Drug Coverage Denied by Medicare and Fighting Back

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Man ConcernedKenneth Buss had taken a blood thinner, for over a year when his mail-order pharmacy refused a request to refill his prescription. He immediately contacted his physician who urged his Medicare plan insurer to approve the medication. 

The request was denied. But Buss, 79, did not let the matter drop. Without coverage, a 90-day supply of Xarelto costs about $1,300 at a local pharmacy — more than 10 times what Buss had been paying.

“That killed me,” said Buss, who remembers phoning his Medicare plan and saying, “Excuse me, are you saying my doctor is wrong and you know better?”

With his physician’s help, this determined Arizona resident persuaded his plan to renew his prescription. But many similarly frustrated older adults are not sure how to appeal Medicare drug plan denials.

“A lot of cases fall through the cracks,” said David Lipschutz, senior policy attorney at the Center for Medicare Advocacy. “People simply do not know exactly how to proceed or they try to go through the process; but it’s complicated, time-consuming and people just give up.”

Concerns about Medicare drug coverage are common: More seniors call the Medicare Rights Center’s national hotline (800-333-4114) about this topic each year than any other Medicare organization.

Here is some essential information about the appeals process:

The Basics

Nearly 41 million Medicare beneficiaries receive drug coverage through stand-alone drug plans or privately run Medicare Advantage plans — Kenneth’s type of coverage.

Some rules apply across the board. Notably, plans must cover substantially all drugs in six categories: HIV/AIDS treatments, antidepressants, antipsychotic medications, anti-convulsive treatments for seizures, immunosuppressive medications and treatments for cancer. In other categories, at least two medications from each class must be offered.

Plans are not allowed to cover such drugs as those for weight loss, coughs and colds, fertility, cosmetic purposes, sexual difficulties and non-prescription medications, among others.

Beyond these generalities, Medicare drug plans have considerable flexibility in choosing which drugs to cover (their formularies), capping the amount filled per prescription (quantity limits), requiring preapproval before a medication is supplied (prior authorization), asking people to try other lower-cost treatments first (step therapy) and assigning medications to different classes with different costs attached (cost-sharing tiers).

A failure to meet any of these requirements may result in a denial. In Buss’ case, his plan requires annual prior authorization of Xarelto. Although his doctor submitted the proper request, as he did in 2016, this time the plan deemed his rationale for prescribing the medication as insufficient.

Persistent Problems

The latest government audit of Medicare’s drug program confirms that plans often impose limits on drug coverage without advance approval from the Centers for Medicare & Medicaid Services (CMS), as required.

Notably, 64 percent of plans applied quantity limits that had not been approved by CMS, while 41 percent improperly dealt with requests for prior authorization or exceptions to plan requirements.

Also, insurance plan representatives were deficient in communicating with members and providers: 70 percent of denial notices did not offer adequate explanations for the actions taken, were incorrect or were written in a manner that was difficult for most people to understand.

About 45 percent of the insurance plans did not reach out to Medicare members or physicians to acquire the necessary additional information to make a coverage decision.

The takeaway for seniors: You must take the initiative in supplying relevant materials. Your chances are best if your physician clearly and comprehensively states, in writing, why you must take a particular medication and the likely harm of not doing so while referring to your particular medical circumstances.

Appeals Process

Seniors tend to think that when they are unable to get a medication at a pharmacy, they have grounds to appeal. But that is not true.

Another step awaits: An individual needs to request a formal “coverage determination” from the Medicare drug plan before the appeals process can start. Included should be an “exceptions request” asking that a plan’s rules be waived so a senior can obtain a medication or pay less for a drug.

Once a coverage determination is issued, there are five steps to the appeals process: a “redetermination” by the drug plan; a “reconsideration” by an independent review entity (MAXIMUS Federal Services serves this purpose across the U.S.); a hearing before an administrative law judge; a review by the Medicare Appeals Council; and a review by a federal district court.

Breakdowns in the process can occur right at the start: Individuals are supposed to get a notice from the pharmacy informing them of their right to appeal when a prescription cannot be filled, but much of the time this does not happen, said Casey Schwarz, senior counsel at the Medicare Rights Center.

Appeals can be processed on an expedited, fast-track timetable or at the standard, slower pace. But even expedited appeals can drag on, as plans and other entities miss decision-making deadlines.

Tips For Seniors

Older adults can become discouraged as they go through the early steps of this process, but “we encourage them not to give up — people are often successful at higher levels of appeal,” Schwarz said.

In 2015, the latest year for which data are available, independent reviewer MAXIMUS reversed drug plan decisions 30 percent of the time. That year, appeals to MAXIMUS climbed 47 percent over 2014 levels.

Some other tips from advocates: Keep careful records of every person you have spoken with and what they told you. Work closely with your physician’s office. Keep a record of any out-of-pocket drug expenses; these can be recovered later if your appeal is successful. Be persistent.

For help, call the Medicare Rights Center national hotline (800-333-4114).

“The complexity is awful, but hang in there if you can,” said Buss, who hopes he will not face similar difficulties when it’s time to renew his Xarelto prescription next year.

 

 

Caregiver ‘Boot Camp” for Dementia Patients

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Boot camp alzheimer caregiversGary Carmona thought he could do it all. He has headed companies and chaired nonprofit boards. But since his wife was diagnosed with dementia, Gary, 77, has felt exceedingly overwhelmed. 

 

 

“I really see myself crashing at times,” he said. “In my mind, I’m saying, ‘You know, I can’t really handle all this.’”

There was the time his wife, Rochelle, wandered outside and fell down. And the time she boiled water and walked away, leaving the burner on.

“I’m always double-, triple-, quadruple-checking everything that she’s around,” he said.

Carmona was among about 25 people who went to a Los Angeles-area adult day care center on a recent Saturday for a daylong “caregiver boot camp.” In the free session, funded in part by the Archstone Foundation, people caring for patients with Alzheimer’s or another form of dementia learned how to manage stress, make their homes safe and handle difficult patient behaviors. They also learned how to keep their loved ones engaged, with card games, crossword puzzles or music.

Doctors and researchers increasingly recognize that caring for people with dementia compromises the physical and mental health of the caregivers. And that, in turn, jeopardizes the well-being of the people in their care. Some studies have shown that the burden on caregivers may increase the likelihood that the loved ones in their charge will be placed in a nursing home.

“People with Alzheimer’s who have stressed caregivers have been shown to have poor outcomes,” said Zaldy Tan, the medical director of the UCLA Alzheimer’s and Dementia Care Program who created the boot camp. “Their caregivers have essentially thrown in the towel.”

People with dementia are also more likely to visit the emergency room and be hospitalized if their caregivers are not prepared for the task, Tan said.

That’s one of the main reasons why UCLA Health and its geriatrics division started its caregiver boot camps in 2015.

UCLA holds four boot camps a year at community and senior centers in Southern California and hopes to expand over the next year to meet the growing need. About 5 million Americans, 1 in 10 people over 65, have Alzheimer’s disease — a number that could balloon to 16 million by 2050, according to the Alzheimer’s Association.

Similar caregiver training programs have taken place in New Jersey, Florida and Virginia.

Tan started the recent session by explaining the progression of dementia, noting that in its later stages people often do not remember their loved ones.

“Do they all reach that stage?” asked one woman, who takes care of her sister.

“They do, if they live long enough,” Tan said. “I know it’s heartbreaking.”

He also warned the group that their actions can inadvertently provoke anxiety or aggression in their loved ones.

“Many times, when you see someone shift from being calm to agitated, happy to angry, typically there’s a trigger,” Tan said. “A trigger is just like a trigger on a gun. Something is pushed and you get a reaction.” He told them that as caregivers they were in the best position to identify and avoid those triggers.

Leon Waxman, who also attended the boot camp, said he tries not to upset his wife, Phyllis. But sometimes she gets angry, as she did the day he dropped her off for day care while he attended the session for caregivers.

Taking care of Phyllis the past few years has been trying, he said. She can still dress herself, but she gets easily confused and can no longer make decisions.

“The hardest part for me is I don’t have my wife anymore,” said Waxman, who has been married to Phyllis for 58 years. “She’s not the same person she was 10 years ago.”

During the boot camp, recreational therapist Peggy Anderson demonstrated a game caregivers could play at home: music bingo. Each square had the name of a song, and she played music.

“What’s this song?” Anderson asked the group.

“Bye blackbird,” one yelled out.

“If you have that one, mark it off,” she said.

Anderson said that even people with dementia can sometimes recognize songs and read their titles. “There’s a lot of good things that come out of this activity — just listening to music, clapping your hands, reminiscing,” she said.

In another room, occupational therapist Julie Manton explained how to prevent people with dementia from falling. She advised the group to ensure their homes have good lighting and bed rails, as examples. She also urged them to remove throw rugs.

Manton warned the participants that their loved ones might wander off and suggested the use of monitoring devices. “The key thing is to know where your loved one is at all times,” she said.

 

Making Homes User Friendly for Wheelchairs and Walkers

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Lady in wheelchairWhen Dan Bawden teaches contractors and builders about aging-in-place, he has them sit in a wheelchair to feel what it’s like to function from this perspective. That’s when previously unappreciated obstacles snap into focus. 

Bathroom doorways are too narrow to navigate through. Hallways do not allow enough room to turn around. Light switches are too high and electrical outlets too low to easily reach. Cabinets beneath a kitchen sink prevent someone from rolling up close and wash dishes, etc.

It’s an “aha moment” for most of his students, who have never actually experienced these examples of limitations or realized so keenly how home design can interfere with — or promote — the daily functions for an individual.

About 2 million older adults in the United States use wheelchairs, according to the U.S. Census Bureau; another 7 million use canes, crutches or walkers.

That number is set to increase with the aging population: Twenty years from now, 17 million U.S. households will include at least one mobility-challenged older adult, according to a December 2016 report from Harvard University’s Joint Center for Housing Studies.

How well has the housing industry accommodated this population?

“Very poorly,” said Bawden, chairperson of the remodelers division at the National Association of Home Builders and president of Legal Eagle Contractors in Bellaire, Texas. “I give them a grade D.”

Researchers at the Harvard center found that fewer than 10 percent of seniors live in homes or apartments outfitted with basic features that enhance accessibility — notably, entrances without steps and extra-wide hallways or doors needed for people with wheelchairs or walkers.

Even less common are features that promote “usability” — carrying out the activities of daily life with a measure of ease and independence.

Laws that guarantee accessibility for people with disabilities are limited. The Americans with Disability Act applies only to public buildings. And while the Fair Housing Act covers apartments and condominiums built after March 1991, its requirements are not comprehensive and enforcement is inconsistent.

We asked several experts to describe some common issues mobility-challenged seniors encounter at home, and how they can be addressed. The following is what the experts suggested may need attention with alterations, however is not a comprehensive list.

 Getting inside.

A ramp will be needed for homes with steps leading up to the front or back door when someone uses a wheelchair, either permanently or temporarily. The estimated price for a five-to-six foot portable nonslip version is $500 to $600.

One consideration is to take out the weather strip at the bottom of the front or back door and replace it with an automatic door bottom. “You want the threshold to be as flat as the floor,” Bawden said. Consider installing an electronic lock that prevents the need to lean forward and insert a key.

Doors.

Getting through doorways easily is a problem for people who use walkers or wheelchairs. They should be 34 to 36 inches wide to allow easy access.

Widening a doorway structurally is expensive, with an estimated cost of about $2,500. A reasonable alternative is swing-free hinges, which wrap around the door trim and add about 2 inches of clearance to a door.

Clearance.

Ideally, people using wheelchairs need a five-foot-wide path in which to move and turn around, Bawden said. Often that requires removing some furniture in the living room, dining room, and bedroom.

Another rule of thumb: People in wheelchairs have a reach of 24 to 48 inches. That means they will not be able to reach items in cabinets above kitchen counters or bathroom sinks.

Also, light switches on walls will need to be placed no more than 48 inches from the floor and electrical outlets raised to 18 inches from their usual 14 inch height.

Older eyes need more light and distinct contrasts to see well. A single light fixture hanging from the center of the dining room or kitchen most likely will not offer enough illumination.

It is suggested to distribute balanced lighting throughout each room and repaint the walls so their colors contrast sharply with the floor materials.

“If someone can afford it, I place recessed LED lights in all four corners of the bedroom and the living room and install closet rods with LED lights on them,” Bawden said. LED lights do not need to be changed as often as regular bulbs.

Kitchen.

Mark Lichter, director of the architecture program for Paralyzed Veterans of America, recommends that seniors who use walkers or wheelchairs take time to navigate around in the kitchen of a unit they are thinking of moving into and imagine preparing a meal or other tasks.

Typically, cabinets need to be removed from under the sink, to allow someone with a wheelchair to get up close, Lichter said. The same is true for the stovetop, understanding that the area underneath needs to be open and control panels placed in front.

Refrigerators with side-by-side doors are preferable to those with freezer areas on the bottom or top. Slide out full-extension drawers maximize storage space, as can carousel shelves in bottom corner cabinets.

Laundry.

A side-by-side front-loading washer and dryer works best to allow for easy access, instead of stacked machines.

Bathroom.

When Jon Pynoos’ frail father-in-law, Harry, who was in his 80s, came to live in a small cottage in back of his house, Jon put in a curbless shower with grab bars, a shower seat and a handheld shower head that slides up and down on a pole.

Even a relatively small lip at the edge of the shower can be a fall risk for someone whose balance or movement is compromised.

Also, Pynoos, a professor of gerontology, public policy and urban planning at the University of Southern California, installed nonslip floor tile and grab bars around a “comfort height” toilet.

Cabinets under the bathroom sink should be removed and storage space for toiletries placed lower for better accessibility. A free-standing toilet paper holder is better than a wall-based unit for someone with arthritis who has trouble extending their arm sideways.

“It really would not take much effort or expense to design homes and apartments appropriately in the first place, to make aging-in-place possible,” Pynoos said. Although “this still does not happen very often,” he noted the awareness of requirements is growing and well-designed, affordable products are becoming more widely available.

The housing industry has failed to accommodate an aging population, experts say.