Life After 50 Expo

Dear Marci,

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Dear Marci,

I think I need a power wheelchair to get around my home. How do I get one, and how do I get Medicare to cover it?

– Jacob (Concord, NH)

Dear Jacob,

The first step to getting a power wheelchair is to speak with your doctor. You may feel you need one, or your doctor might suggest it, but either way, you must have an office visit with your doctor before you get your wheelchair. This visit should take place no more than 45 days before the order is placed, and should address with the medical reasons you need the wheelchair. Your provider must sign an order or fill out a prescription that states:

  • Your health makes it very hard to move around in your home, even with the help of a walker or cane
  • You have significant problems in your home performing activities of daily living such as getting to the toilet, getting in and out of a bed or chair, bathing, and/or dressing
  • You cannot use a manual wheelchair or scooter, but you can safely use a power wheelchair
  • The required visit with your doctor took place

Once you have the doctor’s order or prescription, you must take it to the right kind of supplier in order to get your power wheelchair covered. The supplier you use depends on what kind of Medicare coverage you have and where you live.
If you have Original Medicare, the kind of supplier you can use will depend on where you live. In many areas, called competitive biddingareas, Medicare will only pay for most durable medical equipment (DME) from a select group of suppliers known as contract suppliers. In other areas, you can use any supplier that has signed up with Medicare. To find out whether you live in a competitive bidding area and which Medicare suppliers you can use, call 1-800-MEDICARE or visit www.medicare.gov/supplier.  

Additionally, in 19 states, if you have Original Medicare, your provider or supplier will need to ask Medicare for permission before you can get a power wheelchair or scooter. This is called prior authorization. Click here to find out if you live in one of these states, and how to request prior authorization and/or appeal if prior authorization is denied.

If you have Medicare Advantage, you must follow your plan’s rules for getting a wheelchair or scooter. Your plan might require you to get its approval before you get your wheelchair. It may also ask you to use suppliers that are in your plan’s network. Your plan may also have a list of preferred brands of power wheelchairs and scooters. These brands will cost you the least while you are a plan member, so you should use preferred brands when possible. Call your plan to find out what you must do to get your power wheelchair covered.

-Marci
 

Dear Marci,

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Dear Marci,
 
I am recovering from a surgery in a skilled nursing facility (SNF). I was told a date for my discharge, which was earlier than I felt ready to go home, so I appealed. I just found out my appeal was denied. Is there anything else I can do?
 
-Lindiwe (Severna Park, MD)
 
Dear Lindiwe,
 
You have the right to further appeals after an initial denial of your appeal by the Quality Improvement Organization (QIO). Since your appeal was denied by the QIO, remember that you may be responsible for the cost of any care you receive after the end date on your Notice of Medicare Non-Coverage if you do not win your appeal.
 
What to do next will depend on whether you have Original Medicare or a Medicare Advantage Plan, but remember that at every step in the appeals process, it is important to read notices thoroughly and follow all instructions and deadlines.
 
If you have Original Medicare, your next step is to appeal to the Qualified Independent Contractor (QIC). The instructions for where to send this appeal should appear on the notice you received from the QIO. To continue the expedited appeals process, you should appeal to the QIC by noon of the day following the QIO’s decision. The QIC will make a decision within 72 hours. Your skilled nursing facility cannot bill you for continuing care until the QIC makes a decision. However, if you are denied by the QIC, you will be responsible for paying all the costs of your care out-of-pocket, including costs incurred during the 72 hours when the QIC was making its decision.
 
If you have a Medicare Advantage Plan, your next step will be to appeal to the QIO again. You should file this second appeal within 60 days of the QIO’s initial denial. A different set of staff will reconsider your appeal. They should make a decision within 14 days of getting the appeal. If you continue to stay in the nursing facility, they will not be able to bill you until the QIO makes its decision. However, if you lose your appeal, you will be responsible for all costs, including costs from the time when the QIO was making its decision. 
 
If you win in your second appeal, your continued care in the nursing facility will be covered by Original Medicare or your Medicare Advantage Plan. If you are not successful, you can still appeal further. You may want to consider seeking assistance from a lawyer or legal services organization at this point, although you do not need to have legal representation. The steps for further appeals will be the same whether you have Original Medicare or a Medicare Advantage Plan:
 

  • You can request a hearing with the Office of Medicare Hearings and Appeals (OMHA). The bill for care that is not covered must be at least $160 in 2017 to be able to use this level of appeal. This is called the amount in controversy, and it may change from year to year. You should file your appeal within 60 days of the date on your denial letter from the QIC (if you have Original Medicare) or QIO (If you have a Medicare Advantage Plan). OMHA should make a decision within 90 days.
  • If OMHA denies your appeal, you can appeal to the Council within 60 days of the date on your denial. There is no timeline for the Council to make its decision.
  • If the Council denies your appeal, you can appeal in Federal District Court. To file a case in Federal District Court, you must have an amount in controversy of at least $1,560 in 2017. You should appeal to the Federal District Court within 60 days of the date on your denial letter from the Council. Most people who file a claim in Federal District Court have an attorney help them. There is no timeframe for the Federal District Court to make a decision.

 
If you have not already, you should ask your physician if they can support your appeal with a letter of medical necessity that addresses the reasons you continue to need care in a skilled nursing facility. Also, remember that a family member or other representative can appeal for you if you are too ill or otherwise unable to appeal on your own. If you have questions about the appeals process, you can call your Medicare Advantage Plan or 1-800-MEDICARE, or you can seek help from your State Health Insurance Assistance Program (SHIP) by visiting www.shiptacenter.org or calling 877-839-2675.
 
-Marci

Alzheimer’s awareness !

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November is Alzheimer’s Disease Awareness and Caregiver’s Month. While increasing forgetfulness is a normal sign of aging, more severe memory loss that impacts daily life might be a sign of Alzheimer’s disease or other forms of dementia. Alzheimer’s Association lists the following as ten early signs and symptoms of Alzheimer’s disease:

  1. Memory loss that disrupts daily life
  2. Challenges in planning or solving problems
  3. Difficulty completing familiar tasks at home, at work, or at leisure
  4. Confusion with time or place
  5. Trouble understanding visual images and spatial relationships
  6. New problems with words in speaking or writing
  7. Misplacing things and losing the ability to retrace steps
  8. Decreased or poor judgment
  9. Withdrawal from work or social activities
  10. Changes in mood and personality

If you believe you or a loved one might have Alzheimer’s disease or dementia, you should speak with a doctor. While there is currently no cure, there are ways to manage Alzheimer’s and dementia and treat their symptoms.
 

Dear Marci,

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Dear Marci,

My wife is currently a hospital inpatient following a surgery. She is getting excellent care, but we are both nervous about what would happen if she were discharged before she is ready. What should we do if that happens?

George (Hartford, CT)

Dear George,

First, know that your wife has a right to discharge planning as a hospital inpatient, which will give her a chance to address any concerns she has about her health and safety after she leaves the hospital. If she is discharged before she is ready, though, she also has the right to a fast appeal to challenge her provider’s decision to end her care. This is called an expedited appeal. To have the highest chance of being successful, you should pay attention to the paperwork your wife receives, and follow directions and deadlines as closely as possible. Also, know that if your wife is too ill or unable to file an appeal for herself, you, another family member, or representative can do so for her.

Your wife should have received an Important Notice from Medicare within two days of being admitted to the hospital as an inpatient. This notice has information on how to appeal her discharge. She should receive this notice again no less than four hours before her discharge. In order to begin your wife’s appeal, follow the instructions on this message to file an expedited appeal to the Beneficiary and Family-Centered Quality Improvement Organization (BFCC-QIO, or QIO for short). She must appeal to the QIO by midnight on the day of her discharge. If she misses this deadline, she will be able to appeal according to the Original Medicare standard appeal process or the Medicare Advantage post-service standard appeal process. She may also be able to request a good cause extension if exceptional circumstances kept her from filing her appeal on time. These extensions are granted on a case-by-case basis.

Once your wife appeals to the QIO, the hospital must give her a Detailed Notice of Discharge. This notice explains in writing why hospital care is ending and lists any Medicare rules related to your wife’s case. At this time, the QIO will also request your wife’s medical records from the hospital. You may also ask the hospital for a copy of these records, although the hospital may charge you to access them. The QIO will also likely call your wife at this time to get her opinion on the discharge, but she may also submit a written statement.

Within 24 hours of receiving all the information it needs, the QIO should call your wife with its decision. If this decision is favorable, her care will continue to be covered.

If the decision is unfavorable, your wife will not be responsible for the cost of the 24-hour period she spent in the hospital waiting for the QIO to make its decision. If she remains in the hospital past this period, however, she will be responsible for the cost of her care if she does not win at a higher level of appeal.

If you and your wife are unsuccessful at appealing her discharge at this first level, you can continue to appeal. The steps in the processes are different depending on whether your wife is covered by Original  Medicare or a Medicare Advantage Plan.

Throughout the appeals process, it is important to try to get support from your physician to support the medical necessity of your hospital stay. Follow all instructions and deadlines very carefully, and keep copies of all appeal paperwork.

-Marci

Depression among older adults!

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Depression is a common health concern among older adults, but that does not mean that it is natural part of aging. It is important to pay attention to the symptoms of depression and seek professional help if needed. According to the National Institute on Aging, if you exhibit several of the following symptoms for more than two weeks, you may have depression, and you should follow up with your health care provider:

  • Persistent sad, anxious, or “empty” mood
  • Feelings of hopelessness, guilt, worthlessness, or helplessness
  • Irritability, restlessness, or having trouble sitting still
  • Loss of interest in once pleasurable activities, including sex
  • Decreased energy or fatigue
  • Moving or talking more slowly
  • Difficulty concentrating, remembering, making decisions
  • Difficulty sleeping, early-morning awakening, or oversleeping
  • Eating more or less than usual, usually with unplanned weight gain or loss
  • Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease with treatment
  • Frequent crying

 
If you are thinking about harming yourself, you should contact a doctor, visit an emergency room, and/or ask your friends and family to help you as soon as possible.