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Welcome to HAP’s April Webinar!

Conference Call Instructions To access the audio portion of the webinar, please

follow these steps:

• Dial 1-866-740-1260• When prompted, enter the Access Code of 7376340

Lines are muted: press *7 to un-mute, press *6 to re-mute

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Mining Medicare’s Manuals: Build Your Skills to Find Answers

Health Assistance Partnership

Becky Scheckelhoff, Program Associate

Mike Klug, J.D., Senior Program Director, Training

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Webinar Objectives

• Describe SHIPhelp’s 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

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What is SHIPhelp?

SHIPhelp@hapnetwork.org is HAP’s technical assistance email address designed to support SHIPs.

• Questions come from SHIPs and beneficiaries

• 48-hour response time• Receive a range of questions pertaining

to Medicare Parts A, B, C, and D

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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” languageb. Include practical example, if possible

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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

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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.”

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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….”

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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 400-429– Organizes, summarizes, interprets statutes

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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

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§410.36 Medical supplies, appliances,and devices: Scope.(a) Medicare Part B pays for the followingmedical supplies, appliancesand devices:(1) Surgical dressings, and splints,casts, and other devices used for reductionof fractures and dislocations.(2) Prosthetic devices, other thandental, that replace all or part of an internal body organ, including colostomybags and supplies directly related tocolostomy care, including—(i) Replacement of prosthetic devices;and(ii) One pair of conventional eyeglassesor conventional contact lensesfurnished after each cataract surgeryduring which an intraocular lens is inserted.

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Sources of Medicare Coverage and Payment Policy

• CMS Online Manual System– www.cms.hhs.gov/manuals/– 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”

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Sources of Medicare Coverage and Payment Policy

• Example: CMS Part B coverage policies for prosthetic devices– Medicare Benefit Policy Manual (CMS Pub.

No. 100-02) contains 16 chapters– Chapter 15, “Covered Medical and Other

Health Services” comprises 27 sections (numbered 10-270) and is 262 pages long

– Section 120, “Prosthetic Devices,” has four pages of examples, rules, and clarifications

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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.

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Find the Answer to Question #1

• Go to Medicare Benefit Policy Manual– Chapter 15, section 120, page 123 – www.cms.hhs.gov/Manuals/IOM/list/asp

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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.

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Find the Answer to Question #2

• Go to www.cms.hhs.gov

• Go to the Medicare Managed Care Manual, Chapter 2, section 30.4.4 #9E, page 43 for “SEPs for Exceptional Conditions”– http://www.cms.hhs.gov/MedicareMangC

areEligEnrol/Downloads/2009MAenrollmentguidance.pdf

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How Did We Find the Answer?

• Go to CMS’s homepage: www.cms.hhs.gov• 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

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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

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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.

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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”– www.cms.hhs.gov/Manuals/IOM/list.asp

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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 it’s trial and error. May not find info right away; sometimes it’s not there.

4. You can call us. We will walk through the steps on CMS’s website with you.

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Thanks for Joining HAP’s Webinar!

• Do you have any suggestions, or unanswered questions? If so, please contact us at:

SHIPhelp@hapnetwork.org202-737-6340

• For more information, or to join the HAP community, visit HAP’s website at:www.hapnetwork.org