Dear Marci, 

I received a discharge notice from the hospital, but I need to continue medical care. I think I can appeal but I’m not sure what to do. Please help!

-Lorraine (Buffalo, NY) 

 

Dear Lorraine, 

You’re right! If you think you’re being discharged from the hospital too soon, you do have the right to file an appeal.


You should’ve gotten a notice that explains this right titled, Important Message from Medicare, when you were admitted. If you were there more than 3 days, you should receive another copy of the same notice between 4 hours and 2 days before you are to be discharged.


The Important Message from Medicare notice will have instructions for filing a fast (expedited) appeal. This appeal will be sent to the Quality Improvement Organization (QIO), a company that is contracted to evaluate discharge appeals. For a fast appeal, you must appeal by no later than midnight on the day of your scheduled discharge. Once you file the appeal, the hospital must give you a Detailed Notice of Discharge, which must explain, in specific detail, why the hospital believes that Medicare coverage for your stay is ending, and that discharge is appropriate. You can also send additional information about why you, and your care team, if appliable, believe the discharge is too soon. The QIO should call you within 24 hours with their decision.


If the QIO agrees with the hospital that Medicare coverage of your hospital stay should end, you have the right to continue to appeal to higher levels of review. If you stay in the hospital after the QIO decision agreeing with the hospital, however, you may be responsible for the full cost of your care from the date of that decision forward if you don’t win at a higher level of appeal. There are five levels of appeal, and instructions for the next steps are included in each decision. Keep in mind that at each level there is a separate time limit for when you must file the appeal and when you’ll receive a decision.


Here are a few tips to help you succeed:

Follow the appeal timelines for each level.
Take good notes throughout the process & keep original copies of all documents.
Include a letter from your doctor or other care-team member explaining why your specific circumstances require additional hospital care to support your appeal.
Contact your State Health Insurance Assistance Program (SHIP) for more guidance on your appeal.
(Later appeals processes differ for Medicare Advantage and Original Medicare. For more information about higher levels of appeal if you are in a Medicare Advantage plan, see: Medicare Advantage appeals if your care is ending – Medicare Interactive. For more information about higher levels of appeal if you have Original Medicare, see: Original Medicare appeals if your care is ending – Medicare Interactive )


Good luck!

-Marci

Dear Marci,

I heard there are a few changes to Medicare costs this year. What should I expect?


-Marco (Chattanooga, TN) 

Dear Marco,

Yes, that’s right! Here’s a breakdown of the costs you can expect in 2024: 


Part A (Hospital Insurance)

Premium:
Free if you’ve worked 10 years or more 
$278 per month if you’ve worked 7.5 to 10 years 
$505 per month if you’ve worked fewer than 7.5 years 
Deductible:
$1,632 each benefit period 
Coinsurance:
$0 for the first 60 days of inpatient care each benefit period 
$408 per day for days 61-90 each benefit period 
$816 per lifetime reserve day after day 90 in a benefit period (You have 60 lifetime reserve days that can only be used once. They’re not renewable.) 
Skilled Nursing Facility:
$0 for the first 20 days of inpatient care each benefit period  $204 per day for days 21-100 each benefit period 

Part B (Medical Insurance)

Premium: $174.70 is the standard premium 
Deductible: $240 per year 
Coinsurance: 20% for most services Part B covers 

Part D (Prescription Drug Insurance)

National Average Part D Premium: $32.74/month
Maximum Deductible: $545 per year
Coverage Gap Begins: $5,030 (you and your plan together)
Catastrophic Coverage Begins: $8,000 (your costs, including brand coverage gap discounts)
Costs after catastrophic limit: $0

For more details, check out our Guide to Medicare Costs in 2024 here: Medicare Costs in 2024.

You can also review your Medicare & You 2024 handbook (contact 1-800-MEDICARE (633-4227) to receive one) if you have Original Medicare. If you have a Medicare Advantage Plan, contact your plan directly to learn about changes in 2024 that might affect you.


I hope this helps!

-Marci

Dear Marci,

My pharmacist said my Part D plan won’t cover my medication. Why would this happen?

-Tony (Plano, TX)

Dear Tony,

There are several reasons that your Part D plan might refuse to pay for your drug. Some of the most common reasons are:

Your drug is off formulary: The drug is not on your plan’s list of covered drugs.
Prior authorization: You must get approval in advance from your plan before it will cover a specific drug.
Step therapy: Your plan requires you to try a different (usually less expensive) drug first.
Quantity limits: Your plan only covers a certain amount of a drug over a certain period (like 30 pills per month).
To find out the reason, you can contact the plan and request a coverage determination, or a formal decision about paying for the drug. Once you know the reason that your drug has been denied, you’ll be able to work with your doctor to communicate with the plan. Your doctor may need to submit additional evidence or information. For example, if your drug is denied because of a step therapy requirement, your doctor may need to submit documentation that you’ve already tried the other, drugs the plan covers to treat your condition. If you and your doctor think that trying the alternative drugs would be dangerous or ineffective for you, you can request an exception to the step therapy rule by filing an appeal. Similarly, if the drug is denied because it is off formulary, you can ask your provider whether the formulary alternatives would be appropriate for you, and, if not, you can request a formulary exception.

There are some reasons that your drug might be denied where you are less likely to obtain a favorable decision through an appeal. In these situations, you still have the right to appeal, but the odds of a successful outcome are lower.
Your drug has been prescribed for an off-label use: “Off-label” is a term used to describe situations where a doctor has prescribed a drug for a reason other than the use(s) approved by the U.S. Food and Drug Administration (FDA) or listed in certain medical reference texts. If your doctor prescribes a medication on your plan’s formulary for a reason other than the use approved by the FDA, your drug will probably not be covered unless it fits into certain narrow categories.
Your drug is excluded from Medicare coverage: Some drugs or specific uses of drugs are excluded from Medicare coverage.
Again, your first step should be to contact your plan to learn why it isn’t covering your medication. Learning the reason for denial is important as you consider your next best step.

I hope this helps!

-Marci

Dear Marci,

I recently started taking a new medication. It’s covered by my Part D plan, but when I went to the pharmacy, I was charged a high copay! What’s going on? How do I fix this?

-Maria (Sacramento, CA)

Dear Maria,

If your Part D plan covers your medication but your copayment is expensive, it could be that the medication is on a high tier. Part D plans use tiers to categorize prescription drugs. Higher tiers are more expensive and have higher cost-sharing amounts. Each plan sets its own tiers, and plans may change their tiers from year to year.

If you can’t afford your copay, you can ask for a tiering exception by using the Part D appeal process. A tiering exception is a way to request lower cost-sharing. To request a tiering exception, you or your doctor must show that the drugs for treatment of your condition that are on lower tiers of your plan’s formulary are ineffective or dangerous for you. Here is some guidance on requesting a tiering exception:

If you are charged a high copay at the pharmacy, talk to your pharmacist and your plan to find out why. If your copay is high because your prescription is on a higher tier than other drugs to treat your condition on the formulary, you can ask for a tiering exception.
Note that you can’t request a tiering exception if the drug you need is in a specialty tier. The specialty tier is limited to drugs above a certain dollar amount and plans may not require more than 33% coinsurance for drugs on this tier.
Ask your plan how to send your tiering exception request. It’s usually helpful to include a letter of support from your prescribing health care provider. This letter should explain why similar drugs on the plan’s formulary at lower tiers are ineffective or harmful for you.
If your plan approves your tiering exception request, your drug will be covered at cost-sharing that applies to the lower tier. Normally, an approved exception will be in effect until the end of the current calendar year. If your plan denies your request, it should send you a letter titled Notice of Denial of Medicare Prescription Drug Coverage. You can appeal this decision.
You may wish to consider switching plans during the Fall Open Enrollment Period to a Part D plan that covers your drug with lower cost-sharing. I hope this helps. Best of luck!

-Marci

Health Tip
November is National Chronic Obstructive Pulmonary Disease (COPD) awareness month. COPD is a chronic disease that makes it more difficult to breathe. According to the American Lung Association, early detection and treatment is very important. They suggest that if you are experiencing any of the following symptoms, you should discuss COPD with your doctor:

Chronic cough
Shortness of breath while doing everyday activities
Frequent respiratory infections
Blueness of the lips or fingernail beds
Fatigue
Producing a lot of mucus
Wheezing