1 Welcome to HAPs April Webinar! Conference Call Instructions To access the audio portion of the webinar, please follow these steps: Dial When prompted, enter the Access Code of Lines are muted: press *7 to un-mute, press *6 to re-mute

2 Mining Medicares Manuals: Build Your Skills to Find Answers Health Assistance Partnership Becky Scheckelhoff, Program Associate Mike Klug, J.D., Senior Program Director, Training

3 Webinar Objectives Describe SHIPhelps work with technical questions and the CMS manuals Describe connections between sources of Medicare coverage and payment policy Demonstrate how to use CMS manuals to find answers to technical questions Answer questions

4 What is SHIPhelp? is HAPs technical assistance address designed to support Questions come from SHIPs and beneficiaries 48-hour response time Receive a range of questions pertaining to Medicare Parts A, B, C, and D

5 Steps to Find the Answers 1.Identify topic Spotting issues 2.Determine the resource information likely to be referenced CMS Manuals State law or regulations 3.Research authority for answer 4.Respond to SHIPhelp a.Include authority language b.Include practical example, if possible

6 Sources of Medicare Coverage and Payment Policy Constitution of the United States Statutes (Congress: legislative branch) Code of Federal Regulations (HHS: executive branch) CMS Online Manual System

7 Sources of Medicare Coverage and Payment Policy The Medicare Statutes: Title XVIII of the Social Security Act –Enacted in 1965, with many amendments –Gives the big picture Scope of benefits Definitions Payment systems Authorizes HHS Secretary to provide for such limitations as necessary.

8 Sources of Medicare Coverage and Payment Policy Example: Part B statutory language –The benefits provided to an individual by the insurance program established by this part shall consist of Prosthetic devices and orthotics and prosthetics (described in section 1834(h)(4)) furnished by a provider of services or by others under arrangements with them made by a provider….

9 Sources of Medicare Coverage and Payment Policy Code of Federal Regulations (CFR) –Rules issued by federal departments and agencies, e.g., HHS, CMS –Formal public notice and comment required –Published first in Federal Register –50 CFR titles (with many parts) –HHS Regulations: Title 42, Public Health –Medicare regulations: 42 CFR Parts –Organizes, summarizes, interprets statutes

10 Sources of Medicare Coverage and Payment Policy Example: Regulation on Part B coverage for medical supplies, appliances, and devices. –Summarizes scope of benefits for prosthetic devices with 3 short clauses –See 42 CFR §410.36(a)(2) on next slide

11 § Medical supplies, appliances, and devices: Scope. (a) Medicare Part B pays for the following medical supplies, appliances and devices: (1) Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations. (2) Prosthetic devices, other than dental, that replace all or part of an internal body organ, including colostomy bags and supplies directly related to colostomy care, including (i) Replacement of prosthetic devices; and (ii) One pair of conventional eyeglasses or conventional contact lenses furnished after each cataract surgery during which an intraocular lens is inserted.

12 Sources of Medicare Coverage and Payment Policy CMS Online Manual System – –22 Internet Only Manuals (IOMs) –Examples include: Medicare Benefit Policy Manual, Medicare Managed Care Manual –Expands upon, interprets, regulations –Incorporates CMS guidance and transmittals –Informal public notice and comment process –Day to day operating instructions, policies, and procedures

13 Sources of Medicare Coverage and Payment Policy Example : CMS Part B coverage policies for prosthetic devices – Medicare Benefit Policy Manual (CMS Pub. No ) contains 16 chapters –Chapter 15, Covered Medical and Other Health Services comprises 27 sections (numbered ) and is 262 pages long –Section 120, Prosthetic Devices, has four pages of examples, rules, and clarifications

14 SHIPhelp Question #1 Will Medicare cover the replacement of a breast prosthesis implant years after a mastectomy and reconstruction surgery? –Someone told the client that Medicare will not pay to replace her implant because of the cosmetic surgery exclusion.

15 Find the Answer to Question #1 Go to Medicare Benefit Policy Manual –Chapter 15, section 120, page 123 –

16 SHIPhelp Question #2 Do disabled Medicare beneficiaries have another opportunity to make changes to their current Medicare coverage upon turning 65? –A SHIP counselor could not find a specific SEP for these individuals in the Medicare and You handbook.

17 Find the Answer to Question #2 Go to Go to the Medicare Managed Care Manual, Chapter 2, section #9E, page 43 for SEPs for Exceptional Conditions – eEligEnrol/Downloads/2009MAenrollmentg uidance.pdfhttp:// eEligEnrol/Downloads/2009MAenrollmentg uidance.pdf

18 How Did We Find the Answer? Go to CMSs homepage: Click on Medicare Managed Care Manual –Most updated version usually listed first Use bookmark feature or use Table of Contents (ToC) –to scroll through topics more easily Go through SEPs –Note: any text in red signifies most recent edits

19 What Did We Learn? Disabled Medicare beneficiaries have an MA SEP upon turning 65 This SEP begins and ends concurrently with the Subsequent Part D IEP Additional MA SEP was added to Medicare Managed Care Manual in July 2008

20 SHIPhelp Question #3 Will Medicare pay to modify and equip a vehicle for a beneficiary who is disabled? Could the equipment be seen as covered durable medical equipment (DME) or as a prosthetic device? –A local official called to get information on programs that might help a constituent.

21 Find the Answer to Question #3 Go to the Medicare Benefit Policy Manual, Chapter 15, section 110.1, page 115 for Definition of Durable Medical Equipment, and page 123 for Prosthetic Devices –

22 Tips: Four Things to Remember 1.Key manuals: Medicare General Information, Medicare Benefits Policy, Medicare Managed Care, Prescription Drug Benefit, Claims Processing 2.Use manuals Table of Contents feature to help guide your search. 3.Sometimes its trial and error. May not find info right away; sometimes its not there. 4.You can call us. We will walk through the steps on CMSs website with you.

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