Marci’s Medicare Answers August 2015

August 2015

Dear Marci,

I am having heart valve replacement surgery soon and spoke with my primary care doctor about care after my surgery. She said that I should ask the hospital for a discharge plan before I leave so that I understand how to continue my care once I am home. I have never received a discharge plan before. Does Medicare require the hospital to provide a discharge plan to me as part of my hospital stay?

– Louise (Washington, DC)

Dear Louise,

Hospital discharge planning services are intended to make your move from the hospital to your home or other location as smooth and safe as possible, and aim to prevent additional trips to the hospital for you. Under specific circumstances, Medicare does require all hospitals to provide discharge planning services as part of a hospital stay. Let’s see if those circumstances might apply to you.

Hospital discharge planning is only required if you are admitted to the hospital as an inpatient. If you are considered a hospital outpatient, Medicare does not require hospital staff to help you prepare for your care following a hospital stay. However, some states may provide you with greater rights to discharge planning services. Since you had heart valve replacement surgery, it is likely that you will be considered a hospital inpatient. Here are additional steps you can take to ensure that you leave the hospital with the plan you need.

1. You or your doctor should ask hospital staff for a comprehensive discharge planning evaluation. A discharge planning evaluation tries to foresee your medical and other care needs after your hospital stay. Some hospitals automatically evaluate the discharge needs of all patients, and some do not. That said, if you or your doctor asks for a comprehensive discharge evaluation, the hospital must give you one. Know that the discharge evaluation is not the same as a discharge plan, but it is a necessary step for acquiring a discharge plan if you are eligible.

2. Be aware that the hospital’s main goal during your evaluation should be to return you to the place you left before your hospital stay (this may be your home or another facility). If this isn’t possible, the hospital should recommend other, more appropriate places for you.

3. Make sure hospital staff members consider your range of needs following your hospitalization. If you are returning home following your surgery, the discharge planning evaluation should see whether you can care for yourself or if you will need assistance from family, friends, or other community caregivers. For example, do you need home health care or meal delivery services? The hospital staff should also see whether you will need medical equipment or changes to your home to make it safe. If you are going back to a facility, the hospital must make sure the facility can still care for you after your hospital stay.

4. Review which post-discharge services will be covered by Medicare and how much they will cost. If you have another type of insurance, such as Medicaid, check what is covered by that insurance.

5. Tell the hospital discharge planning staff about your needs and preferences for care after your hospitalization. If you are eligible for a discharge plan, your needs and preferences must be incorporated into your plan of care.

6. Be sure the hospital prepares you for discharge. Before you leave the hospital, staff must educate and train you, your family, and/or your caregivers about your care needs. Hospital staff should also provide a clear list of instructions for your care and all medications you will need. The hospital must explain what to do if problems occur, including who to call and when to seek emergency help. The hospital must provide referrals as appropriate for other care, including referrals to home health, skilled nursing or hospice agencies, physicians, and medical equipment suppliers, among other supportive services.

Be sure to follow up with your primary care provider and other providers involved in your care after your hospitalization. The hospital should send your providers information about your medical condition no later than seven days after you leave the hospital. Keep in mind that Medicare now pays for your primary care provider to manage your care right after your hospital discharge. Click here to learn more about this benefit.

Marci

Dear Marci,

I recently went to my pharmacy, and my pharmacist told me that my prescription was not covered by my insurance. I asked my pharmacist how I might be able to get my prescription covered. She told me that I can appeal but before I start an appeal, she told me to ask for an exception request from my plan. What is an exception request?

- Nancy (Madison, WI)

Dear Nancy,

An exception request is a formal request made to your stand-alone Part D plan or Medicare Advantage plan that asks the plan to make an exception to its normal rules and cover your drug. You must submit an exception request to your plan before starting the appeal process. If your exception request is denied, your plan will provide you with a written denial letter, which then allows you to start your formal appeal.

When your pharmacist told you your insurance would not cover your drug, you should have received a notice titled Medicare Prescription Drug Coverage and Your Rights. This notice provides a general set of options for you to potentially get your drug covered. This is not a formal denial notice. When you receive this notice, call your plan to ask why your drug was denied and share this information with your doctor who prescribed the drug. The drug may have been denied because it is not on your plan’s formulary, or because it has restrictions like prior authorization, quantity limits, or step therapy. After reading this notice and speaking with your plan about the reason for denial, you should submit your exception request.

You can make your exception request over the phone or in writing, but it is recommended that you send your request to your plan in writing. You must include a letter from your doctor to your plan that states why you need this drug, and that the drugs on the formulary will not work as well for you or will harm you. This is called a letter of medical necessity. You also can include any medical records that support your request, such as lab reports or medical histories. Ask the plan representative you speak with if the plan has a form that it recommends you and your doctor use to submit the exception request. In addition, ask the representative for the plan’s address or fax number where you can send your written exception request.

You must specifically state what kind of exception you are requesting. You and your doctor may request that the plan covers a drug that is not on the plan’s formulary, or that the plan overrides a drug restriction, such as requiring step therapy before it will cover your drug.

Keep copies of all documents and records that you send to your plan. If you speak with a plan representative over the phone about the exception request, note the date, time, and representative’s name.

Your plan must issue a decision within 72 hours of receiving your exception request. Know that if it is an emergency and your health is in danger, your doctor can request a fast, or expedited, exception request. If your plan approves your exception request, your drug will typically be covered for the rest of the calendar year. If your plan denies your exception request, you should get a letter titled Notice of Denial of Medicare Prescription Drug Coverage, which explains how to begin a formal drug appeal.

-Marci