Humana and Medicare Guidelines

[WCMason]

Nope. Doesn't work that way. First, I read every manual under the sun. Made no fewer than 3 calls to Medicare. But the crowning jewel, and the controlling feature, was Humana's Job Aid. It is patterned after CMS rules of course, and it is identical to every other carrier's. If your client enrolls in Part B under General Enrollment Period and has "free" Part A, then he/she is NOT entitled to enroll in a PDP plan for July 1. Why? I don't know. In fact, nobody does that I could find. But that's the rule. I did find a few discrepancies also, similar to what you mention, but when those carriers put out those Job Aids, you are fighting a battle you will not win. Remember - this was an actual case, not a hypothetical one. I started out doing all of the research like it didn't matter so much but in the end I was not about to submit an application that would get kicked back. Simply stated, there is no SEP for the PDP in that situation and it does not qualify for initial enrollment status either. Sad, but true

I don't doubt that it didn't work that way for you. But it can work that way. It has worked that way. For me. Though I did come up empty-handed on commission as a result on one enrollment due to misunderstanding of this.

I submitted the PDP to WellCare. They rejected it. I called them and explained the delayed part B and the general enrollment. I was told both by the first customer rep and her supervisor that there was no such thing as a GEP. So on a conference call with Medicare and the client we enrolled her over the phone successfully using a delayed part B ICEP. It is not considered an SEP.

I should add that I did do more than one this GEP. And one was through Humana. I submitted a paper application as an ICEP and it went through.

See bottom of page 3: http://www.medicare.gov/Pubs/pdf/11219.pdf. This is more explicitly clear that this ICEP is a variation of the IEP referenced in the earlier link.

Can't make it any clearer.

 

[jbage007]

I thought my info was rather clear.

If you got someone to push through an application as you discussed, it was an improper sale. It is not authorized by CMS.

Humana's own Job Aid clearly prohibits any PEP enrollment for someone who has free Part A into a GEP Part B enrollment.

You do it your way, and I'll do it the CMS-approved way.

How's that?

 

[WCMason]

I thought my info was rather clear. If you got someone to push through an application as you discussed, it was an improper sale. It is not authorized by CMS. Humana's own Job Aid clearly prohibits any PEP enrollment for someone who has free Part A into a GEP Part B enrollment. You do it your way, and I'll do it the CMS-approved way. How's that?

Please enlighten us all on how you interpret the bottom of page three of this document?

http://www.medicare.gov/Pubs/pdf/11219.pdf

I'll summarize it: If you already have Part A and enroll in Part B in the General Enrollment Period of 1/1-3/31, you are entitled to an Initial Enrollment Period to enroll in a PDP between 4/1-6/30 for a 7/1 start. It is one of the Initial Enrollment Periods. There are FIVE available IEP opportunities, not one. You only get to use one, but one of multiple.

This document could not be clearer. You may just be beyond educating, but I do want to prevent others viewing this from giving their clients they same disservice you gave yours, who now has to wait for AEP due to your ignorance of eligibility rules.

So tell us, how do you interpret this IEP on page three of this CMS publication?

 

[jbage007]

click on this link (it is Medicare.gov)

When can I join a health or drug plan? | Medicare.gov

Find the part where it says I have Part A and enrolled in Part B in General Enrollment Period.

Click there.

You'll see that such a person only is entitled to enroll in an MA or MAPD plan.

Interestingly, you'll see the bullet point right above that is for people who do not have Part A but enrolled in Part B in General Enrollment Period. Those people ARE able to purchase a PDP with July 1 effective date.

Unfortunately, the link you provided appears to be a mistake (published by Medicare, of course). That happens to be the same PDF I was parading around to people arguing that my client should be allowed to enroll in a PDP for July 1. I was overruled by everyone including 3 separate reps with Medicare (on 3 separate phone calls).

Also, please see the Humana Job Aid for Election Periods. (I presume since this thread relates to Humana products that you would have access to the relevant Job Aid.) The company itself prohibits enrolling in a stand alone PDP for July 1 effective date for anyone who already has Part A and who has late enrolled in Part B via the General Election Period. This provision is found on lines 3 and 4 on page 18 and of course was written to reflect CMS guidelines (not just some PDF floating around on the Medicare website).

Line 4 page 18 applies to the population of people who "enrolled into Part B during the Part B General Enrollment Period (GEP)." And there is a special SEP reason which is GEP Part B.

But there is a qualification that applies to line 4 on page 18. This SEP only applies to people who enrolled into Part B during GEP and who are "not entitled to premium-free Part A."

I was on the phone (this time) with Humana who got one of their CMS analysts to confirm that the Job Aid reflects CMS guidelines (big surprise) and that the restriction referenced above does in fact mean that someone who is not entitled to premium-free Part A is not allowed to enroll in a Part D plan to coincide with a GEP enrollment into Part B.

Stated differently, line 3 on page 18 seems to apply to the situation my client was in, and not line 4. Line 3 refers to the general population of people who enroll into Part B after delaying enrollment. That's it - much broader wording for the population than line 4 but apparently meant to indicate the same population only without the qualification, which is another way of saying that if someone enrolls in Part B during GEP and is entitled to premium-free Part A, then they are not entitled to a SEP to enroll into a PDP at this time, although they are entitled to enroll in an MA or MAPD plan, with or without PDP coverage.

See also, Line 3 on page 7 governing the ability to enroll in an MA or MAPD plan with or without Rx coverage. Interestingly, line 3 on page 7 is exactly the same population as line 3 on page 18, and line 4 on page 7 is exactly the same population as line 4 on page 18, yet line 3 is "not applicable" to PDP plans on page 18 while line 4 is "not applicable" to MA plans on page 7. (Page 7 is the MA qualification section while page 18 is in the PDP qualification section.) Surely, there must be some little nuance between the two populations described in relevant populations referenced on both lines 3 and lines 4, but I have no idea as to what that might be.

That's the best I can do for you, my friend. I happen to agree with your position, or at least I did, until I went through this process just a few weeks ago. I'm just telling you how it panned out, and why. I see no reason to further debate the issue. It is what it is.

Ours is not to understand why, just what.

 

[WCMason]

click on this link (it is Medicare.gov) When can I join a health or drug plan? | Medicare.gov Find the part where it says I have Part A and enrolled in Part B in General Enrollment Period. Click there. You'll see that such a person only is entitled to enroll in an MA or MAPD plan. Interestingly, you'll see the bullet point right above that is for people who do not have Part A but enrolled in Part B in General Enrollment Period. Those people ARE able to purchase a PDP with July 1 effective date. Unfortunately, the link you provided appears to be a mistake (published by Medicare, of course). That happens to be the same PDF I was parading around to people arguing that my client should be allowed to enroll in a PDP for July 1. I was overruled by everyone including 3 separate reps with Medicare (on 3 separate phone calls). Also, please see the Humana Job Aid for Election Periods. (I presume since this thread relates to Humana products that you would have access to the relevant Job Aid.) The company itself prohibits enrolling in a stand alone PDP for July 1 effective date for anyone who already has Part A and who has late enrolled in Part B via the General Election Period. This provision is found on lines 3 and 4 on page 18 and of course was written to reflect CMS guidelines (not just some PDF floating around on the Medicare website). Line 4 page 18 applies to the population of people who "enrolled into Part B during the Part B General Enrollment Period (GEP)." And there is a special SEP reason which is GEP Part B. But there is a qualification that applies to line 4 on page 18. This SEP only applies to people who enrolled into Part B during GEP and who are "not entitled to premium-free Part A." I was on the phone (this time) with Humana who got one of their CMS analysts to confirm that the Job Aid reflects CMS guidelines (big surprise) and that the restriction referenced above does in fact mean that someone who is not entitled to premium-free Part A is not allowed to enroll in a Part D plan to coincide with a GEP enrollment into Part B. Stated differently, line 3 on page 18 seems to apply to the situation my client was in, and not line 4. Line 3 refers to the general population of people who enroll into Part B after delaying enrollment. That's it - much broader wording for the population than line 4 but apparently meant to indicate the same population only without the qualification, which is another way of saying that if someone enrolls in Part B during GEP and is entitled to premium-free Part A, then they are not entitled to a SEP to enroll into a PDP at this time, although they are entitled to enroll in an MA or MAPD plan, with or without PDP coverage. See also, Line 3 on page 7 governing the ability to enroll in an MA or MAPD plan with or without Rx coverage. Interestingly, line 3 on page 7 is exactly the same population as line 3 on page 18, and line 4 on page 7 is exactly the same population as line 4 on page 18, yet line 3 is "not applicable" to PDP plans on page 18 while line 4 is "not applicable" to MA plans on page 7. (Page 7 is the MA qualification section while page 18 is in the PDP qualification section.) Surely, there must be some little nuance between the two populations described in relevant populations referenced on both lines 3 and lines 4, but I have no idea as to what that might be. That's the best I can do for you, my friend. I happen to agree with your position, or at least I did, until I went through this process just a few weeks ago. I'm just telling you how it panned out, and why. I see no reason to further debate the issue. It is what it is. Ours is not to understand why, just what.

I get it now. We were both told by a carrier representative that this was not a valid election. You decided that the carrier rep was correct and CMS published information was wrong. I decided that the carrier rep was an ***, CMS was correct. My client got enrolled July 1 and yours has to wait for a plan until next year.

Just two different ways of meeting a client's needs, I suppose.

 

[vic120]

The Sad Part

Is some gets paid to make this so complicated

And Honestly wouldn't it be easier and make sense
to make any one first effective for part B for any reason
to be eligible for enrollment whether it be MAPD PDP MA or whatever

I just went through this lost a NJ deal last month
I was about to enroll and seen in AARPs cheat sheet that this would not be eligible for enrollment

only to later find out they were and did enroll direct to UHC

Just stupid and just not Necessary be so complicated

 

[jbage007]

I get it now. We were both told by a carrier representative that this was not a valid election. You decided that the carrier rep was correct and CMS published information was wrong. I decided that the carrier rep was an ***, CMS was correct. My client got enrolled July 1 and yours has to wait for a plan until next year.

No, you don't get it at all.

There is no published CMS information supporting your position. All of the CMS published information supports my position.

The printed Job Aid information provided by Humana (which apparently you don't have) follows CMS published guidelines. I did not make any decision based on something a carrier rep said - the CMS analyst (not a rep) with Humana works closely in conjunction with CMS and was advising me as to what the actual CMS guidelines are.

Why don't you stop fighting the facts and just start submitting apps for July 1 effective dates for GEP Part B enrollees who already have Part A and just so what happens bubba.

 

[WCMason]

No, you don't get it at all. There is no published CMS information supporting your position. All of the CMS published information supports my position. The printed Job Aid information provided by Humana (which apparently you don't have) follows CMS published guidelines. I did not make any decision based on something a carrier rep said - the CMS analyst (not a rep) with Humana works closely in conjunction with CMS and was advising me as to what the actual CMS guidelines are. Why don't you stop fighting the facts and just start submitting apps for July 1 effective dates for GEP Part B enrollees who already have Part A and just so what happens bubba.

I just posted the CMS publication twice in this thread. Okay, here we go for the hat trick:

http://www.medicare.gov/Pubs/pdf/11219.pdf

Before this post someone mentioned "the sad part." I'll tell you the real sad part. The only one harmed by this lack of knowledge is the beneficiary. The clueless rep at the carrier bears no cost. The agent who doesn't have enough confidence in his/her knowledge of the rules to pushback on the carrier rather than cave to them doesn't bear any cost, except perhaps a delay in a small commission.

But then there's the beneficiary. The beneficiary goes without a drug plan for six months, at who knows what cost. Also the beneficiary is faced with six months of a lifetime late enrollment penalty. Of course, the beneficiary isn't sharp enough on all of these rules to consider filing a complaint against the clueless carrier rep or the clueless agent.

 

[vic120]

I just posted the CMS publication twice in this thread. Okay, here we go for the hat trick:

http://www.medicare.gov/Pubs/pdf/11219.pdf

Before this post someone mentioned "the sad part." I'll tell you the real sad part. The only one harmed by this lack of knowledge is the beneficiary. The clueless rep at the carrier bears no cost. The agent who doesn't have enough confidence in his/her knowledge of the rules to pushback on the carrier rather than cave to them doesn't bear any cost, except perhaps a delay in a small commission.

But then there's the beneficiary. The beneficiary goes without a drug plan for six months, at who knows what cost. Also the beneficiary is faced with six months of a lifetime late enrollment penalty. Of course, the beneficiary isn't sharp enough on all of these rules to consider filing a complaint against the clueless carrier rep or the clueless agent.

still if they wanted too it could be clearer

and I get it mainly because of this forum

but I can see how some one might not

 

[jbage007]

I just posted the CMS publication twice in this thread. Okay, here we go for the hat trick:

http://www.medicare.gov/Pubs/pdf/11219.pdf

Before this post someone mentioned "the sad part." I'll tell you the real sad part. The only one harmed by this lack of knowledge is the beneficiary. The clueless rep at the carrier bears no cost. The agent who doesn't have enough confidence in his/her knowledge of the rules to pushback on the carrier rather than cave to them doesn't bear any cost, except perhaps a delay in a small commission.

But then there's the beneficiary. The beneficiary goes without a drug plan for six months, at who knows what cost. Also the beneficiary is faced with six months of a lifetime late enrollment penalty. Of course, the beneficiary isn't sharp enough on all of these rules to consider filing a complaint against the clueless carrier rep or the clueless agent.

I see your problem now. You think some random PDF file posted on the MEDICARE website is some kind of mandatory rule issued by CMS.



You actually did publish CMS guidelines earlier and I went in and clearly showed you where the language is that controls this issue but for whatever reason you don't want to read it or you simply don't want to believe it.

You'd rather have your clients rely on some random PDF file posted on the MEDICARE website.



When you think about it, the (actual CMS) rule makes sense. When someone first becomes eligible for Part A, they are entitled to enroll in a PDP AT THAT TIME. If they opt not to do so, then their one and only INITIAL ENROLLMENT opportunity passes them by.

After that, they can only enroll in a PDP plan during AEP, just like everyone else, or unless a SEP applies, where here it clearly does not.

I am done discussing this with you because you refuse to read the actual CMS guidelines and/or the Humana Job Aid which tracks the CMS guidelines.

You just want to issue your own interpretation based on your own misunderstanding or inadequate research ("hey I found a PDF file, wooppie").

Just be sure your E&O stays up to date.



---
By the way, you go on and on about how pitiful and sad it is that people have to go (another - although you leave that word out) six months without a drug plan and they will have an even larger late enrollment penalty.

Well guess what bubba? That is their OWN CHOICE. They had the option to enroll in a stand alone part D plan when they became eligible for Part A. They passed it up. Now they suffer the consequences.

Too bad. Too sad. I'm not crying any tears for those people who opt to try and bamboozle the system by not purchasing a drug plan when they first could just because they don't want to pay the premiums.

And one final big FYI - if those folks really wanted drug coverage in this situation, all they have to do is enroll in an MAPD for July 1. Problem solved. If they don't live in an area where any viable MAPD plans are marketed, again, too bad, too sad. Play by the rules or suffer the consequences.