Life After 50 Expo

Dear Marci!

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Dear Marci, I am enrolled in Original Medicare. I will need to recover from an upcoming surgery in a skilled nursing facility (SNF) and I am nervous because I’ve heard of people being discharged from SNFs before they are ready to go home. What can I do if this happens? -Rex (Louisville, KY)

 Dear Rex, If you are receiving care from a SNF and are told that Medicare will no longer pay for your care (meaning that you will be discharged), you have the right to a fast (expedited) appeal if you do not believe your care should end. There is a different process if you are enrolled in a Medicare Advantage Plan. Note that this process is different if your care is being reduced but not ending, and you do not agree with that reduction.

 If you are enrolled in Original Medicare: If your care is ending at a SNF 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 have reached the limit on your care or do not qualify for care, you do not receive this notice and you cannot appeal. If you feel that your care should continue, follow the instructions on the Notice of Medicare Non-Coverage to file an expedited appeal with a Quality Improvement Organization (QIO) by noon of the day before your care is set to end.

The QIO should make a decision no later than two days after your care was set to end. Your provider cannot bill you before the QIO makes its decision. 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 miss the deadline for an expedited QIO review, you have up to 60 days to file a standard appeal with the QIO. If you are still receiving care, the QIO should make its decision as soon as possible after receiving your request. If you are no longer receiving care, the QIO must make a decision within 30 days.  If the QIO appeal is successful, you should continue to receive Medicare-covered care, as long as your doctor continues to certify it.

If the QIO denies your appeal, you can choose to move to the next level by appealing to the Qualified Independent Contractor (QIC) by noon of the day following the QIO’s decision. The QIC should make a decision within 72 hours. Your provider cannot bill you for continuing care until the QIC makes a decision. However, if you lose your appeal, you will be responsible for all costs, including the costs incurred during the 72 hours the QIC deliberated. If you miss the QIC deadline, you have up to 180 days to file a standard appeal with the QIC. The QIC should make a decision within 60 days.  If the appeal to the QIC is successful, you should continue to receive Medicare-covered care, as long as your doctor continues to certify it.

If your appeal is denied and your care is worth at least $170 in 2020, you can choose to appeal to the Office of Medicare Hearings and Appeals (OMHA) level within 60 days of the date on your QIC denial letter. If you decide to appeal to the OMHA level, you may want to contact a lawyer or legal services organization to help you with this or later steps in your appeal—but this is not required. OMHA should make a decision within 90 days. If your appeal to the OMHA level is successful, you should continue to receive Medicare-covered care, as long as your doctor continues to certify it.

If your appeal is denied, you can move to the next level by appealing to the Council within 60 days of the date on your OMHA level denial letter. There is no timeframe for the Council to make a decision. If your appeal to the Council is successful, you should continue to receive Medicare-covered care, as long as your doctor continues to certify it. If your appeal is denied and you are appealing care that is worth at least $1,670 in 2020, you can choose to appeal to the Federal District Court within 60 days of the date on your Council denial letter. There is no timeframe for the Federal District Court to make a decision. -Marci 




Summer health tip!

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Spending too long in high temperatures can be dangerous for anyone, and your risk of heat-related illness can increase as you get older. The National Institute on Aging provides these tips for lowering your risk of heat-related illnesses: 

Drink plenty of liquids, like water or fruit or vegetable juices, and avoid drinks containing caffeine or alcohol.
 
If you live in a home or apartment without fans or air conditioning, try to keep your house as cool as possible. Limit your use of the oven, keep your shades closed during the hottest part of the day, and open your windows at night If your house is hot, and you need help getting to a cool place, as a friend or relative. Some religious groups, senior centers, and Area Agencies on Aging provide this service. Dress for the weather. Don’t try to do exercise or a lot of activities outdoors when it’s hot. 


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Dear Marci,

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Dear Marci, I have a surgery scheduled soon and will probably need to stay in a skilled nursing facility to recover afterward. Will Medicare cover my stay in the skilled nursing facility? -Megumi (Honolulu, HI)

 Dear Megumi, Skilled nursing facility (SNF) care is post-hospital care provided at a SNF. Skilled nursing care includes services such as administration of medications, tube feedings, and wound care.

Keep in mind that SNFs can be part of nursing homes or hospitals.  Medicare Part A may cover your SNF care if: You were formally admitted as an inpatient to a hospital for at least three consecutive days You enter a Medicare-certified SNF within 30 days of leaving the hospital, and receive care for the same condition that you were treated for during your hospital stay And, you need skilled nursing care seven days per week or skilled therapy services at least five days per week The day you become an inpatient counts toward your three-day inpatient stay to qualify for Medicare-covered SNF care. However, the day you are discharged from the hospital does not count toward your qualifying days. Also remember that time spent receiving emergency room care or under observation status does not count toward the three-day hospital inpatient requirement for SNF coverage. If you meet all the above requirements, Medicare should cover the SNF care you need to improve your condition, maintain your ability to function, or prevent your health from getting worse. Note: Because of the coronavirus public health emergency, Medicare has removed the three-day qualifying hospital stay requirement for beneficiaries who experience dislocation or are otherwise affected by the coronavirus public health emergency.

According to Medicare, this waiver includes but is not limited to beneficiaries who: Need to be transferred to a SNF, for example, due to nursing home evacuations or to make room at local hospitals Need SNF care as a result of the current public health emergency, regardless of whether they were previously in the hospital Speak to your doctor or hospital discharge planner if you need help finding a SNF that meets your needs. Ask them to find Medicare-certified SNFs in your area that will address your medical needs. If you are in a Medicare Advantage Plan, contact your plan to find out which SNFs are in their network. -Marci 

Dear Marci,

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Dear Marci, I will be eligible for Medicare soon and may need to enroll. What steps should I take to make sure that I have coverage that works for me?  -Thelma (Atlanta, GA)

 Dear Thelma, There are several steps you’ll want to take when you’re new to Medicare: First, know when to enroll in Medicare Part A (hospital insurance) and Part B (medical insurance). If you are already receiving retirement benefits from the Social Security Administration or Railroad Retirement Board at the time you become eligible for Medicare, you will be automatically enrolled in Medicare Parts A and B. There are three times you can enroll in Medicare Parts A and B for the first time.  First, during the Initial Enrollment Period (IEP), which is the three months before, the month of, and the three months after your 65th birthday. The effective date of your Medicare coverage will depend on when you enroll. If you want Medicare Parts A and B to begin the month of your 65th birthday, you should enroll in the first three months of your IEP.

  Second, if you have a Part B Special Enrollment Period (SEP), it lets you delay enrollment in Part B without penalty if you were covered by insurance based on your, your spouse’s, or sometimes a family member’s current work when you first became eligible for Medicare. You can enroll in Medicare without penalty while covered by insurance based on current work, or for up to eight months after you lose your group health coverage or you (or your spouse or family member) stops working, whichever comes first. Medicare coverage generally begins the first of the month after you enroll.  Third, you can enroll during a General Enrollment Period if you did not enroll in Medicare when you first became eligible for it. The GEP takes place January 1 through March 31 each year, with coverage starting July 1. You may have a Part B late enrollment penalty and face gaps in coverage if you sign up during the GEP. Second, consider enrolling in Part D prescription drug coverage. Medicare’s prescription drug benefit (Part D) provides outpatient drug coverage. Part D is provided only through private insurance companies that have contracts with the federal government. If you want to get Part D coverage, you have to choose and enroll in a private Medicare prescription drug plan (PDP) or a Medicare Advantage Plan with drug coverage (MAPD). Typically, you should sign up for Part D when you first become eligible to enroll in Medicare. If you have creditable drug coverage from employer or retiree insurance, you can delay Part D enrollment without penalty and you don’t need to enroll in a drug plan until you lose this coverage. Contact your employer or drug plan to learn if your drug coverage is creditable. Also note that if you qualify for certain Medicare cost assistance programs, you may be automatically enrolled in a Medicare drug plan.
 
Third, decide between getting your coverage through Original Medicare or Medicare Advantage. Unless you choose otherwise, you will have Original Medicare. Instead of Original Medicare, you can decide to get your Medicare benefits from a Medicare Advantage Plan, also called Part C or Medicare private health plan. Remember, you still have Medicare if you enroll in a Medicare Advantage Plan. This means that you must still pay your monthly Part B premium (and your Part A premium, if you have one). Each Medicare Advantage Plan must provide all Part A and Part B services covered by Original Medicare, but they can do so with different rules, costs, and restrictions that can affect how and when you receive care.  If you get your coverage through Original Medicare, you will also have the option to purchase a Medicare supplemental plan, also known as a Medigap. Medigap plans pay secondary to Medicare and cover some or all of the costs of Medicare cost-sharing. You can only enroll in a Medigap plan if you have Original Medicare. 

Stay healthy notes!

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Type 2 Diabetes Tip
Type 2 diabetes is a chronic condition that affects the way the body metabolizes sugar. Left uncontrolled it can be life threatening.
Johns Hopkins School of Medicine offers some tips to prevent or manage this adult onset condition.


* Lose weight – Keep your body mass index (BMI) below 25


* Eat a diet rich in fruit and vegetables. Whole grains and legumes are low in saturated fat.


* Be physically active – Exercise 30 minutes per day.


* Do not smoke
Bad Breath? Clear the Air
Bad breath ranks high in the hierarchy of social stigmas. As americans, we spend more than $4 billion a year on mints, gum, mouth washes and sprays. Halitosis has many causes. Here are some and possible remedies.


* Oral Hygiene – Ineffective brushing and flossing leaves particles that attract bacteria and can cause bad breath. Brush at least twice a day and floss at least daily. Be sure to brush your tongue.
* Dentures – Bacteria can get trapped and produce odor. Thoroughly clean daily or as directed by your dentist.
* Periodontal Disease – Gum disease can cause persistent bad breath and bad taste in your mouth. Have your teeth professionally cleaned at least every six months.
* Dry Mouth – Adequate saliva is needed to cleanse the mouth and remove food particles that can cause odor. Some medications dry the mouth as well as breathing through the mouth continually. Drink plenty of water and use sugarless gum to increase saliva flow.


* Alcohol – In a cocktail or a mouthwash, alcohol creates an environment that bacteria love. Alcohol pulls the moisture out of the cells. Choose a mouthwash that is free of alcohol.


* Certain Food (Garlic/Onions) – As food is digested and absorbed into the body , some molecules are released into the lungs. As we exhale, our breath may carry offending molecules into the faces of others. This will resolve itself over time. You can minimize your consumption of the offending items. it helps to brush, floss and chew sugarless gum.
* Smoking – Tobacco smoke is the main culprit for smokers breath. Good oral hygiene helps. To completely eliminate the problem, don’t smoke.


* Sinus Problems – Colds, respiratory infections and allergies can promote the flow of postnasal drip onto the back of the tongue. Taking an antihistamine may help but will dry the mouth. Drink lots of fluids and scrape your tongue.