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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
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