1. 2015 Web Resources for Regulations and Guidance For Those Who Counsel People With Medicare June 2015

2. Purpose of Session  This session was developed in response to requests from our partners and stakeholders for guidance in locating and navigating trusted information sources used to solve Medicare- related cases Part 1—Provides a brief overview of web resources Part 2—Includes 2 practical case scenarios 06/01/20152015 Web Resources for Regulations and Guidance2

3. Session Objectives  This session should help you Identify official Medicare-related resources and websites Learn how to use web resources to help with Medicare questions and issues 06/01/20152015 Web Resources for Regulations and Guidance3

4. Part 1- Overview of Web Resources These are the 7 websites we’ll be discussing:  Medicare.gov, the Medicare website  CMS.gov, the Centers for Medicare & Medicaid Services’ website  Regulations.gov, the federal regulations website  eCFR.gov, the electronic Code of Federal Regulations website  SSA.gov, the Social Security Administration’s website, and  HealthCare.gov, the Federally-facilitated Marketplace website  Marketplace.cms.gov, the website for Marketplace information for partners and stakeholders 06/01/20152015 Web Resources for Regulations and Guidance4

5. Medicare.gov and CMS.gov Medicare.gov  Primarily intended for beneficiaries and caregivers  Includes enhanced website features based on data and research CMS.gov  Primarily intended for CMS staff, partners, providers, and researchers  Includes CMS Online Manuals System Can be used to research Medicare-related issues 2015 Web Resources for Regulations and Guidance 5

6. Regulations.gov and eCFR.gpoaccess.gov Regulations.gov  Source for Federal regulations and other related documents Include regulations from nearly 300 federal agencies  Including CMS eCFR.gpoaccess.gov  Currently updated version of the Code of Federal Regulations (CFR) Most up-to-date source for Medicare regulations Isn’t considered an official legal edition of the CFR 2015 Web Resources for Regulations and Guidance 6

7. SSA.gov and HealthCare.gov SSA.gov  Official website of the U.S. Social Security Administration (SSA)  Used to apply for certain benefits  Contains SSA’s Program Operating Manuals Used to make eligibility/enrollment determinations HealthCare.gov  You can use the website to Sign up for a Marketplace plan  Medicaid or CHIP Find out about available insurance options Get help using your health insurance Learn about the new health care law 2015 Web Resources for Regulations and Guidance 7

8. Marketplace.cms.gov  Provides access to Up-to-date Marketplace information for partners and stakeholders  To help counsel people on issues related to the Health Insurance Marketplace Consumer resources, training materials, research and more The application to become Certified Application Counselors and Champions for Coverage Training information for Navigators and Certified Application Counselors 06/01/2015 2015 Web Resources for Regulations and Guidance 8

9. Part 2—Case Studies  The case studies included in this section were designed to help you Learn how to use trusted web resources Help people with Medicare resolve issues 06/01/20152015 Web Resources for Regulations and Guidance9

10. Case Study 1  Ralph has Medicare Part A only. He lost his job and was given a severance package for a few months.  The severance package includes employer group health plan coverage (not COBRA) which is currently the primary payer.  His employer has over 5,000 employees.  Although he was no longer physically going to work, his employer still considers him an active employee. 06/01/2015 2015 Web Resources for Regulations and Guidance10

11. Ralph’s Concerns Will my employer group health plan coverage still pay first (remain primary) now that I’m not actively working? How does this affect my Medicare Part B enrollment? Will I have to pay a Part B penalty if I don’t sign up as soon as I’m eligible? 06/01/2015 2015 Web Resources for Regulations and Guidance 11

12. a.Coordination of Benefits (COB) b.Eligibility/Enrollment c.COB and Eligibility/Enrollment d.COB and Appeals To address Ralph’s concerns what topic(s) do we need to research? 06/01/2015 2015 Web Resources for Regulations and Guidance12 Check Your Knowledge – Question 1

13. Case Analysis  We know that Ralph’s employer views him as an active employee For the purpose of coordination of benefits  Is the arrangement between Ralph and his employer considered “active employment” according to Medicare Secondary Payer provisions? o This would determine if his employer group health plan coverage will remain primary Coordination of Benefits 06/01/2015 2015 Web Resources for Regulations and Guidance 13

14. Case Analysis—Continued  What are his Part B considerations? Does Ralph have “active employment” for the purpose of receiving a Part B Special Enrollment Period (SEP)? Will he have a Part B SEP or have to pay a Part B penalty? Eligibility/ Enrollment 06/01/2015 2015 Web Resources for Regulations and Guidance 14

15. Research Tips  Medicare Secondary Payer rules help to determine If there’s coordination of benefits between Medicare and other insurance plans Which insurance plan has primary payment responsibility  Medicare eligibility and enrollment provisions help to determine Eligibility guidelines  Entitlement for a Special Enrollment Period When the topic that you‘re researching relates to coordination of benefits, seek answers by reviewing Medicare Secondary Payer rules In answering questions that relate to Medicare entitlement, seek answers by accessing Medicare eligibility and enrollment provisions 06/01/2015 2015 Web Resources for Regulations and Guidance 15

16. a.SSA.gov (POMS) & CMS.gov (Manuals) b.eCFR & CMS.gov (Manuals) c.SSA.gov (POMS) & eCFR d.eCFR What resources should be used to determine if Ralph’s EGHP will remain primary? 06/01/2015 2015 Web Resources for Regulations and Guidance16 Check Your Knowledge – Question 2

17. Sources to Determine Coordination of Benefits  For this exercise we’ll use the following 2 methods to access MSP rules to determine if Ralph’s employer group health plan coverage will remain primary 1.CMS Manuals Easy to access A good source of Medicare and Medicaid information for the general public Based on statutes, regulations, guidelines, models, and directives Provide references to official information 06/01/2015 2015 Web Resources for Regulations and Guidance 17

18. Sources to Determine Coordination of Benefits— Continued 2. The electronic Code of Federal Regulations (e-CFR) Most up-to-date source for Medicare regulations Currently updated version of the Code of Federal Regulations (CFR) Isn’t considered an official legal edition of the CFR Edited information from the CFR and Federal Register amendments NOTE: Official legal guidance is contained in the statutes, regulations, and rulings 06/01/2015 2015 Web Resources for Regulations and Guidance 18

19. Employment Status Determination– CMS Manuals  Consistent with CMS Secondary Payment Provisions “An individual who isn't actively working is considered to have current employment status if the employee hasn't had their employment terminated by the employer or hasn't had his/her membership in the employee organization terminated and has employment-based GHP coverage that isn't COBRA continuation coverage.”  Based on the above findings, Ralph has current employment status 06/01/2015 2015 Web Resources for Regulations and Guidance 19

20. “Current Employment Status”—e-CFR Findings  Consistent with CMS e-CFRs Secondary Payment Provisions “An individual who is not actively working is considered to have current employment status if the individual has not had their employment terminated by the employer or has not had his/her membership in the employee organization terminated and has GHP coverage that is not pursuant to COBRA.” 06/01/2015 2015 Web Resources for Regulations and Guidance 20

21. Coordination of Benefits (COB) Determination  Ralph wanted to know if his employer group health plan (EGHP) coverage will remain primary although he is no longer actively going to work Based on Medicare Secondary Payer (MSP) rules (from CMS Manuals and the e-CFR) Ralph has active employment status for the purpose of COB  This means that he will be treated as any other working employee with EGHP coverage  Employment-based GHP coverage that isn't COBRA pays primary to Medicare (MSP rules apply)  His EGHP will continue to be the primary payer, as it was before he stopped actively working 06/01/2015 2015 Web Resources for Regulations and Guidance 21

22. Ralph’s Medicare Part B Concerns  Ralph wants more information about enrolling in Part B Will he get a Special Enrollment Period? Will he have to pay a penalty? 06/01/2015 2015 Web Resources for Regulations and Guidance22

23. Medicare Part B Special Enrollment Period (SEP) Determination  Ralph is considered to have current employment status for purpose of a Medicare Part B SEP  Consistent with the Program Operating Manual (POM) instructions “An individual who is not actively working is considered to have current employment status if the individual has not had their employment terminated by the employer or has not had his/her membership in the employee organization terminated and Has employment-based GHP coverage that is not COBRA continuation coverage SEP lasts through the duration of the continuation of current employment status and ends 8 months after the months of such arrangement ends.” 06/01/2015 2015 Web Resources for Regulations and Guidance 23

24. Case Resolution  Since Ralph is considered currently employed, his Employer Group Health Plan (EGHP) coverage will remain primary  He is eligible for the Part B SEP which is usually available to people with EGHP coverage Ralph can enroll in Part B without paying a penalty from the time he’s eligible until his SEP ends. For example:  If Ralph’s severance package (which includes EGHP coverage) ended on March 1, 2015 o His Part B SEP will expire on October 31, 2015 o He won’t incur a Part B penalty if he enrolls within the duration of his SEP 06/01/2015 2015 Web Resources for Regulations and Guidance 24

25. a.SSA.gov Program Operating Manuals b.Medicare.gov c.CMS.gov (manuals) d.Regulations.gov What resources should be used to determine if Ralph gets an SEP? 06/01/2015 2015 Web Resources for Regulations and Guidance25 Check Your Knowledge – Question 3

26. Case Study—2  Since having a stoke, Marion was hospitalized several times for nausea, vomiting, weight loss, and dehydration, which resulted from difficultly with oral intake  During his last hospitalization in December 2014, a Percutaneous Endoscopic Gastrostomy (PEG) tube was inserted  Medical records indicate a diagnosis of gastroparesis Medicare denied the claim as not medically necessary based on this diagnosis  Marion submitted an appeal along with a letter from his gastroenterologist indicating that he was unable to tolerate a gastric emptying scan and the tube was inserted to maintain his weight and nutrition intake This appeal was also denied 06/01/2015 2015 Web Resources for Regulations and Guidance 26

27. Case Scenario 2—Medicare Coverage Continued  Marion believes the wrong diagnosis was given because his new gastroenterologist indicated that the diagnosis should have been “failure to thrive” instead of gastroparesis  He can’t survive without the PEG tube; it has been his only intake method for the past 11 months  He’s still unable to ingest food or drink orally 06/01/2015 2015 Web Resources for Regulations and Guidance 27

28. Case Analysis—Case 2  Marion’s claims under the diagnosis gastroparesis were denied by Medicare as not medically necessary  His new gastroenterologist indicated that the diagnosis should have been “failure to thrive”  He is interested in finding out if Medicare will cover his services based on his new diagnosis We need to determine if the services that he received should be covered by Medicare under the new diagnosis of “failure to thrive” Coverage Determination Visit CMS “National Coverage Determinations” provisions when researching topics that relate to coverage 06/01/2015 2015 Web Resources for Regulations and Guidance 28

29. a.CMS.gov (Manuals) b.eCFR & CMS.gov (Manuals) c.SSA.gov (POMS) & CMS.gov d.eCFR What resource(s) should be used to determine Marion’s Medicare coverage? Check Your Knowledge – Question 4

30. Source to Determine Medicare Coverage  We will access the CMS Manuals to help Marion determine if the services that he received will be covered by Medicare under his new diagnosis of “failure to thrive” CMS Manuals are  Easy to access  A good source of Medicare and Medicaid information for the general public  Based on statutes, regulations, guidelines, models, and directives  Provide references to official information 06/01/2015 2015 Web Resources for Regulations and Guidance 30

31. Summary of Findings “Enteral nutrition is considered reasonable and necessary for a patient with a functioning gastrointestinal tract who, due to pathology, or non- function of, the structures that normally permit food to reach the digestive tract, cannot maintain weight and strength commensurate with his or her general condition. Enteral therapy may be given by nasogastric, jejunostomy, or gastrostomy tubes.” 06/01/2015 2015 Web Resources for Regulations and Guidance 31

32. Case Resolution—Case 2  To review, Marion was hospitalized numerous times for nausea, vomiting, weight loss and dehydration, which resulted from difficultly with oral intake  His Medicare claim was denied as medically unnecessary under his initial diagnosis of gastroparesis  Our coverage determination shows that the services that he received should be covered under his new diagnosis of “failure to thrive”  Marion may pursue the next level of appeal, which is reconsideration. If he decides to do so, it is recommended that he consult with both the original and current doctor to ensure that the proper coding is submitted with new evidence 06/01/2015 2015 Web Resources for Regulations and Guidance 32

33. CMS National Training Program (NTP) To view all available NTP training materials, or to subscribe to our email list, visit CMS.gov/Outreach-and-Education/Training/ CMSNationalTrainingProgram/index.html For questions about training products email training@cms.hhs.gov training@cms.hhs.gov 06/01/20152015 Web Resources for Regulations and Guidance33