ComplaintsforCarePlus Health Plans, Inc.
Health Insurance
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Complaint Details
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Initial Complaint
03/22/2024
- Complaint Type:
- Product Issues
- Status:
- Resolved
On November 24, 2023, I emailed the company to ask to be removed from their database because I was receiving junk mail for ****** and ***************************. They claimed that they would forward the email to the appropriate department. Nonetheless, they are still sending junk mail to my home for *******************************.****** and *************************** do not live here. Please delete my address from your database.Business response
04/01/2024
Based upon our review a Grievance and Appeals Representative has investigated the Ms. ************ case and addressed the concerns. According to our review: we confirmed that the request to stop all mailings to their address was received on November 24, 2023, and subsequently forwarded to the appropriate department for action. Our records indicate that all necessary steps have been taken to cease all future mailings.
Please be advised if beneficiaries have any questions, they can contact our ************************** 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 p.m.In addition, the beneficiaries can always leave a voicemail after hours,Saturdays, Sundays, and holidays and we will return their call within one business day.
We apologize for any inconvenience they may have experienced. We value our relationship with our members and take all complaints seriously and thank you for alerting us about this issue.Customer response
04/03/2024
Better Business Bureau:
I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
Sincerely,
***********************************Initial Complaint
11/13/2023
- Complaint Type:
- Customer Service Issues
- Status:
- Answered
I am a person with a lot of health is***s and this plan is the worst they left me without my medication am a disabled person with heart problems, psychiatric problems and I end ** in Emergency room,how unprofessional if something else happened to me I will *** the Careplus planBusiness response
11/21/2023
Better Business Bureau
Reference: #********
Based upon our review, a Grievance and Appeals Representative has investigated the beneficiarys case and addressed the concerns regarding their dissatisfaction with CarePlus Health Plans, due to the difficulties they experienced in obtaining their prescription medication. According to our review:
Upon conducting a review of the beneficiary's account, we confirmed that the beneficiary's coverage with CarePlus Health Plans began on November 1, 2023, specifically under the ********* Plus (HMO D-**** policy. Our records indicate that on November 13,2023, the beneficiary reached out to the plan for assistance in obtaining a 30-day supply of 90 tablets, for the medication Hydrocodone-Acetaminophen ******, as prescribed by *********************** on October 5, 2023. After reviewing the beneficiary's prescription claims, we confirmed that the plan had initially rejected the medication, on November 13, 2023, due to exceeding CarePlus' set limit for opioid prescriptions when beneficiaries are new to the plan. For such cases, an exception review is required to proceed. In the meantime, while awaiting the review, the beneficiary has two options. The first is to collect an initial 7-day supply covered by the plan using their original prescription.Once this initial supply is exhausted, they can then obtain any future refills,but a new prescription will be necessary. However, we also found that the medication was being rejected due to the concurrent use of the requested drug Hydrocodone-Acetaminophen ****** and the beneficiary's Alprazolam 1 Mg Tablet.The combination of these two drugs presents a safety concern and requires the beneficiary's doctor to provide an explanation for why they need to be used in conjunction.Regarding exceptions, the plan will provide a response within 24 hours for expedited requests and within 72 hours for standard requests, once we have received the doctor's supporting statement. However, if the beneficiarys health requires it, we will provide a determination sooner. The beneficiary may refer to Chapter 9, Section 7.3, titled "Important things to know about asking for exceptions" in their 2023 Evidence of Coverage for ********* Plus (HMO D-****.
Moreover, in an effort to assist the beneficiary, on November 13, 2023, a ****** Services Representative assisted the beneficiary by submitting a coverage request for their medication.The request was approved, and on November 14, 2023, an approval letter was sent to inform the beneficiary of coverage for Hydrocodone-Acetaminophen ****** MG 90/30. It is important to note that this authorization is valid until December 31, ****, and a new approval will be needed for the same medication in ****.Any changes to prescription coverage in **** will be communicated in advance. Furthermore, a ****** Services Representative initiated an authorization request on behalf of the beneficiary for an office visit with pain management specialist ***********************. The request was approved on November 15, 2023, and is valid until February 9, ****.
In addition, according to our records, a claim for Hydrocodone-Acetaminophen ****** MG 90/30 was processed and filled on November 15, 2023. We have verified with Medicine Shoppe Pharmacy that the beneficiary was able to pick up their 30-day supply of medication.
In accordance with the beneficiary's 2023 Evidence of Coverage Chapter 5, our plan has implemented a *************** Program (DMP) to ensure the safe use of prescription opioids and other commonly abused medications. If a beneficiary obtains opioid medications from multiple doctors or pharmacies or has recently experienced an opioid overdose, we may collaborate with their doctors to assess the appropriateness and medical necessity of their opioid medication usage. Should it be determined, in consultation with their doctors, that their use of prescription opioids or benzodiazepines is not safe, we may impose restrictions on how they can access these medications. The limitations imposed under our DMP may include requiring them to obtain all prescriptions for opioid or benzodiazepine medications from specific designated pharmacy/pharmacies. As well as requiring them to obtain all prescriptions for opioid or benzodiazepine medications from specific designated doctor/doctors. Lastly, this could include limiting the quantity of opioid or benzodiazepine medications covered for them.
Furthermore, on November 14,2023, a Grievance and Appeals Representative reached out to the beneficiary to provide further assistance with medications and medical visits. However, during the conversation, the beneficiary declined the need for any additional assistance apart from receiving their medication. Nevertheless, as the beneficiary indicated that they have many medical and behavioral difficulties,they were informed about the coverage of outpatient mental health care services. These services include mental health treatment provided by licensed professionals such as psychiatrists, doctors, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, physician assistants, or other mental health care professionals who meet ******** qualifications as per relevant state laws. It is important to note that prior authorization requirements may be applicable. They were also educated that that CarePlus is a ******** Advantage Prescription Drug (MA-PD) Health ************************ (HMO) plan in which the beneficiaries and their ******* Care Physician (PCP) coordinate their health care services. For most specialist visits, their PCP must work with CarePlus to obtain a referral. A referral is an authorization from their PCP and health plan to receive care from a specialist. Please note that the timeframe for receiving a decision under Centers of ******** and ******** (CMS) guidelines is up to 14 calendar days for a standard referral request and 72 hours for an expedited request.
Lastly, we received a notification from the Centers for ******** and ******** Services (CMS), advising the beneficiary will be disenrolled from the plan, due to enrolling in another ******** Advantage plan, effective December 1, 2023. A notification was mailed to the beneficiary confirming disenrollment If the beneficiary requires any further assistance after this date, they should contact their new insurance provider.
Should the beneficiary have any additional questions, they may contact our ****** Services 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 p.m. in addition, you can always leave a voicemail after hours,Saturdays, Sundays, and holidays and we will return your call within one business day.
We sincerely apologize for any inconvenience you may have experienced and trust that we have addressed your concerns in full.Initial Complaint
10/20/2023
- Complaint Type:
- Service or Repair Issues
- Status:
- Answered
Been asking for a new pcp for months now pcp is not providing my health needs I have been complaining about neck pain for over a year pcp has done nothing to help I have complained many times to care plus but nothing ever doneBusiness response
10/30/2023
Please see letter attached.Initial Complaint
09/30/2023
- Complaint Type:
- Service or Repair Issues
- Status:
- Answered
I was scheduled for heart valve replacement 10/02/2023 at ************** Health. Due to the nature of the surgery the auth had to be in surgeons office no later than 5pm. It was sent at 5:16 pm. Surgery was cancelled. I spent 3 hrs at hospital for pre op. Paid hospital ** pay. No body at care plus cared one way or the other. Very upsetBusiness response
10/05/2023
hello,
please see attahced. thank you
Initial Complaint
08/02/2023
- Complaint Type:
- Service or Repair Issues
- Status:
- Answered
Im in ********** a ****** hospital for broken shoulder I have to be out in the street by 12 oclock noon that because your insurance they never give rehab center near to my home I am a 90 years old. Have no English speaker I need your help. I will be out in the street by 12 oclock noon today please I need your help soon is possible. Thank you.Business response
08/11/2023
Please see letter attached.Initial Complaint
04/29/2022
- Complaint Type:
- Product Issues
- Status:
- Resolved
My mother was enrolled into Careplus Advantage Plan by *******************. She was under the impression the plan did not take effect until April 1 of 2022. We contacted Careplus on the 30th of March and told them we did not want the plan because we already had ********** Federal Retiree Statewide Health Plan and wanted to stay with it. We were told send a letter stating this and it would be taken care of. We sent the letter and when I called the following week to follow up we were told they needed a signature on the letter. So we sent it back signed. Then I called back to follow up they said they received it and would send a letter within 10 business days confirming the cancellation. When I called to follow up they said they would send a letter stating they received the request but would not make a decision yet if we would be allowed to dis-enroll. We finally received a letter stating that we needed to call customer service to complete the dis-enrollment only to be told to submit a dis-enrollment application and we could not dis-enroll until October. We tried to cancel this within 30 days of having had it and never used it. We contacted ********** and OP ****************** as well as contacting ******** informing each agency of this request. We were told by Careplus to email a letter which we did. We were told to sign the letter and send it back which we did. We were told we would receive a letter stating the coverage has been canceled. Now we are being told this cannot be done until October. I have spent over forty hours on the phone trying to sort this out. We have the original coverage we had before with **********, we do not need to dis-enroll as we never meant to enroll. We just need it undone. We contacted all parties stating we did not want this coverage yet we find ourselves in an endless loop with careplus. We have ******** part a and b and ********** and we want to keep it that way. We first contacted them prior to April 1 which is their imposed deadline to cancel
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Customer Complaints Summary
17 total complaints in the last 3 years.
7 complaints closed in the last 12 months.