Life After 50 Expo

Dear Marci,

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Dear Marci,

I received a notice that I need to pay an Income-Related Monthly Adjustment Amount (IRMAA) in addition to my Part B premium, but I don’t believe I should have to pay it. What can I do?

-Woodie (Topeka, KS)

Dear Woodie,

The Medicare Income-Related Monthly Adjustment Amount is an amount you may pay in addition to your Part B premium and/or Part D premium if your income is above a certain level. The Social Security Administration (SSA) sets income brackets that determine your (or you and your spouse’s) IRMAA. SSA determines if you owe an IRMAA based on the income you reported on your IRS tax returns two years prior, meaning two years before the year that you started paying IRMAA. The income that counts is the adjusted gross income you reported plus other forms of tax-exempt income.

If Social Security determines that you should pay an IRMAA, they will mail you a notice called an initial determination. This notice should include information on how to request a new initial determination. A new initial determination is a revised decision that Social Security makes regarding your IRMAA. You can request that Social Security revisit its decision if you have experienced a life-changing event that caused an income decrease, or it you think the income information Social Security used to determine your IRMAA was incorrect or outdated.
 
Social Security considers any of the following situations to be life-changing events:

  • The death of a spouse
  • Marriage
  • Divorce or annulment
  • You or your spouse stopping working or reducing the number of hours you work
  • Involuntary loss of income-producing property due to a disaster, disease, fraud, or other circumstances
  • Loss of pension
  • Receipt of settlement payment from a current or former employer due to the employer’s closure or bankruptcy

You can make the case that Social Security used outdated or incorrect information when calculating your IRMAA if, for example, you:

  • Filed an amended tax return with the IRS
  • Have a more recent tax return that shows you are receiving a lower income than previously reported

To request a new initial determination, submit a Medicare IRMAA Life-Changing Event form or schedule an appointment with Social Security. You will need to provide documentation of either your correct income or of the life-changing event that caused your income to decrease.
 
If you do not qualify to request a new initial determination, but you still disagree with Social Security’s IRMAA decision, you have the right to appeal. Appealing an IRMAA decision is also referred to as requesting a reconsideration. Keep in mind that there are no strict timeframes in which Social Security must respond to a reconsideration request. Contact the Social Security Administration to learn how to file this request.

-Marci

Dear Marci,

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Dear Marci,

A drug that I need to take is not on my Part D prescription drug plan’s formulary. My friend told me that my plan might need to provide me with a transition refill of this prescription. What does this mean?

-Ezra (Portland, OR)

Dear Ezra,

A transition refill, also known as a transition fill, is a one-time, 30-day supply of a drug that you were taking:Before switching to a different Part D plan (either stand-alone or through a Medicare Advantage Plan)Or, before your current plan changed its coverage at the start of a new calendar year.Transition fills let you get temporary coverage for drugs that are not on your plan’s formulary or that have certain coverage restrictions (such as prior authorization or step therapy).

Transition fills are not for new prescriptions. You can only get transition fills for drugs you were already taking before switching plans or before your existing plan changed its coverage.

The following situations describe when you can get a transition refill if you do not live in a nursing home (there are different rules for transition refills for those living in nursing homes):Your current plan is changing how it covers a Medicare-covered drug you have been taking.If your plan is taking your drug off its formulary or adding a coverage restriction for the next calendar year for reasons other than safety, the plan must either:Help you switch to a similar drug that is on your plan’s formulary before January 1Or, help you file an exception request before January 1, 2020Or, give you a 30-day transition fill within the first 90 days of the new calendar year along with a notice about the new coverage policy.Your new plan does not cover a Medicare-covered drug you have been taking.If a drug you have been taking is not on your new plan’s formulary, this plan must give you a 30-day transition refill within the first 90 days of your enrollment. It must also five you a notice explaining that your transition refill is temporary and informing you of your appeal rights.If a drug you have been taking is on your new plan’s formulary but with a coverage restriction, this plan must give you a 30-day transition refill free from any restriction within the first 90 days of your enrollment. It must also give you a notice explaining that your transition refill is temporary and informing you of your appeal rights.In both of the above cases, if a drug you have been taking is not on your new plan’s formulary, be sure to see whether there is a similar drug that is covered by your plan (check with your doctor about possible alternatives) and, if not, to file an exception request. (If your request is denied, you have the right to appeal.)Note: If you file an exception request and your plan does not process it by the end of your 90-day transition refill period, your plan must provide additional temporary refills until the exception is completed.

Remember: All stand-alone Part D plans and Medicare Advantage Plans that offer drug coverage must provide transition fills in the above cases. When you use your transition fill, your plan must send you a written notice within three business days. The notice will tell you that the supply was temporary and that you should either change to a covered drug or file an exception request with the plan.

-Marci

Arthritis healthy options!

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Having arthritis is common in most people of the world. Even though it is a very common disease, it is painful and very incurable at the moment. You can be at risk for getting arthritis and you may not even know it. Some of the conditions cannot be changed but there are a number of things that you can do to prevent arthritis from happening to you later on in life. Take a look at the risk in your life and what you can do to prevent arthritis from happening to you and causing great pain in your life. You must first understand arthritis. It can affect anyone of any age, gender or race. Even babies at a young age of six months can develop arthritis. It is true that your risks will increase after the age of 40. There are different things that can increase your risk of arthritis as well. For example sports injuries can often occur and it is necessary to continue treating your injury throughout your life to prevent more serious conditions later on in life. Weight is very important when it comes to having arthritis. If you are more than 30 pounds overweight, having this extra stress can affect your joints and create arthritis pain. Having a good healthy weight and exercising and eating right is very important when it comes to your health. Genetics will also play a very important part in the development of arthritis. There is not much that you can do to counteract it. However if you live a good and healthy life, you can lower the risk of arthritis conditions in your body at a young age. Women are more at risk than men for getting different kinds of arthritis pain. This is because of the hormonal changes that a woman will go through. Keeping hormones in order by seeing your doctor regularly will put you at a lower risk for arthritis. African Americans are more likely to have lupus, which is an arthritic disease. Caucasians are at a larger risk for getting rheumatoid arthritis. There are certain groups of Americans that are at risk for getting certain type of arthritis. If you are at a greater risk for arthritis, you need to take the right steps to reduce your chances of getting a disease. Having a healthy lifestyle by eating right and exercising well is going to keep you at a lower risk. Even though arthritis can be difficult to deal with, you can prevent it from happening.

Keeping good medical records!

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Keeping your own records of any medical care that you and your immediate family have received is the only way to be sure that your insurance and bills are free from mistakes. It may seem unimportant now, but later in life when you try to get life insurance or get treatment that is appropriate for you, the importance will be in the spotlight. Everything from your allergies to your payment records with medical facilities can hurt you if they are wrong in your report. You could be given improper treatment or even denied treatment at all. By keeping your own records, you can dispute anything that is false.

Would you believe that you could be denied a job because of something erroneous on your medical records? It is true; if you are reported to have a disability, whether it is true or not, you could be turned down. You would be labeled as a risk, especially if the company offers insurance; they would know that you are going to cost more money to employ. The same goes for applying for health insurance where your medical records show that you would require prescription drugs, doctor visits, and increased chance of emergencies. It is quite the ordeal if you do in fact have a disability, but imaging if you did not have one at all—you would be turned down for insurance, while also being completely ineligible for disability financial help.

An example of a mistake that could be made on your record would be a diagnosis error. Perhaps you request that your doctor check a suspicious lump in your breast. On the first visit he may suspect that it is cancer. Most people will get a second opinion or go for a more thorough conclusive examination. If the second doctor decides that it is only a cyst and has it removed, your personal records would show that you are cancer-free. However, if this visit was documented incorrectly, or not at all, you may have trouble getting insured and not know why. If you had a record of the second visit that found the cyst, this situation would be easily disputed and your record would be accurate.

Human error is simply a part of life, even on medical documents. It is important to always keep your own records so that insurance companies get accurate information about you and your health condition. If you are being turned down for insurance and do not know why, you are best advised to be sure that you are not being misrepresented within your medical records. This problem can be cleared up quickly and easily if you are responsible enough to keep your own personal records.

Dear Marci,

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Dear Marci,

I have arthritis, and I recently went to my doctor to talk about some new symptoms I’ve been experiencing. In my opinion, my doctor does not take my concerns seriously, and I’m worried about the quality of care I am receiving. What can I do?

-Enid (Newark, NJ)

Dear Enid,

If you have a concern about the quality of care you receive from a Medicare provider, your concern can be handled by the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) for your area. The BFCC-QIOs are made up of practicing doctors and other health care experts. Their role is to monitor and improve the care given to Medicare enrollees. BFCC-QIOs review complaints about the quality of care provided by:PhysiciansInpatient hospitalsHospital outpatient departmentsHospital emergency roomsSkilled nursing facilities (SNFs)Home health agencies (HHAs)Ambulatory surgery centersExamples of situations that you might wish to file a quality of care complaint about include:A medication mistakePicking up an infection during a stay in a facilityReceiving the wrong care or treatmentRunning into barriers to receiving careTwo ways that the BFCC-QIO might review this complaint are:Immediate advocacy: Immediate advocacy is an informal process used by the BFCC-QIO to quickly resolve a concern or complaint. This process starts when you, a family member, or an advocate gives the BFCC-QIO permission to address the concern or complaint. The BFCC-QIO will then contact your provider. If your provider agrees to participate in the resolution of the issue, the BFCC-QIO will work with both you and your provider to resolve the issue. If your provider declines to participate, you will be able to file a written complaint. Immediate advocacy can take place when the complaint is unrelated to the clinical quality of health care, or when it is related to the clinical quality of health care, but does not rise to the level of being a significant quality of care concern. For example, immediate advocacy could be used to address complaints about a hospital staff’s poor communication. In cases when immediate advocacy is used, the issue should be resolved within no more than two business days. This process is not available if you wish to remain anonymous.Quality of care complaints: If you have concerns related to the quality of clinical care that you have received, you can file a complaint with the BFCC-QIO so they can review the case. You can do this by calling your QIO or submitting a written complaint. When the BFCC-QIO gets your complaint, they should call you to ask clarifying questions about your complaint and to get the contact information for your provider. A physician of matching specialty will review the medical record to determine whether the care provided met the medical standard of care, or whether the standard of care was not met. The review process can take up to a few months, and when the review is over, you and your doctor will be notified by phone and in writing.Livanta and KEPRO are currently the two BFCC-QIOs that serve the entire country. To find out which BFCC-QIO serves your state or territory and how to contact them, visit www.qioprogram.org/contact or call 1-800-MEDICARE.

If you have a Medicare Advantage Plan, you can choose to make complaints about the quality of care you receive through your plan’s grievance process, through the BFCC-QIO, or both. If you file a grievance with your plan about the quality of care you receive, the plan should inform you of your right to file a complaint with the BFCC-QIO.

-Marci