9/30/2022
Story #27
Mary Velcich, EBS in Green County, recently helped a client correct her date of birth with SSA. The client turned 65 in 2019, but because her DOB was incorrect in SSA's records, Medicare denied every claim. It turned out that her DOB was entered incorrectly when she changed her last name after her wedding in the 1970s. She was able to call 1-800-Medicare and have them manually correct information for each individual claim so that they could be processed and paid, but her efforts to resolve this with the Janesville office were unsuccessful. The client came to the Mary at the end of July, and Mary helped her call the Janesville office. When they couldn't resolve the issue that way, Mary followed the SSA case escalation guidelines and emailed the Field Office mailbox. Mary finally able to resolve the issue with the Field Office Manager, and she confirmed with Medicare that everything is corrected now.
8/31/2022
Story #25
Mary Velcich, EBS in Green County, recently helped a client straighten out an issue with the IRMAAs he and his wife were paying for Medicare Part B and Part D. The client was confused about the Medicare premium bills he was receiving, because the amount billed didn't match what he thought he would be paying for his Part B premium and IRMAAs. After a phone call with SSA, Mary learned that the client was being charged an IRMAA from the correct income category for Part D, and an IRMAA from a higher income category for Part B. After talking with the client some more, Mary learned that he had recently retired. Mary helped the client fill out an SSA-44 to reduce the couple's IRMAAs going forward because of his retirement. She also sent a letter to SSA asking them to correct the IRMAA amounts he had been paying. A little over two weeks later, the client let Mary know that the IRMAA issues had been fixed and that this will save the couple approximately $8000.
Monetary Impact = $8,000
7/28/2022
Story #21
Eau Claire County EBS Jessica Smith persisted in assisting a woman with her ambulance appeal until they received a successful decision. The woman had a medical history of chronic heart failure, severe aortic stenosis, a heart murmur, and kidney failure. On the day of service, she was experiencing left-sided chest pain, back pain, and believed she was having a heart attack. Her husband called 911 so that an ambulance could take her to the hospital as soon as possible. Sadly, her adult son had just passed away two weeks prior due to heart disease, which was very prevalent in her family history. The ambulance company had correctly billed the claim as “advance life support—emergency transport" due to the fact that she was given a 12-point ECG during the ambulance ride which indicated tachycardia. However, the ambulance company also submitted the claim to Medicare with a “GY" code at the end meaning “statutorily not covered by Medicare." Due to the “GY" code, Medicare denied payment for the claim. Jessica collected the Medicare Summary Notice, the ambulance run report, and medical records as evidence. She then helped the couple to appeal to Medicare twice only to receive denials by both NGS and also C2C Solutions. However, Jessica knew that this claim should have been covered by Medicare because there is a presumption of Medicare coverage for ambulance rides when the person can only be moved by stretcher (which was the case here), and when the patient exhibited signs and symptoms of acute cardiac distress or chest pain. Jessica helped the client to request an Administrative Law Judge (ALJ) hearing. Prior to a hearing being scheduled, the ALJ issued an on-the-record decision, meaning that he had reviewed the file and exhibits that had been submitted and felt that a hearing did not need to be held because he already had sufficient information to make a favorable decision. After a year and a half of appealing, Jessica and the client finally received a fully favorable decision.
6/30/2022
Story #18
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
Tiffany Scully, EBS in Dane County, worked with a client who had an IUD placed as part of a hysteroscopy procedure. The IUD was denied by Medicare as it was coded for prevention of pregnancy instead of a medically necessary procedure, which this was. The client went to the EBS after the deadline for filing an appeal. The EBS helped the client contact the hospital billing and they sent it back to be recoded. When the EBS later called Medicare SHIP, she was told that the claim was reprocessed but the procedure code was the same and it was denied for the same reason. The client and EBS contacted the billing dept and were told that they had adjusted the charge off since they didn’t have her sign an ABN. She was very happy to save almost $600!
Monetary Impact = $600
5/31/2022
Story #12