Life After 50 Expo

After losing a loved one?

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After the loss of a loved one, you may experience a wide range of both physical and emotional pains. Grieving during the COVID-19 pandemic can be even more challenging, when coming together in person with friends and family to grieve may not be possible. The National Institute on Aging recommends various kinds of support (like a support group or grief counseling) until you can manage the grief on your own. The Center for Disease and Control Prevention (CDC) additionally recommends ways to safely connect and grieve with others during this time, such as with virtual memory books or websites. For more resources to help with mourning and grief, click here to visit the National Institute on Aging.  

Dear Marci,

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Dear Marci,

I just realized my new Part D plan doesn’t cover one of my prescriptions. I have an appointment with my doctor in a few weeks to discuss switching to a similar drug that is covered by my plan, but what should I do about my prescription until then? Am I eligible for a transition refill?

-Ruth (Akron, OH)

Dear Ruth,

Yes, it sounds like you are likely eligible for a transition refill! Let’s discuss why:

A transition refill, also known as a transition fill, is typically 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 refills 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 refills 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):

1. 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 1
    • Or, help you file an exception request before January 1
    • Or, 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.

2. 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 give 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.

Best of luck with your transition refill!

– Marci

Goals for the New Year!

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The start of a new year can be a good time to look ahead and set goals.

One common goal for adults is to incorporate more physical activity into our lives. If our bodies are not used to much physical activity, though, it can be tough to get started or to reach our goals. The National Institute on Aging has some helpful tips on how older adults can get started with exercise
.First, start slowly! Begin with low-intensity exercises for short amounts of time and work your way up. Also incorporate warm-ups before exercising and cool-downs afterwards to ease your body in and out of activity.
Consider talking to your doctor about exercise. You can ask questions like: Are there exercises or activities I should avoid? Is my preventive care up-to-date? How does my health condition affect my ability to exercise?
Finally, write down and track your fitness goals. It can be helpful to have short-term goals (for example, in the next two weeks I will make sure I have the shoes and comfortable clothes I need to start walking for exercise) and long-term goals (for example, next summer I will be able to play catch with my grandchild).Whatever your goals are for this year—big or small, fitness-related or not—they are worth pursuing!

Dear Marci,

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Dear Marci,

I have been thinking about making changes to my Medicare coverage. I know there are specific times of the year during which I can make changes, though. When can I change my Medicare coverage in 2021?

– Alexandra (Roswell, NM)

Dear Alexandra,

Yes, there are certain periods of time when you can make changes to your Medicare coverage. These periods of time are called enrollment periods.

If you have a Medicare Advantage Plan, you may be able to use the Medicare Advantage Open Enrollment Period (MA OEP).The MA OEP occurs each year from January 1 through March 31.During the MA OEP you can switch from your Medicare Advantage Plan to another Medicare Advantage Plan or to Original Medicare with or without a prescription drug plan.You may only make one change during this period, and it will be effective the first of the next month after you make the change.Remember, you can only use this enrollment period if you have a Medicare Advantage Plan.Depending on your circumstances, you may qualify for a Special Enrollment Period (SEP) to change your Medicare health and drug coverage.There are many circumstances in which you may have a Special Enrollment Period (SEP), such as if you moved outside of your plan’s service area, your Medicare Advantage Plan terminated a significant amount of its network providers, or you are enrolled in a State Pharmaceutical Assistance Program (SNAP).Those with Extra Help, the federal program that helps pay for drug costs, have an SEP to enroll in a Part D plan or switch between plans once per quarter in the first three quarters of the year.If you need to make changes to your coverage but you are not sure whether you qualify for an SEP, call your State Health Insurance Assistance Program (SHIP) to learn more. If you do not know how to contact your SHIP, call 877-839-2675 or visit www.shiptacenter.org.If you enrolled in a plan by mistake or because of misleading information, you may be able to disenroll and change plans.Typically, you have the right to change plans if you joined unintentionally, joined based on incorrect or misleading information, or, through no fault of your own, were kept in a plan you did not want.You can call 1-800-MEDICARE to explain to a customer service representative how you joined the plan by mistake and to request retroactive disenrollment or a Special Enrollment Period.Finally, both individuals with Original Medicare and those with a Medicare Advantage Plan can make changes during Fall Open Enrollment.The Fall Open Enrollment Period occurs each year from October 15 through December 7.During this period you can join a new Medicare Advantage Plan or stand-alone prescription drug plan (Part D) plan. You can also switch between Original Medicare with or without a Part D plan and Medicare Advantage.You can make as many changes as you need during this period, and your last coverage choice will take effect January 1.As you can see, there are various enrollment periods in which you can change your Medicare coverage. Which enrollment period you use depends on your specific circumstances and the kind of coverage you have.

– Marci

Dear Marci,

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Dear Marci,

I have been recovering from surgery at a skilled nursing facility (SNF), but recently was told I am being discharged this week. How can I appeal my discharge from a SNF?

– Matthew (Rochester, NY)

Dear Matthew,

If you are receiving care in a non-hospital setting and are told that Medicare will no longer pay for your care (and you will be discharged), you have the right to file a fast appeal if you do not believe your care should end. Non-hospital settings include skilled nursing facilities, Comprehensive Outpatient Rehabilitation Facilities (CORFs), hospice, or home health agencies.

If your care at a non-hospital setting is ending because your provider believes Medicare will not pay for it, you should receive a Notice of Medicare Non-Coverage. You should get this notice no later than two days before your care is set to end. If you receive home health care, you should receive the notice on your second to last care visit. If you have reached the limit in your care or do not qualify for care, you do not receive this notice and you cannot appeal. 

If you feel that your care in a non-hospital setting should continue, follow the instructions on the Notice of Medicare Non-Coverage to file an expedited appeal with the Quality Improvement Organization (QIO) by noon of the day before your care is set to end. Once you file the appeal, your provider should give you a Detailed Explanation of Non-Coverage. This notice explains in writing why your care is ending and lists any Medicare coverage rules related to your case. 

The QIO will usually call you to get your opinion. You can also send a written statement. If you receive home health or CORF care, you must get a written statement from a physician who confirms that your care should continue. 

If you have Original Medicare, the QIO should make a decision no later than two days after your care was set to end. If you have a Medicare Advantage Plan, the QIO should make a decision no later than the day your care is set to end. Your provider cannot bill you before the QIO makes its decision. If the QIO appeal is successful, you should continue to receive Medicare-covered care, as long as your doctor continues to certify it.

If your appeal is denied at this first level, you can continue to appeal by following instructions on the denial notices you receive. There are five levels of appeal in total; the timing and agency involved depend on whether you have Original Medicare or a Medicare Advantage Plan. You have the right to continue appealing if you are not successful. 

Expedited appeals have tight deadlines, so it is important to pay attention to the timeframes for appealing at each level. Keep copies of any appeal paperwork you send out, and if you speak to someone on the phone, get their name and write down the date and time that you spoke to them. It is helpful to have all of your appeal documents together in case you run into any problems and need to access documents you already mailed.  

Note that the appeal process is different if your inpatient hospital care is ending or if your care is being reduced but not ending, and you do not agree with that reduction.

– Marci