Reviews

Dear Better Business Bureau:

I am writing in response to the inquiry the beneficiary submitted to CarePlus on behalf of **** M. *********. We have researched the concern and identified the following:

In regard to the beneficiary's concerns against the CarePlus associates who did provide accurate information over the phone, these allegations have been forwarded to the appropriate department/leaders for investigation. A full investigation will be conducted, and corrective action taken, if needed.Please be advised that all review findings are confidential and not subject to disclosure to our beneficiaries.

In addition, we reached out to the CarePlus ********************* and requested a review of their records. They informed us that the beneficiary was disenrolled from CarePlus effective May 1, 2023, because CarePlus did not receive a response to the letters that were mailed to the beneficiary requesting them to call the plan and confirm their address. On October *******, CarePlus received a notification from the ****************************************** (CMS) advising that the beneficiary may be out of the service area. Per CMS guidelines, the beneficiary was mailed the required letters, and any responses were tracked for six (6) months. The beneficiary did not contact the plan to confirm their address during that time period, and therefore they were disenrolled from the plan. The first letter was sent to the beneficiary on October 22, 2022, notifying them that they may be residing outside of the plans service area - and that they would be disenrolled six months from the date of the letter. A reminder letter was mailed on January 23, 2023; and the final letter was mailed on April 10, 2023. On May 4, 2023, a letter was mailed to the beneficiary confirming their disenrollment with the effective date of disenrollment: May 1, 2023.

According to our records, the beneficiary is currently enrolled in the CarePlus CareOne Plus Health ************************ (HMO)H1019-001 policy effective August 1, 2023. On July 10, 2023, the health plan received an enrollment application on the beneficiarys behalf, and it was processed with an effective date of August 1, 2023. Please be advised this application was forwarded to CMS for processing and the beneficiarys enrollment application was accepted by *** on July 12, 2023. On August *******, CarePlus Health Plans received a notification from CMS advising of a creditable coverage change with an effective date of August 1, 2023.Subsequently, on August 23, 2023, CarePlus Health Plans received a notification from CMS advising that a new enrollment penalty was accepted with an effective date of August 1, 2023.

In addition, the CarePlus ********************* reported that the beneficiarys monthly Late Enrollment Penalty (***) amount is $1.00 effective August 1, 2023. According to their records, a letter was mailed to the beneficiarys residence on July 13, 2023, advising that the beneficiary did not have creditable prescription drug coverage that met ********* minimum standard. The letter stated that if the beneficiarys records show that the beneficiary had prescription drug coverage from May 1, 2023, to August 1, 2023,the beneficiary can avoid paying the monthly penalty by returning the enclosed form to CarePlus Health Plans, Inc. ******************************************* or by calling *************** at ************** to provide information by August 12, 2023. On July 21, 2023, a final notice letter was mailed to the beneficiarys residence requesting proof of prescription drug coverage be submitted by August 12, 2023. On August 23, 2023, the ********************* mailed a letter to the beneficiarys residence informing the beneficiary that starting August 1, 2023, the beneficiarys new premium will include a late enrollment penalty of $1.00 per month. According to ********'s records, the beneficiary did not have creditable coverage for 3 months from May 1, 2023, to August 1, 2023. The beneficiary was advised that the beneficiary can submit a reconsideration request within ************************************************************************************************************************************** ******** may not consider the request.

Furthermore, the ********************* informed us that the *** is sent to CarePlus directly from CMS, and the beneficiary must request a reconsideration to the contracted ************************* (***):***************************** The Late Enrollment Penalty is an amount that is permanently added to a beneficiarys monthly Part D premium. This accumulates when a beneficiary goes 63 days or more without credible prescription drug coverage. A Creditable coverage is a prescription drug health insurance (coverage)that meets a minimum set of qualifications established by ***. The Late Enrollment Penalty is assessed by ********. The *** is calculated by multiplying 1% of the ********************************* times the number of full, uncovered months without prescription drug coverage. The final amount is rounded to the nearest $0.10 and added to the beneficiarys monthly Part D premium.

Please be advised, if the beneficiary would like to reconsider their ***, the beneficiary must send a signed reconsideration request to the ***: ****************************. The request should include any supporting documentation and may be submitted to:

******************************
Part D *** reconsiderations
P.O. ******************************************
Fax: **************
Toll free customer service: **************
Web portal: ****************************************

Lastly, please be advised if beneficiaries have any questions, they can contact our *************** Department at **************;TTY: 711. From October 1 - March 31, we are open 7 days a week, 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 ****** addition, the beneficiaries can always leave a voicemail after hours,Saturdays, Sundays, and holidays and we will return their call within one business day.

Thank you for alerting us about this issue. We value our relationship with our members and take all complaints seriously.

Sincerely,       

**** *******
Supervisor
Grievance/Appeals Department

Dear Better Business Bureau,

I am writing in response to the inquiry you submitted to CarePlus on behalf of ****** *********. We have researched the concern and identified the following:

The beneficiary's allegations have been forwarded to the appropriate department/leaders for investigation. A full investigation will be conducted, and corrective action taken, if needed. Please be advised that all review findings are confidential and not subject to disclosure to our beneficiaries.

As per the Centers for ******** and ***************** (CMS)guidelines, CarePlus Health Plan has 14 days to make a determination for a standard authorization request and 72 hours for an expedited authorization request. When an authorization is approved, the beneficiary's ************ Physician (PCP) has access to the submitted authorization through a delegated portal. In the case of an expedited organization determination, the beneficiary receives a phone call. If CarePlus is unable to reach them, a voicemail is left, and/or a letter is sent notifying them of the decision. The denial letter is mailed to the beneficiary the same day it is generated.  If the authorization is denied, the beneficiary has the right to appeal the decision within 60 days of the date of denial.

According to CarePlus records, on July *******, the beneficiary contacted CarePlus and was assisted by a *************** Representative with opening an expedited authorization on his behalf for Home Health Care (***)services. This request was denied under authorization 15420839**** on July *******, because CarePlus contacted the office of the beneficiarys ************ Physician (PCP) Dr. ********* *********-********* to discuss his case. However,CarePlus did not receive the **** consent, an order, and the clinical information required for the request. CarePlus contacted the beneficiary and left a voicemail advising of the authorization denial and educating on their appeal rights. On August 3, 2024, we mailed a denial letter to the beneficiary with appeal rights. Additionally, per the beneficiarys request, we have mailed the denial letter again on October 2, 2024.

In addition, on September 30, 2024, the beneficiarys PCP,Dr.*********-*********, submitted an authorization for *** with Registered Nurse (RN) visits this authorization request (15583909****) was denied on October 1, 2024, because CMS guidelines state that for an enrollee to qualify for *** services or a home health aide (HHA), the beneficiary needs to be confined to the home, be under the care of a physician, and receiving services under an established plan of care that is periodically reviewed by the physician.The beneficiary must also be in need of skilled nursing care on an intermittent basis, or physical therapy or speech-language pathology, or have a continuing need for ********************. CarePlus reviewed the information received from **************************** (IHCS), CarePluss delegated provider for *** services, which indicates that the beneficiary does not meet the ******** criteria for ***, because he receives daily ***** care/maintenance under ************ Insurance. The clinical information did not indicate that the beneficiary requires additional skilled care at home. Please be advised that the decision to deny this request is based on: Centers for ******** and ***************** (CMS) - 100-02-******** Benefit Policy Manual - Chapter 7 -Conditions Patient Must Meet to Qualify for Coverage of Home Health Services,Section 30. On October 4, 2024, CarePlus mailed a denial letter to the beneficiary with appeal rights.

Furthermore, the beneficiary has the right to appeal our decision.The beneficiary has the right to ask CarePlus Health Plans to review our decision by asking us for an appeal within sixty days of the date of the denial notice. We can give the beneficiary more time if they have a good reason for missing the deadline. They may file an appeal by mailing their request to:

CarePlus Health Plans,INC.
P.O. Box 277810
*****************
Fax: ************
Email: ******************************************************************************

Please note that upon receipt of the beneficiarys appeal they will receive a decision in writing as expeditiously as their health requires but no longer than sixty calendar days.

Lastly, the Grievance and Appeals Representative attempted to contact the beneficiary on October 2, 2024, and October 9, 2024, to offer further assistance; however, we were unable to reach the beneficiary. Since the beneficiary expressed having a negative experienced with CarePlus Associates because of concerns with inappropriate behavior or attitude, these allegations were forwarded to the appropriate department/leaders for investigation. Please be advised that all review findings are confidential and not subject to disclosure to our beneficiaries.

Thank you for alerting us about this issue. We value our relationship with our members and take all complaints seriously.

Dear Better Business Bureau,

I am writing in response to the inquiry you submitted to CarePlus on behalf of ******************************. We have researched the concern and identified the following:

As per the Center for ******** and ******** Services (CMS) guidelines, CarePlus Health Plan (CPHP) has 14 days to make a determination for a standard authorization request and 72 hours for an expedited authorization request. When an authorization is approved, the beneficiary's ******* Care Physician (***)has access to the submitted authorization through a delegated portal. In the case of an expedited organization determination, the beneficiary receives a phone call. If CarePlus is unable to reach them, a voicemail is left, and/or a letter is sent notifying them of the decision. If the authorization is denied,the beneficiary has the right to appeal the decision within 60 days of the date of denial.

According to CarePlus records, on January 17, 2024, the beneficiary's ***, ***************************, submitted an authorization for office visits with gastroenterologist **************************, which was approved that same day under authorization number 14857490*PO for three visits expiring on January 16, 2025. Furthermore, on July 9, 2024, the beneficiary's *** submitted an expedited authorization for a colonoscopy and biopsy with ************** at *****************, which was approved on July 10, 2024, under authorization number 15367084*OS for one visit,expiring on October 9, 2024. CarePlus contacted the beneficiary and left a voicemail advising of the authorization approval and instructed them to contact CarePlus ****** Services or their *** for further information about the approved service.

Moreover,the Grievance and Appeals Representative reached out to the office of *** ************************** and requested a review of their records. The office reported that they first received the referral request for the colonoscopy on July 2, 2024,and that it was submitted to CarePlus Health Plans for review and determination on July 9, 2024. The office received the approved authorization on July *******, and it was faxed to the specialist that same day. As per the office policy of **************, once they receive a referral request from a specialist,they will process and submit it to the health plan within 72 business hours.Once it is approved by the plan, they will fax it to the specialist. The office of ************** clarified that they were closed on July 4 and July 5 of 2024, for the holiday.

Please note that the *** is responsible for providing routine health care needs and overseeing care. If the beneficiary requires certain types of covered services or supplies from network providers, they must obtain approval in advance from their ***, such as getting a referral. All communications with medical offices are conducted through the Provider ********************** and provider offices can always contact CarePlus Provider Services for assistance. For authorizations, all providers have access to submitting and receiving approvals via an electronic portal.

Furthermore,a Grievance and Appeals Representative contacted the beneficiary on July 1******, to offer further assistance. During the call, the beneficiary advised that she only needs a colonoscopy and that she is currently scheduled to have it completed with gastroenterologist ************** on October 2, 2024. The Grievance and Appeals Representative offered to assist in finding a new gastroenterologist with an earlier appointment; however, the beneficiary declined as they preferred to have ************** perform the colonoscopy.Therefore, we contacted ******************************* office at *****************. They confirmed that the beneficiary is scheduled for a colonoscopy on October ******. Their records indicate that the beneficiary was previously scheduled for the colonoscopy on July 10, 2024. The office indicated that no sooner appointments were available. We inquired if they have a waitlist for cancellations to help the beneficiary get an earlier appointment, but they do not have one. Due to high demand, there is limited availability for these procedures. Some providers are scheduling appointments as far out as February.

In regard to the wait of the call center, we apologize for any inconvenience regarding the expressed concern. We are currently experiencing higher than normal call volumes and are working diligently to resolve this issue. Wait times fluctuate throughout the week based on member demands. We appreciate their concern and sincerely apologize for any inconvenience caused.

Thank you for alerting us about this issue. We value our relationship with our members and take all complaints seriously.

Best Regards,