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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
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
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
Mindy Shrader, EBS in Sauk County, helped a client do a significant amount of detective work to prove that she was eligible for receiving benefits related to her ex-spouse. The client initially came to see Mindy because she was worried that she couldn't afford her increased rent. After talking to the client, Mindy learned that the client might be eligible for benefits on her ex-husband's record. Unfortunately, the client had been married in another country before moving to the United States, and the divorce had taken place in another state. The client provided all the records she had about her marriage, which were not in English, and Mindy helped her bring those to SSA. In addition, Mindy helped the client request a copy of her divorce judgment from the other state to send to SSA. Unfortunately, SSA was unable to accept the marriage documents because the agency is prohibited from accepting documents from that country. However, the client was able to connect Mindy with an old friend who had witnessed the wedding and was willing to write a letter to SSA verifying when the wedding had taken place. SSA finally approved the client's application for benefits, which increased the client's total monthly benefit amount by over $1,200 and got her over $17,000 in back pay!
Monetary Impact = $17,000
6/29/2023
Story #90
Pam Fuchs, EBS in Sauk County, helped a client successfully appeal an SSDI overpayment in a case that took nearly two years to resolve. The client was injured while working in another state many years ago and received worker's compensation (WC) after that. She later moved to Wisconsin and applied for SSDI benefits after her WC payments had ended. SSA sent a letter to her representative payee asking for information about the WC payments, but the representative payee had significant medical issues and was unable to respond to that letter. As a result, SSA assumed the client was receiving WC payments and SSDI benefits at the same time without any offset calculated. Because the overpayment notice was so vague, Pam helped the client request reconsideration because SSA had not provided enough information for us to evaluate whether an overpayment had actually occurred. SSA responded by asking for records of the client's WC payments. Pam tried to track down the records, but the client's former employer, medical providers, and WC attorney no longer had any records. She was finally able to obtain records from the state where the work injury occurred, which showed that the client had not been receiving any WC payments at the time she applied for SSDI. SSA agreed, and not only did the client no longer have an overpayment issue, but SSA actually owed her some money!
6/29/2023
Story #89
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
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
Emma Borck, EBS in Jefferson County, met with a client who had an emergency medical situation in January and had no insurance. She worked with the client to submit paystubs showing his annual earnings and was able to get backdated BadgerCare coverage using gap filler rules. The client now has coverage for more than $100,000 in medical bills!
Monetary Impact = $100,000
4/28/2023
Story #70
Pam Fuchs, EBS in Sauk County, helped a client who mysteriously lost QMB early in the pandemic. The client applied for benefits in February 2020, and she was confirmed eligible for QMB in March 2020, which meant that QMB began on April 1, 2020. However, the client's QMB benefits ended as of April 30, 2020, despite the federal rules that required states to maintain continuous coverage for people enrolled in Medicaid programs. Because the client had not paid her Part B premiums, she was disenrolled from Part B. Pam emailed the ForwardHealth Partners Inbox, and after following up several times, she learned that the client's QMB benefits should not have ended. The client was reenrolled in QMB as of May 1, 2020, which meant that she would be reenrolled in Part B as of that date, and the state would pay her retroactive Part B premiums.
5/1/2020
Story #62
Amanda Higgins, EBS in Dodge County, helped a client clear up an issue related to the amount she was contributing to her household's food and shelter expenses. The client was living with her daughter's family, and when she applied for SSI, she told SSA that she was unsure how much she contributed to household expenses. Instead of explaining to the client why this information was needed and giving her an opportunity to follow up with the agency, SSA assumed that she was not paying for her own food and shelter expenses and reduced her SSI benefit amount by 1/3. Amanda helped the client submit information showing that the client was paying her fair share of household expenses in July 2022, but SSA did not act on that information for many months. After a number of unsuccessful attempts to work with the local field office, Amanda and the client were finally able to speak with someone at SSA in January of 2023. That worker was able to update SSA's records showing that the client had been paying for her food and shelter expenses, and the client is now receiving the full federal SSI benefit amount. In addition, the client will be receiving a significant amount of backpay for the months her benefits were incorrectly reduced!
1/31/2023
Story #54
Ashley Greene, EBS in Crawford County, recently helped a client regain access to her online bank account so that the client could continue to receive her SSI benefits. The client lost her debit card several months before, and when she tried to request a replacement card online, she accidentally created a second account. Thinking that this could be fraud, the bank put a hold on her account and asked her to send copies of a state ID card and Social Security card so they could verify her identity. Unfortunately, the client had also lost her Social Security card. To make matters worse, SSA sent the client a letter saying that they stopped her SSI benefits because her most recent benefit check had been returned. This left her with no income and no access to any of the money in her bank account. The client set up a new account at a local bank, but SSA could not change her direct deposit information without confirmation of her old bank account routing number. Ashley helped the client set up a MySSA account so that she could request a new Social Security card. That card arrived within a week, and Ashley helped the client send a copy to the online bank. Although customer service said they would reset her account, that still wasn't resolved a month later. Ashley helped the client send additional documentation to prove her identity, and after meeting with the client four times in one week in order to work on this, the client finally regained access to her account. This meant that the client could change her direct deposit information with SSA, and SSA deposited over $3,000 in SSI backpay the following week. Ashley also helped the client file complaints about the online bank with the Consumer Financial Protection Bureau and the Wisconsin Department of Financial Institutions.
Monetary Impact = $3,000
11/30/2022
Story #40
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
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