Tricked by Carrier That Enrolled Client in HMO

[somarco]

MBO involved and requesting phone records, etc from Wellcare. Management at WC says the application looks odd as it was signed by the agent, not the member. Phone call to member was mid October . . . app was not submitted until the end of November. WC says agent will be reprimanded.

Now WC wants to "make it right" for the member but no retroactive change. New coverage can be effective 2/1/2024. Client is very upset but is looking at things rationally. I believe my client will pick a different PDP carrier. Shocking . . .


And thanks for the speculative comments based on assumptions without facts. Very revealing . . .

 

[TwoCents]

If the Wellcare HMO enrollment letter was received by 12/31, then why didn't they just request a cancellation of that plan; the PDP would have been put back in force. Figure out how the HMO enrollment happened afterwards. Clients really should be encouraged to file a complaint with Medicare to have the problem researched. Compliants hurt plans stars ratings; they'll give them a little better attention than just calling into the plan's customer service who knows nothing.

 

[bill3173]

I also told her to pay the January Medigap premium and, if possible, postpone any provider appointments scheduled in January.

Why does she need to postpone appointments, if she didn't cancel her Med Supp?

 

[somarco]

Why does she need to postpone appointments, if she didn't cancel her Med Supp?

Because of the WC SNAFU, their HMO plan is primary in January, OM & Medigap are moot.

When someone has MA and supp (which is not supposed to happen) claims are routed to the MA plan as the primary payer and are never seen by OM or the Medigap.


I was not notified of this problem until Saturday 12/30 when the client sent me an email alerting me. I didn't get the full picture until the next day and they didn't send me the WC letter until Monday 1/1.

Much of this could probably have been avoided if they had contacted me when they got the WC letter . . . but they tried to handle it themselves and it only got worse.

 

[bill3173]

Because of the WC SNAFU, their HMO plan is primary in January, OM & Medigap are moot.

When someone has MA and supp (which is not supposed to happen) claims are routed to the MA plan as the primary payer and are never seen by OM or the Medigap.


I was not notified of this problem until Saturday 12/30 when the client sent me an email alerting me. I didn't get the full picture until the next day and they didn't send me the WC letter until Monday 1/1.

Much of this could probably have been avoided if they had contacted me when they got the WC letter . . . but they tried to handle it themselves and it only got worse.

Okay, I thought the MA was going to be canceled back to 1/1. I had a similar case last year.

 

[somarco]

Okay, I thought the MA was going to be canceled back to 1/1. I had a similar case last year.

That's what I hoped for, but I wasn't invited to the party until my client got fed up with trying to unwind things by calling WC.

By the time they asked me for help it was a holiday weekend and they didn't know about a Medicare Beneficiary Ombudsman until I told them of this route. The MBO contacted WC and is waiting on responses.

I have had several conversations with my client since Saturday (12/30). Initially she wanted to get as far away from WC as possible. Now she thinks she wants to keep WC but a different plan that offers a lower cost for her expensive med and includes her pharmacy as a preferred vendor.

If the MA was cancelled retroactively she would have also had the WC Value Script which would have been fine but the WC Value Plus generates a lower total cost . . . saving her about $300 per year.

She just needed an education on how drug plans work and someone (me) to hold her hand and walk her through it.