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In This Chapter

^ Discovering and choosing healthy activities

^ Taking care of yourself, your life, and your relationships

^ Communicating effectively

7he way that you think influences the way that you feel and behave. How you behave also influences the way you end up feeling and thinking.. . and round and round the cycle goes.

So, how you Live From day to day has an effect on your overall mood. In this chapter, we look at what makes a lifestyle Healthy. Developing a healthy lifestyle can contribute enormously to keeping you in tiptop physical and psychological condition.

We use the term ‘healthy’ to mean looking after your physical self, which includes exercise, sleep, sex, your eating habits, and keeping your living environment a pleasant place to be. Psychological health overlaps with this and is about doing things that give you a sense of enjoyment and achievement, holding helpful and balanced attitudes toward life, and building satisfying relationships.

Make looking after yourself a priority rather than an afterthought. An ounce of prevention really is worth a pound of cure.

Planning to Prevent Relapse

Once you start to recover from your problems, your next step is to devise a plan to prevent a resurgence of symptoms – to ensure that you don’t suffer a Relapse. A relapse basically means that you return to your original state of mind. An important part of your relapse prevention plan is nurturing yourself and guarding against falling back into old, unhelpful lifestyle habits, such as

Working too late, eating unhealthily, drinking too much caffeine and alcohol, or isolating yourself. Chapter 18 deals with relapse prevention in depth. The following sections in this chapter provide some pointers on how you can make your life fuller and how to take care of yourself.

Fitting In the Gaps

When you start to recover from some types of emotional problems, such as depression, anxiety, or obsessions, you may find that you have a considerable amount of spare time available to you, which previously your symptoms took up. Indeed, you may be astounded to find out just how much energy, attention, and time, common psychological difficulties can actually consume.

Finding constructive and enjoyable things to do to fill in the gaps where your symptoms once were is important. Keeping yourself occupied with pursuits that are meaningful to you gives you a sense of well-being and leaves less opportunity for your symptoms to re-emerge.

Choosing absorbing activities

Activities that you used to enjoy may take a back seat while you wrestle with your problems. However, maybe you can think of some new activities that interest you and that you may like to try. The following are a few pointers to help you generate ideas about what activities and hobbies you can begin building into your life:

Make a list of things you used to do and would like to start doing again.

Make a separate list of new activities that you’d like to try.

Try to create a balance between activities that do and don’t involve physical exercise.

Include everyday activities like cooking, reading, DIY, and keeping up social contacts. These activities are often neglected when you’re overwhelmed by symptoms.

Choose to focus on around five activities to revive or pursue, depending on how full your life is with work and family commitments.

In case you’re still at a loss as to what you want to do, here’s some ideas – but remember that this list is by no means exhaustive: Antiques, art appreciation, astronomy, baking, chess, dance, drama, dressmaking, enamelling, fishing, football, gardening, golf, interior decorating, kick boxing, languages, motoring, painting, pets (get a kitty – Rhena’s cat Jack has transformed her life!), quizzes, tennis, voluntary work, wine-tasting, writing.. .

Don’t just think about it! Decide When You’re going to begin doing your chosen activities. If you don’t give yourself a concrete start date, forgetting about things or putting them off can be all too easy.

Matchmaking your pursuits

You know yourself better than anyone else, so you’re the best person to judge which hobbies can bring you the most satisfaction. Try to match your recreational pursuits to your character. If you know that you love paying attention to detail, you may enjoy needlework or making jewellery. Extreme sports may appeal to you if you’ve always been good at physical activities and like adrenalin rushes. Conversely, if you’ve never been very musical, taking up an instrument may not be the best choice for you.

We recommend that you stretch yourself by trying things that you haven’t done before. Who knows – you may end up really liking the new activities. However, if you choose pursuits that are too far removed from your fundamental personality or natural abilities, you might lose heart and abandon them.

Putting personal pampering into practice

Oh, the joys of a good massage, a hot foamy bath, or a trip to the opera (okay, we understand that not everyone feels the same about opera). You can’t overcome your problems without a significant degree of personal effort. Congratulate yourself for your hard work, and treat yourself to a few nice things.

Take care of yourself on a day-to-day basis, and look out for times when you deserve a few extra special treats. Friday nights are a good time to regularly treat yourself after a long week at work.

Your treats don’t have to be expensive. You can do many small things – such as putting some cut flowers in a vase, making your living space smell nice, playing pleasant music, watching a favourite film or television programme – which are free or inexpensive.

Consider pampering yourself as part of your Relapse-prevention plan (see Chapter 18 for more on relapse prevention). Even doing little things like using nice bath oils or eating a special meal once a week can remind you to value yourself and to treat yourself with loving care.

Oi/erhaulinq \lour Lifestyle

We suggest that you take a close look at the way you currently live and decide on the things that are good, and the things that are not so good for you. Be sure to consider the following key areas:

Regular and healthy eating. The principle is relatively simple: Have three meals and a couple of healthy snacks a day, with plenty of fruit, vegetables, and wholegrain foods. Minimise your consumption of sugar and simple carbohydrates, like white bread, and don’t overdo the saturated fat. Have what you fancy in moderation. If you think you need extra help with healthy eating, talk to your doctor, who can refer you to a dietitian.

Try keeping a record of everything you eat, for a week. Identify where you can make positive changes towards eating more regularly and more healthily. If you find that your actions don’t match with your good intentions, use the Tic-Toe technique (which we discuss in Chapter 17) to tackle the thoughts and attitudes that can get in the way of healthy eating.

Regular exercise. Ample evidence suggests that exercise is very beneficial for both your mental health and your physical health. Aim for at least three sessions of physical exercise, lasting 20-30 minutes each, per week. Consult your doctor if you haven’t exercised regularly for some time.

Leisure pursuits. Include activities that bring you pleasure or satisfaction and aren’t attached to your job or home life. Remind yourself of what you used to do and of what you’ve been meaning to do, when choosing activities and hobbies.

Social contact. Get to know new people or reinvigorate your existing relationships. Sometimes relationships suffer as a result of psychological illness; read more about getting intimate further on in this chapter, which address issues of intimacy and communication.

Vitally-absorbing interests. Get involved with causes you feel are important, such as recycling or animal rights campaigns.

Resource management. This catch-all may involve you doing a budget, getting an accountant, developing a system to deal with your household bills efficiently, renegotiating your working hours, or hiring a cleaner.

Ideally, you can create a nice balance between the different aspects of your life so that none is neglected.

Look at the things you do on a daily or weekly basis, and decide what you’re doing Too much of, Such as drinking in the pub, working late, or eating fast food. Try to replace some of these activities with others that you’re doing too little of, such as getting exercise, spending time with your family, or studying.

Walking the Walk

The best-laid plans of mice and men are apt to go astray. And how.

You’re really serious about making positive changes to your lifestyle; however, just thinking about it and setting out plans aren’t enough – although they Are A great first step. The next step is to Do it\ Actions speak louder than words, so act on your intentions sooner, rather than later.

Keep your body moiling

We cannot emphasise enough about the multiple benefits of you taking regular exercise. It’s so darn good for you, in so darn many ways. If you don’t believe us, try it out! Exercise a few times each week and see if you don’t end up feeling better – we defy you to contradict us.

You can exercise in ways that don’t involve going to the gym. Gardening, walking, cycling, dancing, and housework, all give your body a workout. Find out which activities suit you, your interests, your schedule, and your current level of fitness – And do them!

Be careful that you’re exercising for the right reasons, such as to enjoy yourself, and to keep yourself physically and mentally healthy. Check that you’re not exercising obsessively. The following are unhealthy motivations for taking exercise:

To keep your weight lower than is medically recommended. People who suffer from eating disorders may often exercise fanatically.

To improve your looks if you are anxious about your appearance.

People with body dysmorphic disorder (BDD), sometimes use exercise to compensate for imagined defects in their physical appearance (Chapter 11 has more about this psychological problem).

To punish yourself. People with feelings of shame and low self-worth may exercise to excess as a means of self-harming.

Ask your physician to work out your Body mass index Or ‘BMI’, which gives you a weight range that is normal for your age and height.

Using your head

Perhaps your emotional problems get in the way of your work or study. Maybe your difficulties interfer with you making progress in your career or changing jobs – after all, many people with psychological problems also experience work and education difficulties.

Start to set goals for how you’d like your work or academic life to develop. Build a realistic plan of action for reaching your professional or educational goals by following these steps:

1. Start your plan by considering where you’d like to be and what you need to do in terms of study and training to get there.

2. Break your ultimate goal down into smaller bite-sized chunks. You

May need to gather references, build a portfolio, write a CV, or apply for a loan or grant to fund your studies.

3. Investigate facilities for learning. Use the Internet to look for specific courses, contact universities and colleges for a prospectus, see a careers advisor, or visit an employment agency.

4. Build your study or training plan into your life with a view to keeping a balance between study, work, social, and leisure activities.

5. Set a realistic time frame to achieve your goal. Pushing yourself to get there too fast is likely to cause you stress, impair your enjoyment of the journey to your goal, or even lead you to abandon your goal all together.

Go out and study just for the sake of it. Developing a new skill or exploring a new subject area can be highly rewarding for you, whether or not the studying is applicable directly to your work. Adult education classes and intensive workshops can be a great way for you to explore new topics – and for you to meet new people, which can be beneficial if your social life has suffered during your illness.

Getting involved

Think about the kind of world you want to live in and how you can contribute towards creating it. You can get involved with anti-litter campaigns, local building-restoration projects, charities, or whatever you feel is important. You can usually choose how much time to devote to these pursuits.

Becoming spiritual

Sometimes, people with specific disorders such as obsessive-compulsive disorder (OCD) or extreme guilt, can find that their religion or spiritual beliefs get mixed up with their problems. Re-establishing a healthy understanding of your faith can be an important aspect of your recovery. Resuming your usual manner of worship – be it mediation, attending mass or going to a synagogue – can help you to reintegrate with your religious beliefs or your community. You might also find that discussing your recent problems with a religious leader or a member of your congregation is helpful.

Talking the talk

Emotional problems can have a detrimental effect on your personal relationships. Sometimes, your symptoms can be so all-consuming that you have little space to show interest in what others around you are feeling and doing. Therefore, you may need to do some work to rebuild your existing relationships when you feel better.

When your symptoms subside, you may want to give more of your attention to the other people in your life. This may involve playing with your kids, talking to your partner about how your problems have affected your relationship (without blaming yourself, of course), or renewing contact with friends and extended family.

People in your life are likely to be aware of how troubled you’ve been and they may notice recent positive changes in you. Let them talk about the changes they’ve noticed within you. Listening to other people’s experiences of your problems can help to reinforce the idea that the other people in your life care about you. Improving your relationships and simply spending time in the company of other people can help you keep your symptoms at bay. You can also involve others in your relapse-prevention plan, if appropriate.

A supportive relationship with a significant other can help you to stay healthy. This relationship doesn’t need to be a romantic relationship – pla-tonic relationships are important as well. Research has shown that having a network of social contacts, as well as having someone you’re able to confide in, helps to reduce your emotional problems in general.

It’s never too late for you to make friends. Even if your problems have led you to isolate yourself, now’s the time to go out and meet people. Be patient and give yourself the time and opportunity to start forming good relationships. Go to where the people are! Join some clubs or classes.

Getting intimate

Your specific problems may lead you to avoid intimate relationships with other people. You may have been too preoccupied by your problems to be able to form or maintain intimate relationships. If you want to be close to others, you’ve got to get your head round the concept of letting others into your life. Allowing yourself to trust others enough to share at least some of your personal history can make you feel closer to your listeners. Intimacy is a give-and-take affair – ideally, the balance is roughly equal.

Six steps for talking and listening

Good relationships are sustained bythoughtful-ness, effort, and time. Many of the changes in your relationships may occur naturally because as you become less preoccupied with your problems you are more able to focus on the world around you.

Effective communication is the cornerstone of good relationships. Bear in mind that you can communicate not only with what you say, but also with how you Listen. Your body language can also convey a message to others. Things like eye contact and physical contact are also means of getting the message across. A simple hug can really mean a lot.

Try the following six steps to improve your communication skills:

1. When you have something importantto discuss with someone, find a mutually good time to do so. Make sure that you both have ample time to talk and listen to each other.

2. Use ‘I feel’ statements, such as ‘/ Feel Disappointed thatyou came home late’, rather than blaming language, such as ‘You Made me so angry’.

3. If you want to give negative feedback to someone about his behaviour, keep it clear, brief, and specific. Remember to also give positive feedback about the behaviour you want to reinforce, for example thank your partner for calling to say he’ll be late.

4. After you’ve given positive or negative feedback, ask the person how he feels and what he thinks about what you’ve said.

5. Don’t fall into the trap of thinking that a right or true way of doing things exists. Accept that different people value different things. Seek compromises when appropriate. Listen to the other person’s point of view.

6. Be prepared to accept negative feedback and criticism from others. Look for points that you agree with in what the other person is saying. Give the other person a chance to air his views before you get defensive or counteractive. Give yourself time to assess the feedbackyou receive.

If you think you’re incapable of getting truly close to someone else, you’re probably wrong. Give other people – and yourself – a chance to be honest with one another. Reciprocally enhancing relationships usually evolve naturally, but you need to be open to the possibilities of intimate relationships for this evolution to happen.

Sex and other animals

Your interest in sex, regardless of your age or gender, may diminish as a result of your emotional disturbance. Many people dealing with emotional problems can lose interest in sex. When you begin to feel better, getting your sex life back on track may take some time.

Sex drive is a bit like appetite: You don’t always realise you’re hungry until you start eating.

Sometimes, couples stop having sex regularly but don’t ever discuss the change. Often, both partners get into a routine of not being sexually intimate and try to ignore the problem. Some people are too shy to talk about sex or feel guilty for having lost their interest in sex. Additionally, many people are afraid of discussing their loss of sex drive with their doctors, or friends, for fear of embarrassment.

Taking the plunge and talking about changes in your sex drive with your therapist or doctor can be very worthwhile. Your therapist or doctor may offer you useful suggestions and may even tell you that certain medications you’ve been taking may contribute to your decreased interest in sex.

Loss of interest in sexual activities is a normal side effect of certain experiences. Many psychological disorders, such as depression, post-traumatic stress disorder, obsessional problems, health anxiety, postnatal depression, and low self-esteem, can impact on your ability to feel aroused. Bereavement, physical illness, and stress can also put your sexual desires on the back-burner. Fortunately, decreased libido is often temporary.

Talking about sex

‘Birds do it, bees do it, even educated fleas do it’, but sometimes the issue of sex is like an elephant in a tutu doing the dance of the seven veils in the middle of your bedroom. Both you and your partner can end up studiously ignoring its presence, even though it’s right there, begging for your attention.

If you can’t bring yourself to broach the topic of sex with your partner as you begin to recover, you can do a few things to help rekindle the flames of desire. Try some of the following:

Resume non-sexual physical contact. Hold hands, stroke your partner’s arm or back as you chat, sit closer to each other on the sofa, and reintroduce cuddling. Non-sexual contact can help you to get comfortable with touching one another again, and set the scene for a revival of more intimate contact.

Kiss. If you’ve got into the habit of a quick kiss on the cheek as you leave the house, aim for the mouth instead. Kissing is a powerful form of communication. It also can be highly sensual and enjoyable.

Create opportunities. Getting into bed at the same time before you’re both bone tired, and then snuggling up, can create a non-threatening reintroduction to sexual relations.

Take the pressure off. If you tell yourself that you’ve Got To get aroused or you’ve Got To have sex tonight, you can work yourself into such a state that all spontaneity is quashed. Try to take the attitude that if it happens, it happens.

Give yourself a chance to get in the mood. You don’t have to feel very aroused to start getting intimate. Sometimes you may need to have a lot of low-level sexual contact like stroking, petting, and kissing before you’re ready to go further. Be patient with yourself and try to talk to your partner about how you’re feeling. Sometimes, just talking about sex is enough to relax you to let nature take its course.

Take the onus off orgasm. Any sexual or close physical contact can be fulfilling. You may not be able to achieve orgasm for some time, so instead enjoy foreplay like you may have done in the early stages of your relationship. You can really get your sex life back on track, and you may even be able to make it better than it was before, if you give a lot of attention to the preliminaries.

Whatever turns you on is worth exploring further. Talk to your partner: You may be able to find things that can help you both get more in the mood for lovemaking. Try to be open-minded about your sex life. Just be careful to set your own personal boundaries about what turns you on and what has the opposite effect.

In This Chapter

^ Finding out about aromatherapy

^ Understanding how aromatherapy works

^ Discovering what aromatherapy can be good for

^ Knowing what to expect in a typical consultation

^ Finding out about safe and effective use of aromatherapy

Romatherapy is the use of essential oils extracted from plants, flowers, trees, and seeds for therapeutic purposes. Scented oils have been used since ancient times for their healing properties, but more recently, scientists have investigated the psychological and physical effects of particular essential oils.

Nowadays, aromatherapy is one of the most popular forms of complementary therapy, and it is even used in schools, clinics, hospitals, maternity units, hospices, and work settings.

In this chapter, you’ll explore the roots of aromatherapy and look at modern day practice from aromatherapy massage to medical aromatherapy (internal use of aromatherapy oils). You’ll get the low-down on how aromatherapy may work, the evidence for its effectiveness, and key points for the safe use of aromatherapy oils.

Then I let you know what a typical aromatherapy consultation involves, and finally I give you some tips on how you can enjoy using aromatherapy oils at home.

Finding Out about Aromatherapy

Aromatherapy Literally means ‘treatment using scents’ and involves the therapeutic use of fragrant essential oils extracted from plants and plant materials. The oils may be massaged into the skin, inhaled, vaporised, or diffused throughout the room. In France, under careful supervision from a medical aromatherapist only, certain oils may also be taken internally.

Never take essential oils internally except under medical supervision because they can be toxic!

The oils appear to work on the brain and nervous system via absorption through the skin into the bloodstream and via the nose to act on the olfactory centres (the areas of the brain that respond to smells).

Aromatherapy may be used to relax or invigorate or to treat specific health problems such as insomnia, nervous problems, circulatory or respiratory problems, digestive disorders, and so on.

A (very) brief history of aromatherapy

The ancient Egyptians, Greeks, Chinese, Persians, Romans, Aztecs, Native Americans, and Indians are all believed to have used aromatic plants and scented oils, either in religious ceremonies, to perfume their clothes and bodies or for massage.

Early aromatic oils were made by soaking herbs in olive or castor oil or by expressing them, for example, by squeezing the oil out of citrus peel. Around the start of the 11th century, however, the great Iranian philosopher, physician, and scientist Abu Ali Sina, also known as Avicenna, is credited with inventing a new distillation process that used steam and a coiled pipe to successfully extract volatile oils from rose and other plant materials.

The Crusaders brought this technique back to Europe, and traders over the next few centuries brought an increasing array of novel herbs and oils from different parts of the world.

In the 15th century, the alchemist Paracelsus is believed to have first coined the term ‘essence’ and began using essential oils of plants medicinally. Soon essential oils were being prepared and sold by apothecaries and perfumery developed as an art and a science in its own right. Later, in the 19th and 20th centuries, individual constituents of essential oils were isolated and research on their aromatic and medicinal uses continued.

Story has it that in 1910, Rene-Maurice Gattefosse, a French chemist working in a perfumery, burned his hand in his laboratory one day and instinctively plunged it into the nearest liquid, which happened to be lavender oil. To his surprise his skin is said to have healed quickly and without scarring. This aroused his curiosity and he went on to investigate and then write about the protective effects of certain essential oils against infection. It is believed that he may have experimented by using them at military hospitals with injured First World War soldiers and that he discovered that lavender, thyme, clove, and lemon all had useful antiseptic properties. Gattefosse is credited with coining the

Term ‘aromatherapie’ and wrote a best-selling book under this title, which is still used today. He is widely regarded as the father of modern aromatherapy and influenced many French physicians to use his methods.

One of the physicians inspired by Gattefosse was French army doctor Jean Valnet, who successfully used essential oils to treat infections of soldiers during the Second World War and went on to pioneer their medical use for treating burns, diabetes, and even cancer. This work has remained a part of French medical practice to this day.

Modern aromatherapy grew out of the chance discovery in the early 1900s, by French chemist Rene-Maurice Gattefosse that lavender oil could heal burns.

The use of essential oils for therapeutic massage and beauty purposes was pioneered in the 1960s, by the biochemist, nurse, and beautician Marguerite Maury. She was born in Austria but moved to France, married a French physician, and spent decades studying and developing aromatherapy.

Modern pioneers who’ve promoted aromatherapy include Micheline Arcier, Shirley Price, Daniele Ryman, and Robert Tisserand.

Grasping the idea behind aromatherapy

Essential oils are concentrated volatile oils extracted from plants and plant materials by means of distillation, expression, or solvents.

Distillation: Involves passing steam through a container holding plant materials, which causes the volatile oils to vaporise. As the vapour travels down a coiled glass tube, it is cooled and turns back into a liquid oil, which can then be collected. This method is used for the extraction of most essential oils such as eucalyptus, peppermint, or lavender. In this

Process, floral waters, also known as hydrosols or hydrolats, may also be produced as a by-product.

Expression: In this method the plant material is collected and then pressed, usually using mechanical equipment, to extract the oil. Essences of lemon, lime, and orange are collected in this way by expressing the peel of the fruit.

Solvent extraction: Some plants only contain minute quantities of volatile oils and so solvents may be used to draw them out of the plant material. An example of this process is the extraction of the essential oil Rose Absolute.

The term Essential Refers to the fact that the oil is the essence of the scent of the plant, or plant material, rather than that it is essential to the plant’s survival.

The oils are extracted from the leaves, flowers, berries, peel, bark, seeds, roots, wood, and resins of plants and then used therapeutically for both psychological and physical ailments by means of inhalation or application to the body.

Aromatherapy today

In the UK, aromatherapy is currently going through a process of voluntary regulation under the auspices of the Aromatherapy Council (Www. aromatherapy Council. co. uk). In the US, no official form of accreditation or regulation exists at this time. In France, aromatherapy remains a part of orthodox medicine, cosmetology, and beauty therapy.

Aromatherapy is hugely popular as both a complementary therapy and a self-help therapy. It is widely used in Europe, North America, Australia, Japan, and elsewhere.

Finding Out How It Works

Aromatherapy is believed to work in two ways, via inhalation or absorption.

In the case of inhalation, as you breathe in the aroma of the essential oil, tiny receptors in the nose are stimulated and these in turn stimulate nerves, which are connected to the olfactory centres of the brain, that is, the areas stimulated by the sense of smell. These areas are linked to other parts of the brain connected to mood and so it is thought that somehow different scents can produce different moods such as feeling relaxed or happy.

Absorption of compounds in the oils takes place when the oil is massaged into the skin. These compounds pass into the bloodstream and from there affect the

Nervous system, which also can somehow affect mood and physical health. Exactly how this process works isn’t yet known and the mechanism for specific effects of individual oils in the body is not yet fully understood.

Exploring Different Types of Aromatherapy

The main types of aromatherapy currently practised are:

Massage aromatherapy: This therapy involves therapeutic massage (see Chapter 17 for more on massage techniques) using essential oils diluted in a carrier oil. Sometimes acupressure and other massage techniques are incorporated. This is the most common form of aromatherapy used in complementary medicine.

Cosmetic aromatherapy: Here, essential oils are combined into various beauty products, such as skin or hair products, and used for beauty therapy treatments or home use. This is also practised by beauticians and beauty therapists.

Olfactory aromatherapy: Essential oils are released into the atmosphere via vaporisers, burners, or sprays for inhalation. This type of aromatherapy is mainly for home use but is also used in some schools, hospitals, and work places.

Medical aromatherapy: This therapy is sometimes called aromatology. It involves essential oils being taken internally. This is only practised by medically trained aromatherapists, mainly in France.

Culinary aromatherapy: This uses essential oils in cooking, for example in the form of infused oils drizzled over vegetables or used to flavour rice or herb butters.

Discovering What Aromatherapy Is Good For

You can use aromatherapy to relax, rejuvenate, and energise, or to promote well-being and aid healing. It is often used for the following types of conditions:

Stress, anxiety or insomnia Joint and muscular problems I Chronic fatigue

I Hyperactivity

I Skin problems

I Sports injuries and pain relief

I Menstrual and menopausal imbalance

Aromatherapy is also used in cancer and hospice care and in burns and cardiac units in hospitals as well as sometimes in classrooms, to facilitate learning.

6

When not to use aromatherapy

Only use aromatherapy under careful supervision by an experienced aro-matherapist with very young children or if you are:

I Pregnant

IU Breastfeeding

I Suffering from asthma, high blood pressure, epilepsy, varicose veins, deep-vein thrombosis, or broken or infected skin

Always tell your aromatherapist if you are, or may be, pregnant; if you’re trying to conceive; or if you suffer from any of the above mentioned disorders.

Possible side effects

Pregnant and breastfeeding women and young infants need to be careful because essential oils can be toxic. For this reason they should also never be taken internally except under medical supervision.

The oils are very concentrated and may cause irritation or allergic reactions if applied neat to the skin. For this reason always dilute them in a suitable vegetable carrier oil (exceptions are lavender oil for burns and tea tree oil for infections, which you can apply neat). Test a small amount of oil on the back of the earlobe to test for allergic reactions before full use. Avoid contact with the eyes.

Certain oils may interact with prescribed medicines so seek advice from your aromatherapist or GP if you’re on medication. Some citrus oils also increase the skin’s sensitivity to light, making it more prone to pigmentation.

Evidence that it works

Research on individual oils has confirmed their various properties. For example, tea tree has been shown to have potent antiseptic, anti-bacterial, and anti-fungal properties, while the sedative properties of neroli and lavender have also been confirmed.

In clinical studies, aromatherapy has been found to aid relaxation and help relieve anxiety and depression. Aromatherapy may also be helpful for other conditions such as dementia, premenstrual syndrome, and bronchitis, as well as in cancer care. However, many studies have only used small numbers of people and have had design flaws, so more research is needed.

For details of some published aromatherapy studies, check out the following:

I NHS Complementary and Alternative Medicine Specialist Library

(Www. library. nhs. uk/cam)

IU The Cochrane Library (Www. cochrane. org/reviews/ clibintro. htm)

What to Expect in a Typical Treatment

Aromatherapy treatment generally starts with some questions about your health.

Questioning

Your aromatherapist may ask questions about your general physical and emotional health including current symptoms, medical history, stress levels, lifestyle and diet. You may also be asked whether you want the aromatherapy for general relaxation or to address a specific health concern.

Selecting the oils

The aromatherapist will use the information from your answers to questions to determine which essential oil, or combination of oils, may be the most

Therapeutic for you. You may also be asked to smell and choose between certain oils to determine your particular preferences.

Aromatherapists don’t make any medical diagnosis, unless they’re medically qualified, so if you’re in any doubt about your condition consult your doctor first.

Good aromatherapists usually only use pure, and sometimes organic, essential oils rather than synthetic or diluted ones.

Aromatherapy treatment

For the treatment you’re usually asked to undress down to underwear and then are covered with towels as you lie on a treatment couch in a warm room.

Most professional aromatherapists treat you with therapeutic massage (see Chapter 17 for more about massage techniques) using selected essential oils diluted in a vegetable carrier oil such as sweet almond, jojoba, sunflower, or grapeseed. Alternatively, the oils may be added to lotions or creams.

The massage may be for the whole body or just part of the body such as the neck and shoulders or a facial massage. Some aromatherapists also incorporate manual lymphatic drainage and/or acupressure techniques into the treatment (check out Chapter 9 on acupuncture and Chapter 17 on massage for more about these).

Other types of treatment

Sometimes you may be advised to use the oils at home as inhalants or added to bath water (see the ‘Helping Yourself with Aromatherapy’ section at the end of this chapter to find out how to do this). Your aromatherapist may also give you some general advice on diet and lifestyle.

At the end of treatment

You’ll often be left alone for a short while to complete your relaxation, allow the oil residues to be fully absorbed into the skin, and to slowly bring yourself back to reality! You can then get dressed and it is a good idea to drink a glass of water or herbal tea to rehydrate after the massage.

Duration and frequency

Aromatherapy sessions usually last around 60 to 90 minutes for a full body massage or 30 minutes for a facial or neck and shoulder massage. Follow-ups can

Be as often as you like. Very tense people often choose to have aromatherapy at regular intervals – say weekly, fortnightly, or monthly – to ease tension and relieve stress.

Knowing whether your aromatherapy treatment is working

The success of aromatherapy depends on the quality of the essential oils used and the skill and experience of the practitioner. Pure, organic essential oils, carefully made and used within sell-by date, are the most effective. Essential oils adulterated with chemicals, pesticides, diluted, or left to go rancid are not likely to be effective and can even smell sickly or unpleasant. Reputable essential oil manufacturers provide information on the purity and quality of their oils. Well-trained aromatherapists are happy to confirm for you their level of training and experience. After the treatment you should feel relaxed and comfortable with an enhanced sense of well-being.

Common Questions about Aromatherapy Treatment

Here are some questions that I’m often asked about aromatherapy that are not covered in the chapter so far:

IU How are essential oils classified and combined into blends? They can be classified according to their ‘notes’, that is their scent characteristics, as well as other characteristics. ‘Top notes’ are scents that give you a quick first impression and that are often fresh and uplifting. They include citrus essential oils such as lemon, lime, and orange as well as peppermint and eucalyptus. ‘Middle notes’ are rounder, softer scents such as lavender, rosemary, or chamomile. ‘Base notes’ are more solid, enduring scents such as sandalwood and cedarwood. Good blends often combine oils with top, middle, and base ‘notes’.

IU What should the ratio of essential oil to carrier oil be? Usually the ratio is between 0.5 and 3 per cent essential oil to carrier oil, depending on age, condition and body size.

I What will I feel like afterwards? You may feel very relaxed, tired, sleepy or thirsty at the end of the session. Allow yourself time to ‘come round’ before driving or operating machinery and, if possible, clear your schedule of demanding activities and avoid heavy meals and alcohol for a few hours after treatment.

Finding a Good Aromatherapist

The Aromatherapy Council (Tel: 0870-7743477; Www. aromatherapycouncil. co. uk), is the new, voluntary self-regulatory body for aromatherapists in the UK and operates a directory of members who follow a code of professional practice and ethics.

In the US, where currently no national system regulates the practice of aromatherapy, and regulations for ‘hands-on’ therapy vary from state to state, the best way to find an aromatherapist is to look in local directories or contact local qualified massage therapists. You can find a lot of information about aromatherapy in the US online at Www. aromaweb. com. However, always remember to ask about training, experience, licensing, insurance, and so on.

Counting the cost of aromatherapy

Aromatherapy sessions can cost from Ј30 to Ј90 depending on whether a full body massage or a partial massage, such as a facial, is carried out. Aromatherapy treatments on the NHS are usually free or subsidised. Private health insurance does not usually cover aromatherapy treatment.

Ensuring satisfaction

If you’re dissatisfied with your treatment, first talk things over with your practitioner.

If you think that the practitioner has been negligent, incompetent, or unethical in any way, contact their professional association. The new Aromatherapy Council has a formal complaints procedure.

Helping Yourself with Aromatherapy

Here are some of the ways that you can enjoy using essential oils at home:

I Baths: Add five to ten drops of a relaxing essential oil such as lavender or geranium to warm bath water and stir vigorously before getting in. Soak for 10 minutes.

I Inhalation: Add two to three drops of essential oil to a bowl of steaming water, cover your head with a towel, lean over the bowl, and then breathe

In the vapour. Oil of eucalyptus or lemon are good for clearing your head and easing colds or nasal blockage.

Make sure that the bowl is on a stable surface and won’t tip and scald you. If you suffer from asthma get advice from a trained aromatherapist on the best and safest essential oils to use.

I Diffusion: Put five drops of essential oil in a vaporiser, aromatherapy burner, or light bulb ring (these can be purchased from health shops) and allow the room to fill with a wonderful aroma. Good oils for freshening rooms are geranium, lime, and ylang ylang, depending on your personal preference.

If using an aromatherapy burner with a dish for water and a lighted candle, take care that the water doesn’t run dry and that the candle can’t become a fire hazard. Keep safely out of reach of children and pets. Alternatively, use a plug-in electric vaporiser. With light bulb rings, make sure that no oil drops onto the light bulb itself as it may then overheat and blow.

I Massage: Mix five to ten drops of essential oil per 10ml of a carrier oil such as almond, jojoba, or good quality sunflower oil. Warm your hands and then massage the oil blend directly onto the skin.

Use towels to prevent staining clothes or bed linen. Ensure that the room is warm so that exposed skin doesn’t get chilled.

I Compresses: Add three to five drops of essential oil to 300ml of warm/hot water and soak a clean flannel or soft cloth in this liquid. Wring out and apply to affected part of the body. Warm essential oil compresses can be used for menstrual pains, cystitis, and boils. For bruises, sprains, or headaches, first cool the compress in a bowl in the fridge for 20 minutes and then apply.

I Gargles and mouthwashes: Add one to three drops of lemon, tea tree, or thyme essential oil to a glass of water and mix well. Take a mouthful and rinse the mouth or gargle and then spit out – don’t swallow.

Don’t take essential oils internally unless under the supervision of a medical aromatherapist. Avoid bringing the oils into contact with the eyes. Halve dosages for children and get professional advice if you’re pregnant, breastfeeding, or wanting to use aromatherapy with infants.

In This Chapter

^ Starting with a game plan

^ Knowing how to file a grievance or coverage determination request ^ Appealing an unfavorable decision ^ Getting help to make an appeal

Ooner or later, you may have some sort of issue with your Part D plan. Note that I’m saying May, Not Will. But you should know that you have every right to challenge your plan’s decisions — or even its ways of doing business — if you don’t agree with them. You can try to resolve a variety of problems through different procedures, such as filing a formal complaint about your plan, requesting a coverage determination to get the prescription meds you need, or appealing a decision you disagree with. In this chapter, I walk you through these procedures and suggest ways to seek free professional help in making appeals.

Having a Game Plan in Mind

<2^~£x Before you embark on filing a grievance, a coverage request, or an appeal, I

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Want to suggest a general game plan to make the process easier:

Have a rough idea of the kind of complaint you want to make. The

Plan may categorize your complaint as an inquiry, a grievance, or a coverage determination, depending on whether you complain about

• One of the plan’s policies in general terms: In this case, the plan can treat your complaint as an inquiry and respond with a simple explanation of the policy.

• How a policy affects you personally: In this case, the plan must treat your complaint as a grievance or (if it concerns coverage or payment for a drug you need) as a coverage determination and take the appropriate action.

Put your problem in writing. You can file a grievance or request a coverage determination just by calling your plan. However, if possible, put your complaint or request in writing so you have a record. If the matter is urgent, fax your complaint to the plan instead of mailing it. Be sure to date all communications.

Gather any documents that support your case. Such documents include statements from your doctor, pharmacy receipts for drugs you think the plan should pay for, and so on, depending on the situation.

Keep all paperwork. Retain copies of all letters or forms you send to the plan, letters you receive from the plan or a higher appeal body, transmission records of any faxes, and receipts and tracking numbers of any correspondence you send by registered mail. This way you have a paper trail if the plan tries to dodge your filing.

Make notes of conversations: Keep track of all the people you talk to at your plan or at Medicare. Write down their names, the date and time you spoke to them, and their phone numbers. Having notes of your conversation gives you evidence that may prove valuable.

Try to use the right terminology. Consumer advocates who help people with Part D appeals find that sometimes decisions are delayed or derailed simply because the consumer doesn’t talk (or write) the same jargon that a plan uses. In this chapter, I tell you the correct terms for different situations. You don’t have to commit them to memory — just know what they mean and have them handy when you need ‘em.

Stick to the deadlines. At every level of appeal, you have a certain length of time (usually 60 days) to file for a review of the previous decision. If it looks like you’ll miss a deadline for good reason — such as sickness or a family crisis — you have the right to ask for an extension.

Don’t give up. If you think you’re right and the plan is wrong, don’t be put off by a "no" decision or feel intimidated by grand-sounding titles at higher appeal levels. The title "administrative law judge" may sound imposing, but ALJs more often decide in favor of consumers than plans. Therefore, if you have a reasonable case, you may just win it!

Get help if you need it. You can designate anyone of your choice to help you, or to act on your behalf, in pursuing a complaint or an appeal. This person can be a relative, friend, consumer advocate, lawyer, physician, or anyone else willing to assist you. At higher levels of appeal or in tricky situations, it’s best to seek help from someone experienced in dealing with Part D appeals on behalf of consumers, such as the advocates I suggest later in this chapter.

Filing a Grievance

A grievance covers many types of complaints — but Not Those that have anything to do with your plan covering your drugs or paying for them, which fall into the coverage determination category that I explain later in this chapter. Understanding the difference between the two is important, because a grievance is Not Open to further appeals.

What is a grievance?

A Grievance Is a complaint about any aspect of a plan’s service or quality of care that requires some action from the plan to resolve. You can also file a grievance if the plan doesn’t respond within a proper time frame to your request for any kind of coverage determination. Here are examples of situations when you may want to file a grievance:

Poor or unsatisfactory customer service: You find it hard to get through to the plan on the phone, hang on hold for ages, or get disconnected. Plan representatives don’t respond to questions satisfactorily, give wrong or inadequate answers, or are rude.

I Misleading information: You choose a plan on the basis of information — such as coverage or charges for your drugs — that turns out, after enrollment, to be untrue.

Absence of required notifications: The plan doesn’t send you required notices — such as its Annual Notice of Change (see Chapter 17), Explanation of Benefits statements (see Chapter 13), or warnings about formulary changes (see Chapter 4) — within the required time frames. Or you find the wording of notices or other written materials difficult to understand.

Problems at the pharmacy: A pharmacy in your plan’s network gives you the wrong medication, the wrong number of pills, or makes other mistakes in dispensing your drugs. You have to wait a long time to have your prescriptions filled, or a pharmacy staff member treats you rudely.

I Poor quality of care for medical services: You can’t easily get appointments or have to wait too long for them. You have a problem with your care from doctors, nurses, hospitals, or other providers in the plan’s network — including rude behavior and facility cleanliness.

Failure to transfer records: You switch Part D plans during the year, and your old plan fails to send your coverage record to the new plan in good time.

I Discrimination: You feel that the plan treats you differently from its other enrollees or seems to be encouraging you to disenroll.

Receipt of unwanted marketing materials: The company offering your plan sends you mailings that you didn’t ask for and that are unrelated to the plan.

I Tardy responses or decisions: The plan fails to respond to your request for a coverage determination or an appeal, or it doesn’t give you its decision within the required time frames. Or perhaps the plan denies your request for a fast coverage determination — in which case, the plan must make a decision within 24 hours.

How do you file a grievance?

To file a grievance, you can call the plan or write to it about your complaint. Look at the informational materials your plan sent you when you enrolled (I describe these materials in detail in Chapter 13). These documents give the appropriate phone numbers and address for filing a grievance, as well as an explanation of how to do so. You can also find this info on your plan’s Web site.

You must file a grievance within 60 days of the incident that prompts it. You can file yourself or have someone else act on your behalf (as explained in the last section of this chapter). You may receive extra time, up to 14 days, for filing if you ask the plan for an extension of the 60-day time frame, for example if you’re sick or have a family crisis during this period.

If you call about your complaint, the plan may be able to resolve it over the phone. Otherwise, the plan must tell you how to file a written grievance. In any event, the plan must give you a written response if you request it, if you complain in writing, or if the complaint involves a quality-of-care issue. The plan must respond no later than 30 days after receiving your complaint, or a lot sooner if the state of your health requires a fast decision. However, the plan may extend the 30-day period by up to 14 days if it needs more time to investigate your complaint — in which case, it must notify you.

A Quality Improvement Organization (QIO) is a panel of doctors and other healthcare experts contracted by the federal government to monitor and improve care given to people receiving Medicare services. If you’re complaining specifically about the quality of care you’ve received (whether under traditional Medicare, a Medicare private health plan, or a Part D plan), you have the right to file a grievance directly with a QIO, your plan, or both. The advantage of involving the QIO in your complaint is that the plan must then work with the QIO to resolve the problem. (But note that QIO complaints almost always involve Medical Services rather than problems with drug coverage.) Your plan must include the phone number and address of your state QIO in the enrollment materials it sends you. You can also call Medicare at 800-633-4227 (or 877-486-2048 for TDD users) for the number.

After the plan looks into your complaint, it should tell you what has been done to resolve it. If the plan decides that no action is needed — in other words, it doesn’t think your complaint is justified — you can’t appeal further. (However, if your complaint is a quality-of-care issue, the plan must inform you of your right to take it up with a QIO if you haven’t already done so.) Alternatively, if the plan decides your complaint should be handled as a coverage determination request rather than a grievance, it must tell you how to go about doing that.

Requesting a Coverage Determination

Unlike a grievance (which I describe in the previous section), a Coverage determination Always relates to drug coverage or payment issues. You can ask for a coverage determination for both nonpayment-related issues (like requesting a nonformulary drug be covered) and payment-related issues (like asking to be reimbursed for going to an out-of-network pharmacy), as the following sections explain. (Should your Part D plan deny your request, you can appeal against the decision, as explained later in this chapter.)

Filing for a coverage determination when it comes to your meds

You may be standing at the pharmacy checkout before you discover that your Part D plan doesn’t cover all of your drugs, or that it requires you to ask its permission before it’ll cover certain ones. Your pharmacist may or may not give you a computer printout from the plan that states the reasons for this denial. Either way, you should contact the plan (using the phone number on your membership card) to make sure you understand why it isn’t covering your drug(s). Alternatively, you may want your plan to charge a lower co-pay for a drug that’s medically necessary for you.

You have the right to ask your plan to do the following (but be sure to always do so with your doctor’s help, as I explain in Chapter 4):

Cover a drug not on its formulary: You’re asking for an exception to the plan’s general policy and require a statement from your doctor explaining the medical reasons why you need the plan to cover this drug.

Waive a restriction: You want the plan to put aside a restriction it has placed on one or more of your drugs — such as prior authorization, quantity limits, or step therapy.

Cover an excluded drug: In most cases, plans have the right to refuse to cover any drugs that Medicare excludes from Part D. But sometimes Medicare pays for these drugs if they’re prescribed for a specific medical reason that Medicare approves. If you’re in this situation, you can ask the plan to cover the drug as an exception, with your doctor’s support. (Chapter 4 lists excluded drugs and examples of times when Medicare is willing to pay for them.)

I Charge you for a drug at a lower tier level: If your doctor thinks that a nonpreferred, brand-name drug on your plan’s formulary is the only one that will work effectively for you, you can ask for it to be covered at the plan’s preferred-tier charge (see Chapter 3).

When you’re filing for an exception, you need to ask your doctor (or another provider who can prescribe drugs) to support your case by sending a written statement to the plan. Your plan provides a form for this purpose. Under Medicare rules, the plan can’t insist that your doctor use this form. Instead, it must accept any statement written on his letterhead. But using the form ensures that your doctor provides all the information that the plan requires. The address or fax number to which the statement should be sent is in your plan enrollment documents. Or you can call the plan for this information.

If your doctor thinks you need a decision immediately because your health may otherwise be at risk, he can ask for a fast decision, otherwise known as an Expedited Decision. Your plan must respond within 24 hours of receiving your doctor’s request for an expedited decision — that’s 24 hours by the clock, not business hours. Otherwise, the plan must respond within 72 hours (by the clock) of receiving the request.

4%

Filing for a coverage determination when it comes to your hard-earned cash

You can ask your plan for a coverage determination in matters related to your pocketbook, as well as to your health. You don’t need your doctor’s support if

You think the plan is charging you at a higher tier level than it should:

Sometimes a plan moves a drug into a higher tier of charges. If this situation happens when you’re already taking the drug, you have the right to continue paying the lower-cost tier rate for the rest of the year (see Chapter 3). If, instead, the plan charges you the new, higher rate, you can file for a coverage determination.

You want to be reimbursed for going to an out-of-network pharmacy:

Occasionally, you may have no choice but to go to a pharmacy outside your plan’s network, as explained in Chapter 14. If you’ve done so for good reason and the plan doesn’t reimburse the extra charges you’ve paid, you can file for a coverage determination. Be sure to send copies of the pharmacy receipts when making this request.

You want the plan to reimburse you for the cost of drugs you’ve already paid for: This scenario may crop up in a number of situations. Perhaps confirmation of your enrollment in the plan was delayed, and in the meantime you paid for drugs out of pocket (as explained in Chapter 12), but your plan hasn’t paid you back for its share of the cost. Or maybe you became eligible for Extra Help (or Medicaid, SSI, or a Medicare Savings Program) and should’ve been reimbursed for excess payments dating back to the time you applied, as explained in Chapter 5.

You don’t think you’ve reached the doughnut hole, but your plan is charging you full price: Look carefully at the Explanation of Benefits notices your plan has sent you and at your pharmacy receipts. Both show the plan’s full price for the drugs, as well as your co-pay. The full price — that is, the combined amount that both you And Your plan have paid from the beginning of the year — determines when you hit the doughnut hole, formally known as the coverage gap (see Chapter 15). If you think your plan’s calculations are wrong, you can file for a coverage determination.

I You believe you’re through the doughnut hole and should be getting catastrophic coverage, but your plan is still charging you full price:

This situation is a dispute over your TrOOP — your true out-of-pocket expenses since the beginning of the year that determine when you get out of the doughnut hole. (Premiums and some other payments, including those for drugs purchased outside of your plan’s pharmacy network, don’t count toward TrOOP; see Chapters 3 and 15.) If you think your plan has calculated your TrOOP incorrectly, you can file for a coverage determination. Make sure to include copies of pharmacy receipts for all prescriptions you filled while in the doughnut hole.

If you’re filing for a determination about any of these payment-related issues, then you don’t need your doctor’s help. You can file on the phone or (preferably) in writing either by submitting a letter or by using the plan’s form. You can also download and print a Medicare form from

Www. cms. hhs. gov/MedPrescriptDrugApplGriev/Downloads/ ModelCoverageDeterminationRequestForm. pdf.

The advantage of using a form is that it tells you what information is required. You can check off the box that applies to your situation. But if you call or write a letter instead, be sure to use the correct terminology. Say: "I want to request a coverage determination because. . ." Again, the plan should respond within 72 hours.

Anyone (a relative, friend, counselor, social worker, lawyer — basically whomever you appoint as your representative) can help you file for a payment-related coverage determination or make the request on your behalf. Be sure to call your plan to find out its requirements for appointing a representative. If you need free advice or help from a professional counselor, contact one of the organizations listed at the end of this chapter.

Dealing with your plan’s response

After you’ve filed a coverage determination request, you should receive a decision quickly, within the time frames Medicare requires. But sometimes plans don’t comply like they’re supposed to. In the following sections, I explain what you can do if your plan doesn’t respond promptly, and what to expect if your plan grants or denies your request.

If your plan doesn’t respond within the required time frame

If your plan doesn’t decide a coverage determination request within the required 24 hours (expedited) or 72 hours (standard), Medicare rules say that

You can file a grievance with the plan (see "Filing a Grievance" earlier in this chapter).

You can file a grievance with Medicare by calling its help line at

800-633-4227 (TTD: 877-486-2048).

The plan should automatically refer your request to an Independent Review Entity (IRE) within 24 hours of failing to meet the required deadline. The IRE is normally the second level of appeal (as explained in the later section, "Level 2: Reconsideration by an Independent Review Entity"). But when a plan fails to decide a coverage determination in the first place, the usual next level of appeal (asking the plan to reconsider an unfavorable decision) is automatically skipped.

The Medicare Rights Center, which helps people file Part D appeals, suggests that in these circumstances, it’s worth writing directly to the IRE yourself. Simply say:

I assume that my Part D plan, [plan name], has forwarded to you my request for a coverage determination, because it has not responded to my request within the required time frame. I am asking for a coverage determination because [state reason]. I have enclosed documents to support my request.

Depending on the situation, these documents may include a copy of your doctor’s statement requesting an exception, receipts from a pharmacy showing what you paid out of pocket, evidence that your plan has miscalculated your correct level of coverage, and the like. Advocates say that writing such a letter ensures that the IRE knows your plan hasn’t acted on your request and may bring a faster decision. They also recommend filing a grievance either with Medicare or with the plan itself so the plan’s delay is on record. (These complaints count when Medicare compiles its plan quality ratings, which are displayed in Medicare’s online Prescription Drug Plan Finder.)

If your plan makes a decision in your favor

When a plan responds within the required time frame and grants your request, it has to make good on its favorable decision within a certain time:

If the plan agrees to waive a restriction or cover a nonformulary or excluded drug, it must allow your prescription to be filled within 72 hours (standard) or 24 hours (expedited) of receiving your doctor’s written statement.

If the plan agrees to pay you back for a drug you’ve already paid for and received, it must send a payment to reimburse you no later than 30 days after receiving your request. (See the later section "Taking action if your plan has been told to pay up — but doesn’t" on what to do if your plan doesn’t send the payment within this time frame.)

If your plan refuses your request

Should your plan decide not to grant your request for a coverage determination, it must send you a letter explaining why. This letter also details the steps you can take to appeal the decision and gives you addresses for contacting the appropriate appeal bodies at each level of appeal, as explained in the next section.

Filing an Appeal against a Decision You Disagree With

The appeals process begins when your plan either turns down your request for a coverage determination or doesn’t give you a decision within the required time frame (72 hours for a standard request, 24 hours for an expedited request). At that point, you have the right to take your complaint to the next level of appeal. If that level also gives you an unfavorable decision, you can take your complaint to the next highest appeal level, and so on. In the next several sections, I guide you through the five levels of appeal, explain how to handle delays you may encounter, and give you tips on obtaining help.

The appeals process is the same whether you’re enrolled in a stand-alone Part D plan or in a Medicare health plan that covers prescription drugs.

Understanding the five levels of appeal

You have up to five opportunities to argue your case through the appeals process. Table 19-1 shows the five levels of appeal, together with the time frames for appealing at each level and the time it takes for a decision to be made. The table is useful for seeing the basic process at a glance, but there are many more details to be aware of. The following sections walk you through the procedures at each level of appeal.

Table 19-1 The Five Levels of Appealing Your

Part D Plan’s Decision

Source: Centers for Medicare & Medicaid Services.

Level 1: Redetermination by your plan

Redetermination, The first level of appeal, gives you the opportunity to challenge your plan’s denial of your initial coverage determination request if you don’t agree with this decision. You’re asking the plan to reconsider its decision and, in effect, signaling your intent not to take no for an answer.

Your plan must send you detailed instructions on how to ask for a redeter-mination in the same mailing as its initial denial. You probably want to make this appeal as soon as possible after receiving the denial. However, you have up to 60 days after the date of the denial notice to make this appeal. If you need more time (due to sickness or some other good reason), you can ask for an extension. If you’re asking for a drug to be covered, you can request a standard decision within 7 days or a fast (expedited) decision within 72 hours if your doctor thinks that further delay would put your health at risk.

Make sure to have supporting paperwork to back up your appeal. If you have documents supporting your request (such as your doctor’s statement), or if you have new supporting evidence that you didn’t send with your original coverage determination request, be sure to send all of this info now.

You have the right to ask your plan to give you any information or evidence it has regarding your request. Just be aware that the plan may charge you a fee for copying and sending these documents.

After you’ve submitted your request and supporting paperwork, the plan should send a coverage decision within the 7 calendar days or 72 hours requested. If the plan doesn’t respond within these time frames, it should automatically forward your case file to the second level of appeal, the Independent Review Entity. (But, as I point out in the earlier section "If your plan doesn’t respond within the required time frame," you can also file a grievance or write to the IRE yourself.)

If the plan decides

In your favor: It must cover the drug you requested no later than 7 days after you filed for a redetermination, or sooner if your health requires the med. If your issue is related to payment, the plan should pay you the amount owed within 30 days of your filing.

Against you: You have the right to appeal to the next level, the IRE. This is also the case if the plan only partially gives you what you’ve requested.

Level 2: Reconsideration by an Independent Review Entity

Reconsideration by an Independent Review Entity (IRE) is the second level of appeal, but the first level outside the plan to review your case. The IRE Is an independent body, under contract with Medicare, and has no connection with your plan. (Medicare currently uses an organization called Maximus as its IRE. For more information on Maximus, go to Www. medicareappeal. com.) At this level, you’re asking the IRE to reconsider your case in the hope that it will reverse your plan’s decision.

You can make this appeal yourself or have someone else act for you (as explained in the later section "Getting Help in Making an Appeal"). Note: You can’t make this appeal through your doctor unless you’ve appointed your doctor as your chosen representative.

You must request a reconsideration in writing to the IRE, either in a letter or (preferably) on the standard form that your plan must send you when it denies your redetermination request. This form asks for contact info for you, your appointed representative (if you’re using one), and your prescribing doctor. It also requires a copy of your plan’s redetermination denial notice. If your doctor thinks you need a fast (expedited) decision from the IRE for the sake of your health, you can check the box asking for a decision within 72 hours. Either way, be sure to return the form to the IRE at the address or toll-free fax number specified on the form.

You can request a reconsideration at any time within 60 calendar days of receiving your plan’s redetermination denial, but I recommend doing so as quickly as possible, if you can. Sending the form by fax rather than mail speeds up the process. If you have supporting documents (such as a statement from your doctor saying you need an expedited decision), attach copies to the form.

Your Part D plan may refer your case to the IRE automatically if it’s failed to give you a redetermination in good time, as explained in the previous section. If so, the plan must notify you that it’s done so and explain what you should do next. If you originated the appeal, the IRE asks the plan to send

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Copies of all the documents in your case file, quickly enough for the IRE to receive them within 24 hours (for an expedited review) or 48 hours (standard review).

The IRE will send you (or your representative) a letter saying that it has received your case file and will give you a reference number for the case. If English isn’t your first language, you have the right to ask the IRE to send you letters written in the language you best understand. You also have the right to ask the IRE for a copy of every document in your case file (which includes information sent by your plan).

During the review process, if you obtain additional information you want the IRE to consider, fax it in immediately. Be sure to write your name and case number on each sheet. The review process moves quite fast after it’s begun, so acting quickly is essential. If the IRE wants more details, it may contact you (and/or the prescribing doctor) by phone or mail.

After reviewing your case — according to Medicare rules and the information sent by you and your plan — the IRE must make a decision within 72 hours (expedited) or 7 days (standard). Here’s what happens next:

If the IRE decides in your favor, the plan must cover the drug(s) in question within 24 hours (expedited) or 72 hours (standard) of the decision. If you’re appealing a payment issue, the plan should pay you the disputed amount within 30 days of the decision.

If the IRE agrees with the plan and not you, you have the right to challenge its decision at the third level of appeal, an administrative law judge, under certain conditions.

Level 3: Hearing with Administrative Law Judge

An Administrative law judge (ALJ) Is a lawyer authorized to conduct hearings on disputes between a government agency and anyone affected by the agency’s actions. ALJs are required to give impartial decisions according to the facts of the case and the law.

Fr – At the ALJ level of appeal, it may be best to get professional help from one of the sources listed later in this chapter. Someone who is experienced in Part D appeals can guide you through the process and act on your behalf in making the appeal if you want. If your appeal involves obtaining an exception for your plan to cover a drug, it may also help if your doctor — the one who prescribed the med(s) in question — agrees to take part in the hearing to speak on your behalf. However, your doc’s presence is by no means essential.

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The ALJ level introduces a new requirement that doesn’t exist at lower levels of appeal. This requirement is the Amount in dispute (sometimes called the Amount in controversy) — a specified dollar minimum that represents the cost to you of having your drug or payment denied. In 2008, the amount is $120 (it

Goes up slightly each year). If your likely cost is less than this amount, you can’t appeal to an ALJ. But bear in mind that

U If you’re trying to get your plan to cover a drug, you can calculate the amount in dispute as what it will cost you out of pocket For the whole year If the plan doesn’t help pay for the drug.

You can submit more than one claim to the same ALJ hearing, and the combined claims may raise the amount in dispute over the threshold level. This can happen if, for example, you’re asking the plan to cover more than one drug or your plan refused to reimburse you for the cost of a drug purchased for good reason at an out-of-network pharmacy on more than one occasion.

If you’re appealing because your plan hasn’t reimbursed you for extra payments you made between the time you applied for Extra Help (or for Medicaid, SSI, or state-paid Part B premiums) and the date when you became eligible, all of those surplus payments count toward the amount in dispute. They include the difference between what you Should Have paid under Extra Help (premiums, deductibles, and co-pays) and what you Actually Paid under the regular Part D program.

You (or your representative) must request an ALJ hearing in writing within 60 calendar days of receiving the IRE’s decision (see the preceding section for more on this level of appeal). Make this request on the form the IRE sends you and mail it to the address given in the IRE’s notice. If you have a good reason to miss the 60-day deadline (such as sickness or a family crisis), you can ask for a deadline extension. You can also ask for a translator or interpreter for your own language (including sign language) if you need to.

Send copies of any written evidence that supports your case, either with your request for a hearing or within 10 days of receiving a notice that specifies the date and time of your hearing. This evidence may include copies of claim denial documents, supporting statements or other records from your doctor, pharmacy receipts, the dated form on which you applied for Extra Help, and so on, according to the circumstances.

You have the right to ask the ALJ to conduct a hearing just on the written evidence, without you taking part, but it’s usually best to participate. You can ask to take part in an ALJ hearing in one of three ways:

U In a telephone conference: You talk with the judge on the phone and, if you want, you can have your representative (or anyone else helping you) join the conversation, no matter how far away she may be.

In a video conference: You (and your representative, if desired) talk with the judge through a video link so you can see each other on television screens. A video conference can often be set up in a location near your home.

U In person in a hearing room before the judge: In-person hearings are held in only four places in the country — Irvine, California; Miami, Florida; Cleveland, Ohio; and Arlington, Virginia. (To find out which of these offices serves your home area, call Medicare at 800-633-4227 or go to Www. hhs. gov/omha/offices. html.) This type of hearing is granted only to claimants who can show "special and extraordinary circumstances" for arguing their case in person.

You can call the ALJ’s office to find out who else will be giving evidence at your hearing. Note: Somebody representing your Part D plan will likely participate. You can ask the ALJ’s office to send you copies of any evidence that has been submitted by anyone besides you.

^jjABE^ ALJ hearings are more informal than a civil court case, and judges are usually understanding and easy to talk to. Just be yourself and give your side of the story in your own words. Remember, though, that you, your representative, the person representing your Part D plan, and any other witnesses are under oath to tell the truth when giving evidence.

Often, the ALJ makes a decision within 90 days of your hearing, but this process may take longer if the judge decides that more evidence is needed. (However, Medicare proposed a new rule in mid-2008 that would allow fast ALJ decisions in some circumstances. By the time you read this book, that rule may be in effect.)

Here’s what to do next based on the outcome of your appeal to the ALJ:

U If the judge decides in your favor, your plan must cover the drug(s) in question within 72 hours of receiving the decision. For payment issues, the plan should pay you the disputed amount within 30 days of the decision. However, the plan also has the right to take the case to the next level of appeal, the Medicare Appeals Council.

U If the judge decides against you, you have the right to appeal against the decision to the Medicare Appeals Council.

Level 4: Review by Medicare Appeals Council

^tABEfl The Medicare Appeals Council (MAC) Is a section of the U. S. Department of

Health and Human Services. If you want to take your case to this stage — the fourth level of appeal — I recommend you have an advocate or lawyer who has experience with the procedure represent you. The MAC review often focuses on a question of law (for example, whether the ALJ interpreted Medicare law correctly), a question of fairness (such as whether the ALJ considered all the evidence), or a question of Medicare policy (when there’s a dispute about how Medicare interprets the law). Most people are way out of their depth here without an advocate preparing their case.

At this level of appeal, the MAC decides a case simply by reviewing the written evidence. No hearing is required, and the amount in dispute (see the preceding section for more info) doesn’t matter.

^MjiEft To request an MAC review, you or your representative must write directly to the MAC within 60 days of receiving the ALJ’s notice of denial. Follow the instructions included in the notice. If you have new or updated evidence that supports your case, you or your representative can submit it to the MAC at this time.

If the MAC decides

U In your favor: Your plan must give you what you were asking for within the same time frames as those given for the ALJ.

Against you or denies your request for a review: You have the right to take your case to the fifth level of appeal in a federal court. The MAC notice tells you how to file for a federal court hearing.

Level 5: Hearing in federal court

If you go to this stage, you really want to be represented by a professional. (I explain how to find free legal help later in this chapter.) You can file for a judicial review in a U. S. district court if both of these circumstances apply:

U The MAC decides not to review your case Or Decides against you (in other words, it upholds the ALJ’s decision).

U The amount in dispute is more than a certain sum — $1,180 in 2008. This sum increases slightly every year.

The amount in dispute at this level of appeal is almost ten times higher than at the ALJ level, but the suggestions on ways to meet the amount that I present in the earlier section on ALJ hearings apply here, too. Also, if an advocacy organization is helping you appeal, it may be able to combine other Medicare beneficiaries’ claims with yours. The rules allow appeals to be heard together if they satisfy certain conditions of similarity, and their claims can be added together to meet the required amount in dispute.

To request this review, you must file within 60 calendar days of receiving the MAC decision. The federal court judge first decides whether to review your case. If the case proceeds to court, it’s heard under normal court procedures. Should the judge decide

U In your favor: Your plan must comply with your request within the same time frames as those given for the ALJ earlier in this chapter.

U Against you: Typically this is the end of the road for the Medicare

Appeals process. But the judge may offer possibilities for further appeals in the federal court system, depending on the legal issues of your case.

Coping with delays

Some of the appeals processes covered in this chapter can take months to decide. That’s one kind of delay. Another is when the case has been decided in your favor, but the plan delays paying the money it owes you.

Handling delays in getting your drugs covered

When you’ve asked the plan to cover a drug you need, your priority is to get it as quickly as possible. Filing for a coverage determination, a redetermina-tion, or an IRE reconsideration can bring relatively fast decisions. At higher appeals levels, however, the process is much more drawn out. If you move into the fourth level of appeal, you may have to decide whether continuing is worth it. Just bear the following in mind:

U The ability to afford to buy the drug(s) out-of-pocket for a while doesn’t stop your right to continue the appeals process. If you win your case, the plan must cover the drug(s) retroactively, meaning it must reimburse you for all the excess payments you’ve made for your medicine during the appeals process. (So be sure to keep your receipts.) However, be aware that if you do pay for the drug, you can’t ask for an expedited decision when requesting a coverage determination, redetermination, or reconsideration.

If you’re receiving Extra Help (see Chapter 5) or living in a nursing home (see Chapter 18), you have the right to switch Part D plans at any time of the year. So enrolling in a plan that Does Cover your drugs may be better than pursuing higher levels of appeal against your current plan.

U If your appeal to an IRE is turned down, you may consider asking it to Reopen (take another look at) your case instead of appealing to the next level (ALJ). You can make this request if you think the IRE’s denial was based on a definite error or if you have new medical evidence to support your case. Requests for a reopening can be tricky, so taking advice from a legal advocate before proceeding with this course of action is wise.

U The situation may change. As this book goes to press, Medicare has proposed new rules that should speed up the appeals process. These proposals include requiring ALJs (the third level of appeal) to decide a case within 90 days and allowing expedited appeals at the ALJ level.

Taking action if your plan has been told to pay up — but doesn’t

Instances of plans not paying due reimbursements within the required 30 days abound. In fact, sometimes they don’t pay for months after losing a payment case on appeal. If you’re in this situation, consumer advocates suggest that you complain to Medicare. If necessary, continue complaining to Medicare until you receive your money.

Here are some suggestions for making your problem heard:

W Call the Medicare help line at 800-633-4227 (or 877-486-2048 if you’re a TDD user). If the customer representative tells you to call the plan, you should specifically say: "I want this complaint entered into the complaint tracking module." Using this bit of jargon should ensure that Medicare logs the complaint and may speed up getting your money back.

File a written grievance with Medicare (as I explain earlier in this chapter) and ask that it be forwarded to the plan manager at your regional Medicare office. The Plan manager Is the area Medicare official responsible for overseeing individual Part D plans. Enclose a copy of the appeal decision to show that more than 30 days have passed since the appeal was granted in your favor.

Consider reporting the plan’s failure to repay you within the required time frame to your regional Medicare Drug Integrity Contractor (MEDIC). This organization is responsible for investigating fraud and abuse in Part D, including legal and administrative violations by plans. To report a complaint, call 877-772-3379 or download a complaint form from MEDIC’s Web site at Www. healthintegrity. org.

U Consider writing to your member of Congress. Alert him or her that this part of the Part D appeals process isn’t working as it should.

Consumer complaints are fed into Medicare’s quality ratings system, which are displayed on Medicare’s online Prescription Drug Plan Finder. If enough people complain about this problem, Medicare may lean on plans more heavily to guarantee they send payments within the required period.

Getting Help in Making an Appeal

Anyone can help you file for a coverage determination or an appeal — a relative, friend, doctor, consumer advocate, or lawyer. If you want any of these individuals to Represent You — that is, prepare and present your arguments — that person must fill out a form provided by your plan or one of the appeal bodies (IRE, ALJ, MAC, or federal court). Free legal help from professionals who are experienced in Part D appeals is available from

The Medicare Rights Center: A national not-for-profit consumer service, the Medicare Rights Center offers free counseling and representation with Part D appeals. Call the Center’s appeals hot line toll-free at 888-466-9050. To download its guide to navigating the system, "Medicare Part D Appeals," go to Www. medicarerights. org.

U State advocacy groups: Several states have organizations that offer residents free legal advice and representation with Part D appeals:

• California: Call the Health Insurance Counseling and

Advocacy Program (HICAP) at 800-434-0222 or go to www.

Cahealthadvocates. org/HICAP/index. html.

• Connecticut: Call the Center for Medicare Advocacy at 860-456-7790 or visit Www. medicareadvocacy. org.

• Maine: Call Legal Services for the Elderly at 800-750-5353 or go to

Www. mainelse. org.

• Massachusetts: Call the Medicare Advocacy Project at Greater Boston Legal Services at 800-323-3205 or visit Www. gbls. org/ map/index. htm.

State Health Insurance Assistance Programs: All states have SHIPs that give free help and counseling to people with Medicare. If your state program doesn’t directly provide legal help with Part D appeals, it can put you in contact with a local service that can. To find your local SHIP’s phone number, see Appendix B.

Part V