Termed for Out-of-service Area

Feb 22, 2016

  1. insuranceconceptscindy
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    insuranceconceptscindy Guru

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    Some days I wonder why I do this. . .

    Got a call from a client who said his Part D plan was termed last August. We called Humana to figure out why. Turns out he was trying to fill an Rx near his 2nd home in Lake Tahoe, on the CA side. They immediately flagged it and termed him for being outside of the service area. He has been on the same plan for 3 years and has been back and forth the whole time. Why they decided to term him now, I have no idea.

    I thought that they could not term a plan unless it was a permanent move? His main address has not changed. He does get his mail forwarded by the post office as he travels from house to house.

    What am I missing? Do I have a case to get an SEP? Humana says this happens all the time. I was informed that each time a client goes on vacation/leaves the service area, they need to inform the plan. For Part D?!?!? I think it's BS- in 10 years, this is the first time I've seen this. What can we do? Thoughts?
     
  2. sshafran
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    Forget we ever heard the phrase, "Part D," "CMS," or "SOA," leave the Medicare business, apply for work at McDonald's and be blissfully happy in poverty??? :goofy:
     
    sshafran, Feb 22, 2016
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  3. insuranceconceptscindy
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    Seriously. Not helpful. If I don't actually know you, please don't post snark- it's not cool. You have to buy me dinner first. If you don't have anything nice to say, don't say anything at all.
     
  4. TwoCents
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    By Part D do you mean a stand-alone PDP or an MAPD? While Humana does have some PDPs that cover multiple states (like KY and IN are paired together), the majority of their service areas are by state.

    Why is he only talking to you now about an August termination? Was he trying to handle it on his own?

    I don't believe Humana would terminate someone for filling an Rx outside the plan's service area -- their pharmacy network (not to be confused with the plan's service area) is basically nationwide so it shouldn't have set off any flags.

    Did he recently change his address with SSA who would report that to CMS who would report him as outside the service area to Humana for investigation? Did he happen to have mail returned to Humana? You really need the full story (like all the mail received from Humana) and you're not going to get it from Humana's customer service.
     
    TwoCents, Feb 22, 2016
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  5. sshafran
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    That wasn't snark!!

    That was 100% agreeing with the start of your post - "some days I wonder why I do this."

    I have a client who just moved and we are dealing with similar issues... just coming along side and saying some days it would be easier to be poor...
     
    sshafran, Feb 22, 2016
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  6. insuranceconceptscindy
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    This is helpful.
    Stand alone PDP- Walmart. He should be able to fill anywhere. Hence the fact that I have NEVER had this happen before.
    I just found out about the issue today. He has not done anything about it on his own. He is saying that he was not aware until he filled an Rx last week.
    I asked about the address- he has it forwarded by USPS to wherever he is. My thinking is that CMS got a notice of new address and changed it, but Humana is saying they (Humana) termed him.
    There is a piece missing here somewhere. . .
     
  7. cadylou
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    As long as his resident address registered with Social Security & Medicare hasn't changed, they should not have termed him. You should be able to file a grievance with Medicare and get him reinstated - unless there's something he isn't telling you. Pharmacy networks are national & shouldn't send a red flag for change of address. I have snowbirds who spend months at a second home in the winter & I've never had this happen.
     
    cadylou, Feb 22, 2016
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  8. sman
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    A little feisty aren't we? While I understand your frustration, just remember we don't get to dictate what people post on here.

    I can only assume that your client doesn't fill medications very often. Otherwise he would have realized this long before now if his plan was terminated last August. If there hasn't been an address change then I would think if he gets a competent person at Medicare he can get this resolved. I'm just wondering if Humana mailed something to him requesting confirmation of an address change and he overlooked it. I had a client with a MAPD who ended up in a nursing home and the carrier mailed a letter stating it appeared her address had changed and she was now out of the service area and needed to her to contact them to confirm. Of course, that doesn't mean Humana sent a letter.

    Now you get to spend a few hours trying to get him back on a PDP. Best of all there's a high probability that you will no longer be the agent of record so no $32 for all your hard work. And yes, I realize that's likely the least of your concerns, but just pointing out the things that seem to be the most time consuming pay us the least amount of money.

    Best of luck and let us know how it goes.
     
    sman, Feb 22, 2016
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  9. TDFnCali
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    Probably, but "Buy me dinner first" was funny as hell!! Ive met Cindy a few yrs ago in LV (sure she doesnt have a clue who I am tho), shes nice & smart....now I can add funny to her description, lol!

    PS- I apologize for this post not being helpful either!
     
    TDFnCali, Feb 22, 2016
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  10. sman
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    Send her a gift card to a restaurant and all will be forgiven.
     
    sman, Feb 22, 2016
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