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I met with a consumer who was on several medications and wanted to compare his current Part D plan with other plans for 2025. The premium for his current plan was going up and removing four of his medications from thier formulary. The Medicare.gov Planfinder tool estimated that if he stayed with his current plan, his cost would be over $200,000 between the pharmacy and premium in 2025. After we ran the Medicare.gov plan options and double-checked the plan's formulary on thier website, we were able to find a plan that covered all but one of his medications. He selected this new plan, and it will cost him around $5,000 in 2025, and this includes the one medication outside of the formulary. He was pleased to find a plan to cover so many of his medications.
Monetary Impact = $195,000
11/15/2024
Story #133
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
Jessica Flores, EBS in Door County, recently helped a client to get access to a working phone. This client came to Jessica for assistance after going months without a phone. The phone he did have was held together with rubber bands. He could only use Wi-Fi to make internet calls only, so it was difficult for him to get in touch with the Lifeline program to get help fixing his issue. Not having a working phone was causing many barriers for him. Even with Jessica's assistance, they were continuously dealing with an automated system and unable to reach a live person for help. Jessica went through the National Verifier system to help get him disenrolled from the old phone company, and then she tried for weeks to get his “household worksheet" resolved. Since he lives with multiple individuals, the system showed that someone else in the household was already getting the lifeline benefit making him ineligible. Jessica was finally able to help resolve this issue after sending the verifications in twice. Finally, they were able to finish the client's Lifeline application, reapply with a new Lifeline provider, and order a new phone. This client was so grateful to the EBS for her assistance because he doesn't think he would have been able to navigate this on his own.
11/30/2023
Story #131
Amanda Higgins, EBS in Dodge County, recently helped a client who was initially referred to her for help with insurance issues. The client is not eligible for premium-free Part A and had a Marketplace plan with a high deductible. Moreover, she was facing bills of over $90,000 after receiving out-of-network care for a stroke. Amanda helped the client apply for financial assistance, which resulted in a significant percentage of the bills being written off. Amanda then helped the client set up a payment plan for the remainder of the amount owed. In addition, Amanda counseled the client about choosing a 2024 Marketplace plan that would be a better fit for her care needs, and the client met with an agent to enroll in a plan for next year. Finally, although the client was over the asset limit for Medicaid, thanks to Amanda's assistance, the client is now receiving $171/month in FoodShare.
11/30/2023
Story #130
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
Lindsey Holden, EBS in Portage County, assisted a client in obtaining QMB. The client's spouse received an inheritance that caused her to lose SSI, Medicaid, and QMB. However, the main portion of the inheritance was real property in the spouse's name, only. This meant that the client could be eligible for MAPP, but because she did not qualify for premium-free Part A, she would be responsible for Part A and Part B premiums without QMB. The client's spouse intended to sell the property eventually, but was hesitant to do so that quickly. When Lindsey explained that she could become QMB eligible if the property was listed for sale, they contacted a realtor (a relative) who listed the property for them. Lindsey was able to show IM that the property was unavailable under MEH 16.2.2 , and with assertive follow-through, the client's QMB was processed.
11/30/2023
Story #128
Jennie Bowers in St. Croix County helped a client with a successful appeal following the denial of a medical procedure. Her client had had prostate cancer and had developed some severe and unpleasant side effects from the medications used to treat the condition. The client worked with his doctor for over a year to try and come up with alternate, non-surgical ways of treating the problems, but was unsuccessful. He had excess skin that had swelled up near his prostate area causing painful urination, difficulty maintaining cleanliness, and painful walking (due to rubbing). Ultimately, his doctors determined surgery was necessary to correct the problem. Medicare initially denied part of the surgical procedure as being “cosmetic." However, by obtaining medical records showing the client's many trips to the doctor regarding the problem as well as his many unsuccessful attempts at treating the issue using less invasive techniques, Jennie was able to demonstrate to Medicare that this surgery was entirely medically necessary for treatment of his pain and condition. The client agreed to let Jennie send in pictures of the condition (taken by his doctor) along with the appeal so that the reviewers could see the scope of the problems that the client had been dealing with. As they say, a picture is worth a thousand words! Upon seeing the pictures and reading the appeal, Medicare agreed that the surgery was not cosmetic, and approved coverage for the remaining $5,000 balance.
Monetary Impact: $5,000
10/31/2023
Story #127
Jessica Smith, EBS in Eau Claire County, helped a client successfully appeal the denial of her gastrointestinal testing. The client was 76 years old and experiencing symptoms initially diagnosed as mild food poisoning and expected to pass within a day or so. However, when her symptoms did not improve after a couple of days and actually worsened, she returned to her doctor's office and insisted on additional testing. Good thing the client was persistent because she actually tested positive for C difficile toxin, commonly known as “C-diff." The client received a phone call from an epidemiologist at Mayo Hospital in Rochester, Minnesota with instructions about starting a strong antibiotic regimen immediately due to the serious implications of the infection. Medicare denied the test as unnecessary; however, upon investigating the facts, Jessica found out that the client had met three of the five conditions in the Medicare Local Coverage Determination (LCD), even though it was only necessary to have met one of those five conditions in order for Medicare to cover the test. Jessica obtained a copy of the patient's medical records regarding the need for the test and sent in the appeal. Medicare agreed that the test was warranted and paid for the $816 claim. And since the client also had a supplement, she did not owe anything for the test after it was covered by Medicare.
Monetary Impact: $816
10/31/20232
Story #126
Mary Velcich, EBS in Green County, recently helped a client with a Medicare Coordination of Benefits and Recovery case. The client had been involved in a car accident and received treatment for her injuries. Although her car insurance paid up to the policy coverage limit for medical expenses, the client needed additional care. Medicare believed that it had paid nearly $27,000 in conditional payments. Mary helped the client submit documentation showing that the car insurance could not pay any additional amount for her care and that all of the money from the insurance company had been paid directly to the hospital. Although the Benefits Coordination & Recovery Center sent another notice insisting that the client received a settlement because of the accident, Mary resubmitted the documentation from the insurance company, and the client finally received a notice saying that the issue had been resolved and that she did not owe Medicare any money.
Monetary Impact: $27,000
10/31/2023
Story #125
Leanne Grover, EBS for Barron County, was recently contacted by a resident of Section 42 subsidized housing who received notice from the housing authority that a review of electronic wage databases showed that she had received two quarters of wages from an out-of-state employer. Leanne worked with her program attorney to determine steps the client needed to take to appeal the incorrect information and to prepare letters she could provide to the housing authority and the reporting employer. After receiving the letter, the employer identified the problem, corrected the information in the reporting system, and provided a letter confirming that she had never been employed with the company. The housing authority accepted that information as best available evidence and decided not to move forward with any effort to evict or non-renew the client's lease.
10/31/2023
Story #124
Leanne Grover, EBS for Barron County, worked with a client who had received a letter from Social Security in March requesting verification of employment for the previous three years. Leanne helped the client submit all of her wage documentation within a week after receiving the letter but, in August, the client received another letter saying she was ineligible for SSDI payments for several months during the review time frame. Leanne submitted the relevant paystubs again, only to receive an overpayment notice in September totaling more than $19,000. Leanne helped the client submit a reconsideration request and included sections from the POMS clarifying that vacation and sick time should not be counted toward earned wages. Upon reconsideration, SSA determined that there was no overpayment and that SSDI payments would be reinstated.
Monetary Impact: $19,000
10/31/2023
Story #123
Marianne Johnson, EBS for Bayfield County, heard from the daughter of a nursing home resident who was facing a divestment penalty amounting to more than $41,000 for selling a parcel of land at less than fair market value. Marianne worked with the daughter and her local Information and Assistance specialist to submit documentation for an undue hardship waiver. The waiver was granted and the family was greatly relieved to have one less looming bill to worry about.
Monetary Impact: $41,000
10/31/2023
Story #122
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
Kathryn Noll-Arias, EBS in Winnebago County, recently had two successful SNF appeals. The second client, an 84-year-old man, suffered a fall at home and fractured his left hip and left clavicle. After hospitalization, he was transferred to a SNF for rehabilitation. About four weeks later, the client's MA plan issued a denial for further SNF services; however, the client had not met his rehab goals and was not yet safe to return home. He continued to receive daily skilled therapies for another two weeks, and then his therapy was cut down to three days per week. Kathryn assisted the client with an appeal and after an ALJ hearing, the client got the additional two weeks covered.
10/31/2023
Story #120
Kathryn Noll-Arias, EBS in Winnebago County, recently had two successful SNF appeals. The first client, an 88-year-old man was in the hospital for meningitis and an infected hematoma from a fall. He was diagnosed with Methicillin-Sensitive Staphylococcus aureus (MSSA) and was started on an IV antibiotic. He was discharged to a SNF for rehabilitation and skilled nursing care for his wound and IV antibiotic. When his therapies were reduced from five days per week to three, the SNF issued a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) stating that Original Medicare would no longer cover his SNF stay. However, the client was still at a skilled level of care for his IV antibiotic. Kathryn assisted the client with appealing and after an ALJ hearing, received a fully favorable decision covering the client's entire stay at the SNF.
10/31/2023
Story #119
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.
10/31/2023
Story #118
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