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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
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
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
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
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
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 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
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