Medicare Enrollment Error by Social Security - How to get it fixed?

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Topic Author
MtnBiker
Posts: 208
Joined: Sun Nov 16, 2014 4:43 pm

Medicare Enrollment Error by Social Security - How to get it fixed?

Post by MtnBiker » Fri Nov 29, 2019 11:44 pm

My wife and I have a disabled adult son who lives with us. He meets the Social Security (SS) definition of a DAC "Disabled Adult Child" aka CDB "Childhood Disability Benefit" (disabled prior to age 22, not married, etc.). I am his SS representative payee. When I started SS retirement in October, 2018, his SSI (Supplemental Security Income) payments ended and he began receiving SSDI (SS Disability Insurance) on my earnings record. Furthermore, we have filed for him to receive SSDI on my wife's earnings record, and that was granted retroactively to September 2017. So he is simultaneously entitled on both parent's records, but is drawing SSDI on my record since my earnings were greater.

A person on SSDI becomes entitled to Medicare 24 months after initial entitlement to SSDI. In his case, based on initial SSDI entitlement in September 2017, he became entitled to Medicare on September 1, 2019. It is the responsibility of SS to automatically do the Medicare enrollment for a person on SSDI; unlike a retiree reaching age 65, there is no way for a person on disability to self enroll. Having not yet received his Medicare card, I called SS back in August to enquire on his Medicare enrollment status. The SS agent acknowledged that SS had dropped the ball on enrolling him in Medicare and stated that a request would be made to the "processing center" to enroll him. The Medicare card should be issued in about a month.

Since then I have called SS and Medicare on a monthly basis and there seems to be no progress toward resolution of this issue. Medicare has no record of his enrollment into their system and Social Security continues to acknowledge their mistake, makes promises to issue requests in their system to fix it, but without result.

In October I asked the constituent services office of our US Senator to assist with this issue. His office did receive an email response dated November 5 from a congressional liaison from the SS Administration explaining the facts of this case. (This is the only written communication that I have been able to get.) The email acknowledges the error and states that the problem lies in the Medicare eligibility being set up improperly on my record (Medicare marked as being effective October 2020), rather than on my wife's record. Furthermore the liaison states that a Manager to Manager request was issued asking for immediate action and that followup would be provided until the problem was corrected.

This issue has now come to a head because our state Medicaid office recently (sometime within the last month) received notification from CMS (Centers for Medicare and Medicaid Services) that my son's Medicare is now active. Thus Medicaid is obligated to not pay anymore since Medicare is primary and Medicaid is now secondary. So even though our son is Dual eligible for Medicare and Medicaid, he effectively has no usable health insurance or prescription drug coverage since he cannot use Medicare benefits without a Medicare card/number and Medicaid will not pay when Medicare is primary.

I have no idea why CMS would mark him Medicare active when he is not enrolled in Medicare, but again have no visibility as to how that bureaucracy works.

Today the SS agent said she would process an "urgent" request and that we should hear back from them in 15 days. I don't hold much hope that that will work either as none of my other requests have resulted in any action.

Does anyone have any suggestions for what other actions I should take to get SS to fix their error?
Last edited by MtnBiker on Sat Nov 30, 2019 11:24 am, edited 1 time in total.

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celia
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Re: Medicare Enrollment Error by Social Security - How to get it fixed?

Post by celia » Sat Nov 30, 2019 1:30 am

As another person who has spent a lot of time this year helping a disabled relative on Medicare and Medicaid and trying to understand their benefits, I sympathize with you and think you have done a great job so far in being your son's advocate! Our situation is a little different in that my relative was being helped by her mother, who died this year, causing confusion since no other relatives understood the situation. No one knew that Medicaid reporting had to be done annually (to show continued eligibility because of low income), so benefits were temporarily lost. Everything has now been restored but, as a warning, I suggest you put things in writing so a future advocate for your son can understand the Medicaid and Medicare rules. This thread may end up being a good overview of how things might not run smoothly at times.

I know Medicaid eligibility and benefits are defined differently by each state and don't know the rules for your state. But in our case, Medicaid does not pay the claims for medical care but rather sends SS the premiums for the Medicare supplemental insurance and the premiums for the drug plan. This is good since the patient can then go anywhere for medical care rather than being restricted to an HMO. I don't know the time lag to get the supplemental insurance to be in force, but when all is done, I would make sure that Medicare and the supplemental medical insurance are retroactive to Sept 1, 2019.

As to what to do next, I suggest you "look" for an advocate within Medicare who is knowledgeable and whom you can call directly (try to get a name and phone number) in case the problems continue. The manager who has already been working on this would be a good person to locate. When you next call Medicare (or SS), ask what do they have as your son's Medicare start date. If it hasn't been corrected yet, ask to speak to the manager working on the case and then ask them what does it take to get it fixed. If that person can't help, ask to speak to THEIR supervisor/manager. Go up the call tree until you find someone who has authority to get it fixed, not just a phone rep. Also ask:

When will the start date be fixed?
Will Medicare AND the supplemental plan will be retroactive to Sept 1?
(if not, why not?)
When will your son receive a Medicare card? (need to show it at doctor visits)
When will he receive a card for the supplemental plan? (need to show it at doctor visits)
When will he receive a card for the drug plan? (may need to show it at a pharmacy)
How can you file claims for care received since Sept 1? (ask even if you did not seek care)

The fact that Medicaid has been notified by Medicare is a good sign that things have started to "change". Hopefully your Medicaid letters also have the name and phone number of a case worker assigned to your son. You should also be able to ask them the same questions, but I suspect they will just refer you to Medicare.

Topic Author
MtnBiker
Posts: 208
Joined: Sun Nov 16, 2014 4:43 pm

Re: Medicare Enrollment Error by Social Security - How to get it fixed?

Post by MtnBiker » Sat Nov 30, 2019 11:57 am

celia wrote:
Sat Nov 30, 2019 1:30 am

The fact that Medicaid has been notified by Medicare is a good sign that things have started to "change". Hopefully your Medicaid letters also have the name and phone number of a case worker assigned to your son. You should also be able to ask them the same questions, but I suspect they will just refer you to Medicare.
Thank you for your well thought out and comprehensive response. I will make use of your list of questions to ask. I have no worries about the Medicaid supplemental plan being set up properly and in a timely manner once Medicare is in place, since I have been working with the state all along in this process.

Thinking about this some more, I am not so sure that anything has started to "change" just yet. I think CMS has been working off the September 2019 start date all along. (CMS notified the state Medicaid office to expect Medicare to start soon, back in August.) So the start date and timeline for implementation being used by CMS has always been different than the start date that SS was/is using for automatic enrollment.

So far, Medicare will not talk to me about this at all; since my son is not yet enrolled in Medicare they only refer me to Social Security to get him enrolled. After reading online about Medicare Rights and Protections ("you have certain rights and protections designed to make sure you get the health care services that the law says you can get"), I think I may try to pursue the Medicare appeal/grievance route (via the State Health Insurance Assistance Program (SHIP) and the Medicare Beneficiary Ombudsman) to see if a backdoor approach will help. After all, it is the premature action of CMS that has caused Medicaid coverage to be denied at the moment.

If anyone else has suggestions, would be much appreciated.

Topic Author
MtnBiker
Posts: 208
Joined: Sun Nov 16, 2014 4:43 pm

Re: Medicare Enrollment Error by Social Security - How to get it fixed?

Post by MtnBiker » Mon Jan 13, 2020 7:42 pm

Just to bring closure to this thread, here is a timeline of what has transpired since the last post.

-On December 16 we were notified by email from the Senator's office that the Medicare enrollment had been processed on December 11.
-On December 19 we received an advance copy of the Medicare enrollment letter, with Medicare number, sent from the office of the congressional liaison.
-At that point we called the state office handling dual-eligible individuals and notified them that the Medicare enrollment actually happened and signed up for their dual-eligible Medicaid coverage.
-On December 23 we received the official Medicare award letter and card, back dated to 9-1-2019.
-On December 23 we received an acceptance letter from the insurance company that is the contracted provider for the state Medicaid duals program.
-On December 24 we were able to fill prescriptions at the pharmacy using the LI-NET (limited Income Newly Eligible Transition) Program by showing proof of dual eligibility for Medicare and Medicaid. (LI-NET can be used during the transition period while Part D coverage is being set up.)
-After Christmas we made phone calls inquiring about how to get signed up for Part D coverage with Extra Help. It was our understanding that this is supposed to happen automatically for dual eligible individuals. Neither Social Security, Medicare, or Medicaid representatives were particularly helpful, but Medicaid suggested we call SHIBA for advise. The state SHIBA (Senior Health Insurance Benefits Advisors) office advised to simply specify having Medicaid coverage when signing up for Part D on the usual Medicare enrollment website. So we selected a Part D provider and signed up.
-On December 30 we received the insurance card for state Medicaid supplemental insurance, with coverage starting effective January 1.
-On January 10 we received the purple form from CMS showing proof of automatic enrollment in Extra Help for Part D drug coverage costs.
-On January 11 we received the acceptance letter and prescription drug card from the Part D provider, with coverage effective January 1.

So thanks to pressure imparted on Social Security by our Senator, everything seems to be fixed and working smoothly again.

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