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The client was placed into LTC facility. The LTS pharmacy was billing SeniorCare and drug cost tripled due to clients large deductible on the SeniorCare program. SeniorCare had lapsed. The drug price went down by two fold. Payee keep calling LTC pharmacy with no outcome. I followed up and asked for all meds to be paid private billing (No SeniorCare). That client saved almost $500.00 dollars. The lesson here is if our client's have a large deducible that they will never meet. They should pay cash/private.
Monetary Impact = $490
1/10/2024
Story #132
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
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
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
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
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
Lindsey Holden, EBS of Portage County, helped a client fix a prescription drug plan issue. The client came to Lindsey after she'd gone to the pharmacy and learned that she'd been disenrolled from her drug plan due to failure to pay premiums. The client had her premiums taken out automatically from her bank account, but when her bank made an update and wanted the client to manage her account with an app, she didn't. The client admitted to receiving so much mail during Open Enrollment that she may have missed messages and thrown something away. Lindsey helped the client call her plan, who explained they would not reinstate her coverage. Before filing a CTM or appealing to her previous plan, Lindsey took the opportunity to run a Planfinder with the client and learned there was a better plan that would save her $500 that year. She helped the client enroll in SeniorCare Level 3 which allowed her to use the SPAP SEP to enroll in this new plan. The client was now better off for the year for visiting with Lindsey.
Monetary Impact = $500
2/28/2023
Story #56
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
Jessica Flores, EBS in Door County, recently helped a resident of an assisted living who was referred to her for help with a SeniorCare renewal. During Jessica's visit with her, she showed Jessica a bank statement along with some other papers she needed assistance with. When glancing at her bank info, Jessica noticed she had a really high pharmacy cost. The assisted living facility provided Jessica her current medication list, and from what was on there, the bill from the pharmacy just seemed way too high. Jessica asked the social worker at the ALF if they knew if the pharmacy had all of the correct insurance information on file. The social worker wasn't sure, and the ALF didn't know for sure either, but they assumed it should be. After Jessica came back to the office, she did some research and coordinated some phone calls to the pharmacy. She discovered that somehow, the contracted pharmacy from the assisted living did have the insurance information on file, but they weren't billing correctly. After correcting these mistakes, the client will receive a refund from the pharmacy of around $3,500!
Monetary Impact = $3,500
7/28/2022
Story #20