Insurance Agent Forum

[kennethbroyles]

Please join a discussion on this complex case I am advising on……I think I’ll take the easy way out and use a letter to briefly tell the “story.” This is a shortened version of the situation, but I think you will get the point. Thanks for any suggestions in advance.



The letter I faxed to congressional Reps…………………………………………..




7-9-2009


To: Senator Johnny Isakson and Congressman Nathan Deal

From:

On Behalf of:


Charlotte XXXXX contacted me about a month ago regarding a problem with her Medicare Advantage plan. I help people with questions about Medicare.


Let me try to briefly tell her story. During AEP Charlotte wanted to change her plan to a Medicare Supplement from Mutual of Omaha and a stand alone PDP from Wellcare. She applied for these plans in November 2008. She was approved for her Med-sup and was paying for it. The problem seems to stem from the inability of CMS to approve her change request from her existing chronic illness MAPD plan from Care Improvement Plus (CIP). The reason for her decision to change was the increasing premiums and fewer benefits provided by CIP. It seems everyone evolved tried until late in February 2009 to enroll Charlotte in the Med-sup and PDP, but CMS was not giving the approval for the Wellcare PDP, which is the key point. Charlotte couldn’t continue to pay the premiums for both Med-sup and CIP, almost $500/ month. It seemed CMS was not going to do anything about it, so Charlotte told Mutual of Omaha and Wellcare she would just have to keep what she had, CIP. CIP continued to deduct her monthly premium of $237 for 5 months.

Now lets move up to the time the problem starts. Late in May 2009 Charlotte was hospitalized. Coverage was verified, I’m sure by the hospital, showing her enrolled in CIP. When she got home about May 25, she was surprised to see a welcome letter from Wellcare along with her PDP card and showing and effective date of Jan.1 2009. Of course CIP dis-enrolled her retroactive to Jan.1 2009 leaving Charlotte with only Medicare A&B&D ,and with the co-pays and deductibles for all of her care also retroactively to Jan.1 2009. Charlotte and her family tried talking to Wellcare and CIP several times to resolve the issue with no success. Charlotte contacted me sometime around June15th 2009 asking for my help. I made calls to Wellcare, CIP and Medicare on her behalf on several occasions, filing an official complaint against CIP. I was told over and over that they had done what was requested originally back in December by CMS and CIP said they were only doing what CMS had told them to do. I asked to appeal to a higher level and they said they couldn’t do that until later.

We want you to contact CMS on behalf of Charlotte and find someone with the authority to see the mistakes and harm this has caused her. I suppose the best outcome we can hope for is to keep Care Improvement Plus from 1/1/2009 till 1/1/2010.

Charlotte would like for you to contact me for further information and follow up on her behalf.

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXX

Thank you for your attention and help.


_________________________________________________ 7/9/2009

__________________________________________________
7/9/2009

[Frank Stastny]

A few questions first.

Were the legislators from your district or hers? It does make a difference. If they are yours they may be slow in reacting if in fact they do at all. It is an effort in futility for people to send letters to any senator or representative unless the author of the letter is a voting constituent.

If they are yours then write a letter so it appears she wrote it to those two individuals and have her sign it along with her contact information. Full contact information is very important.

It does not sound like she officially wrote a letter canceling her MAPD plan. This must be done in a timely fashion. By her simply applying for a Med Supp does not mean automatic disenrollment in her MAPD plan.

Once she officially disenrolls then she should have been placed on Traditional Medicare effective Jan. 1. She needs to get her Medicare back, I know, I don't want to get into that discussion again. She gave up Traditional Medicare when she signed up for the MAPD.

Simply contacting CMS is not going to put her back on Medicare. CMS's records probably show that she is still on the MAPD plan unless she sent a letter to CIP. If in fact she did send the letter then she may have to produce a copy of it. If she can't she may be SOL.

If she has the letter of cancellation then a copy of that needs to be sent to her senator and representative. All of this should have been done in December or January at the latest. She should have kept her Med Supp and raised hell and put a chunck under it when she found out she was still being charged for the MAPD plan.

If it were my client I would recommend that she call her senator and rep in addition to having sent a letter. I would go balls to the wall if necessary.

All the crap CMS came out with this year under the pretense of "protecting seniors"... What a joke!

You have jumped in the middle of a hornets nest. I admire your willingness to jump in and "kick ass and take names".

What happened to the agent who sold her the MOO Med Supp? Why didn't he help her cancel her MAPD. He probably "took his money and ran". Doing what we do is not just about making a commission it is about providing exemplary service to our clients.

[jdeasy]

When she enrolled in the stand alone PDP during AEP for the Jan. 1, 2009 effective date, she should have been automatically disenrolled from the MAPD.

It still helps to send a letter to the comapny being disenrolled from by the client.

Something went terribly wrong in this situation.

[Frank Stastny]

Originally Posted by jdeasy

When she enrolled in the stand alone PDP during AEP for the Jan. 1, 2009 effective date, she should have been automatically disenrolled from the MAPD.

It still helps to send a letter to the comapny being disenrolled from by the client.

Something went terribly wrong in this situation.

Yes it did. I agree, she should have been automatically disenrolled.

Her MOO agent should have been there kicking ass and taking names. Ya got to love agents who don't know the meaning of SERVICE. Funny how they all know the meaning of "commission".

The letter is a CYA in case things go South. This went so far South that it is headed back North again.

[stormtracker]

I wish I were Charlotte's lawyer-- I'd go Pro Bono just to have the chance to nail some asses to the wall on this one. And, I'm talking carriers, not the agent.

[Frank Stastny]

Originally Posted by stormtracker

I wish I were Charlotte's lawyer-- I'd go Pro Bono just to have the chance to nail some asses to the wall on this one. And, I'm talking carriers, not the agent.

You and me both. Crap like this really gets my back up.

Although the agent isn't totally responsible he should at least receive a "tongue lashing" for not providing service and staying in contact with his client. When he doesn't do his job it makes all of us look bad.

[moonlightandmargaritas]

Although the agent isn't totally responsible he should at least receive a "tongue lashing" for not providing service and staying in contact with his client. When he doesn't do his job it makes all of us look bad.

I think we should be careful about jumping to conclusions and quick indictments. It could well have been that he/she tried.

We all have clients who resist "staying in touch". They neither take, nor return calls, etc.

Some aren't looking for a relationship, they just want to buy a policy.

[yabadabadoo1026]

I got involved with 2 weeks ago with a major issue from a client I put on an MAPD who at the time I visited her claimed she only had a Todays Options PDP and a medicare card.

I hate to mention carrier names since I have only heard her side of the story but she claims Wellcare has kicked back to her $4000 of bills they are not covering. For the longest time in trying to sort of the mess she told me she had no Wellcare Card or Wellcare Welcome Kit and didnt even know how Wellcare got involved. After suspecting something fraudulent may have been going on-------we know Wellcare reputation is a bit tarnished----she made some calls at my direction getting different answers from all she spoke to there when I told her to ask for a signed by her application. Eventually they claimed she signed up by phone in Feb which triggered her remembering such--noone had come to her home.. Strangely enough Wellcare showed her cancelled out 4 weeks later and we have no idea what triggered that as the MAPD i put her in wasn't effective till 6/1. She got nothing from them that made since --maybe they hoping she will just drop it in frustration.

It all seems strange but I told her to let it rest since in her inquiries one said they would pay the bill which is her main concern now---could be a lie---maybe cause shes asking questions.

A carrier can not call them and sign them up directly over the phone can they??????????--------wouldnt think so with all the limitations on us.

I told her to get ther bill paid and them well delve into this and see if there was any fraud.

Again I've only heard one side but with Wellstars rep/history of playing it a little loose sometimes I'm not inclined to give them the benefit of the doubt at this point and can only wonder if their involvement in this issue maybe part of the problem.

When we get to the bottom of it I will report back cause I'm not making assertions but only mentioning another messy and strange situation with a Wellcare involvement.

[Frank Stastny]

Originally Posted by moonlightandmargaritas

I think we should be careful about jumping to conclusions and quick indictments. It could well have been that he/she tried.

We all have clients who resist "staying in touch". They neither take, nor return calls, etc.

Some aren't looking for a relationship, they just want to buy a policy.

Point well taken. I may have pulled the trigger too fast.

Guess you just can't shoot them all and let God sort them out.

[moonlightandmargaritas]

Originally Posted by Frank Stastny

Guess you just can't shoot them all and let God sort them out.

Some of these folks just have you pulling your hair out (if you have hair - thankfully I do).

Had a guy who's wife had to have early-stage cervical cancer surgery/treatment (I've had like 6 big cancer claims in the last 6 months or so).

He called me kickin' and screamin' that United Healthcare hadn't paid some bills that they were supposed to. I asked him to go back through his checkbook, or Quicken, or his credit card statements to calculate exactly how much he had paid, to make certain he was over the OOP limit.

Never heard from him again.

[stormtracker]

That answers your question!!!

[kennethbroyles]

Thanks for all of the comments...let me try to fill in some information.

• We both have the same congressman and senators , all three were contacted.
• She enrolled in Welcares PDP at the same time her application was submitted to MOO for her Med Sup. Both application dates in NOV. 2008.
• Yes it seems the agent gave up on the case and so did Charlotte. BTW Charlotte is 80 yrs.young.
• I was told by a sympathetic SSA agent we had to wait at least 4 wks. before filing an appeal to the next level. I’m not very patient.
• Talking to Wellcare they say Charlotte is enrolled in the plan she asked for, over and over they said this along with “this is what CMS says to do.”
• CIP of course returned 5 MO premiums. $237/MO. OUCH! They say they will be happy to enroll her again for “next month,,, yeah I bet they would…… continuing on to say they are just doing what CMS told them to do.
• Remember the real point. She made a valid application in NOV /2008 and was approved for MOO Med SUP. .. at the same time applied for PDP with Wellcare during AEP.No one was able to get it processed (6/15/09 I get the call after family has tried to help)..... Now late in May she finds out Wellcare is PDP.CIP and her MA benefits are gone … retroactive 1/1/09. MOO sent back the payments for JAN and FEB not on the hook.
• No one has the authority so far to see the mistake and injustice.

What do you think the outcome will be? Who is at fault? I know that answer…..=CMS @fault.gov

[jdeasy]

Originally Posted by yabadabadoo1026

I got involved with 2 weeks ago with a major issue from a client I put on an MAPD who at the time I visited her claimed she only had a Todays Options PDP and a medicare card.

I hate to mention carrier names since I have only heard her side of the story but she claims Wellcare has kicked back to her $4000 of bills they are not covering. For the longest time in trying to sort of the mess she told me she had no Wellcare Card or Wellcare Welcome Kit and didnt even know how Wellcare got involved. After suspecting something fraudulent may have been going on-------we know Wellcare reputation is a bit tarnished----she made some calls at my direction getting different answers from all she spoke to there when I told her to ask for a signed by her application. Eventually they claimed she signed up by phone in Feb which triggered her remembering such--noone had come to her home.. Strangely enough Wellcare showed her cancelled out 4 weeks later and we have no idea what triggered that as the MAPD i put her in wasn't effective till 6/1. She got nothing from them that made since --maybe they hoping she will just drop it in frustration.

It all seems strange but I told her to let it rest since in her inquiries one said they would pay the bill which is her main concern now---could be a lie---maybe cause shes asking questions.

A carrier can not call them and sign them up directly over the phone can they??????????--------wouldnt think so with all the limitations on us.

I told her to get ther bill paid and them well delve into this and see if there was any fraud.

Again I've only heard one side but with Wellstars rep/history of playing it a little loose sometimes I'm not inclined to give them the benefit of the doubt at this point and can only wonder if their involvement in this issue maybe part of the problem.

When we get to the bottom of it I will report back cause I'm not making assertions but only mentioning another messy and strange situation with a Wellcare involvement.

The first hint for you should have been that Today's Options is not no, nor has it ever been a stand alone PDP. Is she has Today's Options, she is on an MA plan, either stand alone MA or an MAPD. If she has rx coverage with her Today's Options, it's the MAPD.


To answer another question, yes carriers can sign people up by phone without using an agent. Funny how CMS allows that, huh?

[yabadabadoo1026]

Jd, when i google/go to Todays Options they do show stand alone Part D Drug Plans in Ga sold as Community CCrx---I must say its confusing since it falls under Universal American ---------here's the link

( ????????? -----don't know why this keeps changing the link i pasted in ?????)

So you are saying we can't cold call a propect to sell a plan even in person but the carrier can cold-call and sell them over the phone??????????????????-----------Unbelievable, now how would CMS explain such???????

[jdeasy]

Originally Posted by yabadabadoo1026

Jd, when i go online to Todays Options they do show stand alone Part D Drug Plans in Ga sold as Community CCrx

So you are saying we cant cold call a propect to sell a plan even in person but the carrier can cold-call and sell them over the phone??????????????????-----------Unbelievable, now how would CMS explain such???????

The stand alone PDP from UA is CCRX. It was Prescription Pathways. They have other names as well. Today's Options is not the name of a stand alone PDP. If the lady has a card that says Today's Options on it, it is an MA or MAPD.

I don't know what the rules are for a comapny doing cold calling. They may have to have a prior relationship with the person to call them. I'm not versed in those rules. However, if they have a PDP currently with that company or one of their umbrella companies, that would give them the opportunity to call them. Once on the phone with them, they could enroll them over the phone. If they don't have some sort of relationship with the person that would give a right to call, you could have a remedy there.

CMS allows companies to direct enroll members by phone and/or online.

[yabadabadoo1026]

The issue isnt the Todays Options or CCRX drug card-----she was called and enrolled over the phone by Wellcare and somehow disenrolled 4 weeks later for no apparent reason. She certainly had no prior relationship with them if such is required for a cold call/sell over the phone.

She never even received a card or a Welcome Kit and how her doctors submitted bills to Wellcare is also a mystery since she never present such a card.

Whole think sounds very suspect

Sorry kennethbroyles, never was any intent here to hijack your thread

[G.Gordon]

Sounds like she may be close to break even financially. She got back 5 x $235 and two months of MOO premium, right? I know this isn't the focus, but it really is the main point... her financial impact due to all this mess.

I've had a case somewhat simular to this in the past. Not caused by my actions, but due to ill-advised actions by the beneficiary on part of 1-800-medicare.

Bottom line the refunded premiums were just short of paying his uncovered bills. His situation was finally what he wanted and I helped him get a supp.

Instead of this battle work the numbers. Sometimes helping a client is not about doing battle, but getting them to a place they feel comfortable.

So far it sounds like she's responsible for at least the part A ded.. $1064, part B ded. 135, and unknown co-insurance. So I'd assume at most she's OOP maybe $1500. Assuming $110/mo for the MOO supp and the five mo. of CIP refund... $1395 in premiums. She may have slipped by relatively unharmed... so to speak.

Good luck.

[jdeasy]

Originally Posted by yabadabadoo1026

the issue isnt the Todays Options or CCRX drug card-----she was called and enrolled over the phone by Wellcare and somehow disenrolled 4 weeks later for no apparent reason. She certainly had no prior relationship with them if such is required for a cold call/sell over the phone.

She never even received a card or a Welcome Kit and how her doctors submitted bills to Wellcare is also a mystery since she never present such a card.

Whole think sounds very suspect

Sorry kennethbroyles, never was any intent here to hijack your thread

That is part of the issue now. If you are going to try and get this corrected, you must know how it got to this point. If you contact the carriers or CMS and don't know the accurate trail of events, you will get nowhere fast.

She, obviously, was on an MA and it seems she was on an MAPD. How she got on that is just as important as how she got off of it.

The devil is in the details.

[yabadabadoo1026]

Kennethbroyles, its laffable and horrible that an agent would put anyone on or leave anyone on if it was the case of an increase a $237/mo MAPD rather than a Supp to begin with------what justification could there possibly be for a MAPD thats more costly than a Sup

I'm contracted with CIP as well and know they have a Gold plan at $30-------they even suggest to not push the Platinum------that they even offer a $237/mo a plan discredits them as it suggests they hoping for occational suckers

[stormtracker]

I sold a number of those platinum's-- just depends on matching the customer's needs to the plan's benefits...