casework scenarios navigating through beneficiary issues

Casework Scenarios

Navigating Through Beneficiary Issues

Case #1: Scenario

Mr. King has Parts A & D insurance due to age. He declined his Part B insurance because he has Workers’ Compensation insurance.

Mr. King needs a heart transplant but he does not have Part B insurance to cover his immunosuppressant drugs.

Mr. King applied for Medicaid and the application is pending.

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Case #1: Important Points to ReviewCase #1: Important Points to Review

Workers’ Compensation Parts B & D Special Enrollment Period

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Case #2: ScenarioCase #2: Scenario

Mr. Leno was covered under his wife’s group health plan, but recently enrolled in Medicare Part A and B and a Part D plan.

Mr. Leno is insulin dependent . Mr. Leno went to his pharmacy to get his insulin

under his new Part D plan, but the Part D plan denied the claim.

The pharmacist filed the claim to Medicare, but the claim was denied as well.

He’s confused and needs his insulin.


Primary v Secondary insurancePart B or D: insulinPart D coverage gap

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Mrs. Walters is 62 years old and has been insured under her husband’s retiree health plan since 2010.

Mrs. Walters has been on Social Security Disability since 7/1/11 and became eligible for Medicare Part B on 7/1/13.

When Mrs. Walters received her Medicare enrollment card, she called her insurance plan and was told she can stay on their retiree health plan and did not need Medicare Part B.

As a result, Mrs. Walters declined her Medicare Part B.

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Case #3: Scenario ContinuedCase #3: Scenario Continued

Mrs. Walters’s retiree plan is now denying claims stating her retiree plan is secondary to Medicare and took back payments from her providers.

She enrolled in Medicare Part B on 2/4/15 during the General Enrollment Period effective on 07/01/2015.

Mrs. Walter is now responsible for medical claims incurred from July 2013.

Mrs. Walters’s is concerned about her situation and what recourses if any exist to address her situation.

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Case #3: AnalysisCase #3: Analysis

Since her employer provided incomplete information to her, does it entitle her to a SEP for Medicare Part B? When will Mrs. Walters’s Medicare Part B benefits begin?

Mrs. Walters has combined liquid assets with her husband of $50,000 and is over income for the Medicare Savings Program (MSP).

How would you help Mrs. Walters?

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Primary v Secondary Insurance Special Enrollment Period Part B insurance

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Ms. Doe lost her LIS status on 12/31/2013 and was disenrolled from her Part D Plan for non-payment of premiums, which she claims she wasn’t aware there was a premium because the state was paying for it.

Ms. Doe had to move due to a fire in March and stated that if invoices were sent to her previous apartment it probably burned in the fire.

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Case #4: Scenario cont.Case #4: Scenario cont.

Ms. Doe takes several medications for depression and other mental health issues that were brought on by a heart attack after being raped. She has been unable to afford her medications in 2015 and is requesting reinstatement.

Ms. Doe’s insurance plan said she missed the Good Cause window (60 days) due to the change in residence. She called the SHIP for assistance, but her phone was disconnected for non-payment.

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Non-payment of Premiums Low Income Status (LIS) Good Cause Window

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Ms. Goldberg was enrolled in Medicare Parts A, B, & D effective 9/1/2015 .

Ms. Goldberg states she never signed up for Medicare and feels her rights to chose have been violated.

She wants to terminate Medicare effective immediately.

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Primary v Secondary Insurance Medicare entitlement LIS

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Ms. Sawyer is a 70 year old part time social worker. Ms. Sawyer’s had a Part D plan that was terminated

on 5/1/2010. Ms. Sawyer wants to enroll in a Part D plan because

she is now dealing with a medical issue and needs expensive prescriptions that she can’t afford.

She feels that she was saving the government money by not enrolling in the program when she did not needed it.

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Special Enrollment Period Late Enrollment Penalties

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Mr. Stewart, who considers himself a dual beneficiary, stated a hospital is charging him a $15.30 facility fee illegally and believes it’s balance billing.

Mr. Stewart stated that he had several services rendered at the hospital in the past and was never charged a facility fee.

He wants the charges removed and the hospital investigated for illegal balance billing.

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Balance billing Dual Eligible Beneficiary Medicare Benefits

casework scenarios navigating through beneficiary issues

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