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Topic: Medicare Part C - Medicare Advantage Plans

Marathon County, EBS, Jenae Belmas

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

Outagamie County, EBS, Jennifer Trasser

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.

Monetary Impact =

10/31/2023
Story #118

Kewaunee County, EBS, Angie Pietroske

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

Lincoln County, EBS, Mary Rheinschmidt

Mary Rheinschmidt, EBS of Lincoln County, achieved another win for a client with a Skilled Nursing Facility (SNF) denial. The client had entered the SNF after contracting Covid-19 pneumonia, which exacerbated his COPD (on top of also undergoing treatments for cancer). His Advantage Plan, Security Health Plan, used its naviHealth algorithm to predict he would only need 14-18 days in the SNF, despite his doctors ordering 4-6 weeks of skilled rehab. Sure enough, on the 16th day, the client received notice that SHP would no longer cover his stay despite him being a high aspiration risk and having dangerously low oxygen levels. The client was afraid to pay out of pocket, so he and his family scrambled to get him home (against doctors' orders). Mary helped the client gather all medical information to support his case – and for the first time in GWAAR history – Livanta (the QIO) reversed the Advantage Plan's denial, which meant that Security Health Plan was required to pay for the outstanding days.

9/29/2023
Story #114

Sauk County, EBS, Pam Fuchs

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

Columbia County, EBS, Kathy Cummings

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

Sauk County, EBS, Mindy Shrader

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

Lincoln County, EBS, Mary Rheinschmidt

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

Burnett County, EBS, Karen Nichols

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

Calumet County, EBS, Jodi Kautzer

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

Outagamie County, EBS, Jennifer Trasser

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

Outagamie County, EBS, Jennifer Trasser

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

Dunn County, EBS, Bethany Schneider

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

Sauk County, EBS, Mindy Shrader

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

Douglas County, EBS, Laura Killian

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

Dane County, EBS, Leilani Amundson

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

Sauk County, EBS, Mindy Shrader

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

Sauk County, EBS, Mindy Shrader

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