Finding Medicare Answers When You Need Them · 2019-02-04 · Finding Medicare Answers When You...

1Improving the lives of 10 million older adults by 2020 © 2016 National Council on Aging

January 22, 2016

Finding Medicare Answers When You Need Them

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Agenda

Medicare Coverage and Payment Policy Case Scenarios

Out-of-network Provider Local Coverage Determination DMEPOS Health Savings Account & Part A

Resources Q & A


Sources of Medicare Coverage and Payment Policy


Sources of Medicare Coverage and Payment Policy, continued


The Medicare Statutes: Title XVIII of the Social Security Act (42 USC §1395) Enacted in 1965, with many amendments since then Gives big picture Scope of benefits Definitions Payment systems (PPS, OPPS, MPFS, etc.) Authorizes HHS Secretary to provide for “such

limitations as necessary.”


Link: Social Security Act Title XVIII 42 U.S.C 1395

https://www.ssa.gov/OP_Home/ssact/title18/1800.htm


Code of Federal Regulations (CFR) Rules issued by federal departments and agencies,

e.g., HHS, CMS Formal public notice and comment periods required Regulations published first in Federal Register (FR) 50 CFR titles (with many parts) Medicare regulations: Title 42, Parts 400-429 Organizes, summarizes, interprets statutes Binding on ALJ decisions


Link: Electronic Code of Federal Regulations

http://www.ecfr.gov/cgi-bin/ECFR?page=browse


CMS Internet Only Manual (IOM) System 22 Internet Only Manuals (IOMs) Examples: Medicare Benefit Policy Manual, Medicare

Managed Care Manual, Claims Processing Manual, Prescription Drug Benefit Manual, National Coverage Determination (NCD)

Expands upon regulations; interprets, gives more detail

Incorporates CMS guidance and transmittals Binding on CMS payment contractors and MA plans


Link: CMS Internet Only Manuals

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html



CMS’s Medicare manuals are subject to change and revision Court cases, for example Jimmo and Grijalva Medicare Appeals Council (MAC) decisions MEDCAC recommendations

Informal discussions with providers and advocates

CMS updates Internet-Only Manuals (IOM) regularly


Coverage Determinations A determination made by a Medicare Administrative

Contractor (A/B MAC or DME MAC) as to whether or not it covers a particular item or service on a MAC-wide basis. Local Coverage Determination (LCD) National Coverage Determination (NCD)

13 MACs or “payment contractors” for Original Medicare nationwide

See “Medicare Coverage Database” link on www.cms.gov home page.


Link: Medicare Coverage Database

http://www.cms.hhs.gov/

https://www.cms.gov/medicare-coverage-database/


Case 1

My client is in a Medicare HMO in Michigan. She visited her daughter in Pennsylvania and, while there, a wound got badly infected. A doctor treated her and submitted a claim. The HMO denied it for being out of network. I’m helping my client appeal. Can you direct me to guidance on this issue? I want to cite it in our appeal letter.


Find the Answer for Case 1

Polling Question Which CMS Manual will most likely answer

a question about out-of-network coverage in a Medicare HMO?

1. Benefits Policy Manual2. National Coverage Determinations Manual3. Program Integrity Manual4. Managed Care Manual



Go to the Medicare Managed Care Manual

Chapter 4, Sections 20.2, 20.3, 110. http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html



Go to www.cms.gov

http://www.cms.gov/


Find the Answer to Case 1

Scroll down to the “Top 5 resources” box and select “Manuals”



Click on “Medicare Managed Care Manual”



“Chapter 4 – Benefits and Beneficiary Protections”



Section 20.3 addresses MAO Responsibilities for Coverage of Emergency & Urgently Needed Services



Urgently Needed Services Defined (Medicare

Managed Care Manual, Ch. 4 §20.2) Given the circumstances, it was not reasonable for the

enrollee to wait to obtain the needed services from his/her regular plan provider after the enrollee returns to the service area or the network becomes available.



Out-of-Network Urgent Care (Medicare

Managed Care Manual, Ch. 4 §20.3) The MAO is financially responsible for

emergency services and urgently needed services: Regardless of whether services are obtained within

or outside the plan’s service area and/or network; Regardless of prior authorization for the

services….



Out-of-Network Urgent Care (Medicare

Managed Care Manual, Ch. 4 §110.1.3) HMOs and all other MA plan types must make timely and

reasonable payment to, or on behalf of, plan enrollees for the following services obtained from a provider or supplier that does not contract with the MAO: Emergency and urgently needed services under the

circumstances described in Sections 20.2 through 20.4 of this chapter….


Case 2

I learned that someone from a lab is going to senior centers to provide drug interaction tests for everyone. A lab tech swabs the inside of a beneficiary’s cheek. The lab analyzes the specimen and bills Medicare for a genetic test that tells if a person will have trouble with certain drugs. Does Medicare cover tests like this?


Find an LCD for Case 2

Scroll down to Top 5 Resources and click on “Medicare Coverage Database”



Enter Geographic Area and Key Word from Drop Downs



Polling Question Which key word(s) would you use to

find an LCD that addresses the coverage question in this case? 1. Genome Testing2. Genotyping3. Genetic Testing4. Drug Interaction Test


Case 3

My client’s aunt will stay with her for a while after release from a rehab facility. The rehab facility suggested she get a hospital bed for her aunt while she continues her recovery. She wants to know if Medicare will pay for it and how much it will cost. She mentions her aunt is concerned about how much it will cost.


Case 3

Polling question

Where can we find the answer?

a. National or local coverage determinationb. Medicare.govc. Electronic Code of Federal Regulationsd. All of the above


Finding the Answer for Case 3

Electronic Code of Federal Regulation

Title 42 Chapter IV Subchapter B Part §410.38 Durable medical equipment: Scope and conditions.(a) Medicare Part B pays for the rental or purchase of durable medical equipment, including iron lungs, oxygen tents, hospital beds, and wheelchairs, if the equipment is used in the patient's home or in an institution that is used as a home.

Source: eCFR Title 42 Chp. IV Subchapter B Part §410.38

https://www.gpo.gov/fdsys/granule/CFR-2010-title42-vol2/CFR-2010-title42-vol2-sec410-38


Source: CMS NCD Hospital Bed

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=227&ncdver=1&DocID=280.7&bc=gAAAABAAAAAA&



Visit www.medicare.gov and search “Is my test, item or service covered?

http://www.medicare.gov/


Pick the appropriate link from the search results

Finding the answer for Case 3


Janet: Step 3


Quick reminder: DMEPOS Competitive

Bidding

Mandated by Congress in Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Contracts to those who offer the best price and meet

applicable quality and financial standards

In select cities Diabetic testing supplies nationally

Applies to specific types of DMEPOS Submit inquiries or complaints to 1-800-Medicare

Inadequate supplier network Timing concerns

Use a Competitive Bid supplier


Case 3: Find a Supplier


Quick reminder: Find a Supplier Option 2


Enter zip code

Case 3: Find a Supplier cont’d


Case 3 Answers

1. Will Medicare pay for a hospital bed?Yes, so long as there is a medical necessity for it and a doctors

prescription. The client needs to be sure to use a DME

provider in the Competitive Bid Program as well.

2. How much will the bed cost? We’re not sure. It depends on whether the bed is a rental or

purchase, likely rental in this case. The client will need to

contact DME providers to get a rough estimate of the 20%

coinsurance amount.


Case 4

At age 68, my client retired. He started Social Security benefits and joined Medicare on 4/1/15. He joined Medicare during a Special Enrollment Period when his coverage through his large employer health plan ended 3/30/15, a high-deductible plan with a Health Savings Account (HSA).

He recently learned he may owe the IRS a tax penalty for contributing to his HSA while enrolled in Medicare for the months 10/1/14 to 3/30/15. He states he started Medicare 4/1/15 and wants to know how clear up the misinformation.


Case 4

Polling question

Where can we find the answer?

a. Medicare Medicare General Information, Eligibility, and Entitlement Manual

b. Medicare.govc. Social Security POMSd. All of the above


Quick reminder: What is an HSA?

Available with High-deductible health plan (HDHP) HSA itself is not a not group health insurance plan Provided by an employer or set up with a trustee

Tax-favored account for medical expenses Employee contributes pre-tax dollars Employer may contribute If set up through a trustee, contributions are tax

deductible Neither contributions or gains are taxed if spent on

qualified medical expenses



IRS rules define “Qualifying for an HSA”

You must be covered under a high deductible health plan (HDHP)

You have no other health coverage except what is permitted under Other health coverage , later.

You are not enrolled in Medicare. You cannot be claimed as a dependent on someone

else's 2014 tax return.

Source: IRS Publication 969 – Main Content

https://www.irs.gov/publications/p969/ar02.html#en_US_2014_publink1000204039

https://www.irs.gov/publications/p969/ar02.html#en_US_2013_publink1000204063


Finding the Answers for Case 4

SSA interprets the Social Security Act Application for

Monthly Insurance Benefits 202(j)(1)(B) to require a 6-month, automatic retroactive coverage in Part A for persons over age 65(j)(1) Subject to the limitations contained in paragraph (4), an individual who would have been entitled to a benefit under subsection (a), (b), (c), (d), (e), (f), (g), or (h) for any month after August 1950 had he filed application therefor prior to the end of such month shall be entitled to such benefit for such month if he files application therefor prior to—

(A) the end of the twelfth month immediately succeeding such month in any case where the individual (i) is filing application for a benefit under subsection (e) or (f), and satisfies paragraph (1)(B) of such subsection by reason of clause (ii) thereof, or (ii) is filing application for a benefit under subsection (b), (c), or (d) on the basis of the wages and self-employment income of a person entitled to disability insurance benefits, or(B) the end of the sixth month immediately succeeding such month in any case where subparagraph does not apply. Any benefit under this title for a month prior to the month in which application is filed shall be reduced, to any extent that may be necessary, so that it will not render erroneous any benefit which, before the filing of such application, the Commissioner of Social Security has certified for payment for such prior month.

Source: Social Security Act 202(j), 42 U.S.C 202 (j)(1)(B)

https://www.ssa.gov/OP_Home/ssact/title02/0202.htm


Finding the Answers for Case 4

SSA Program Operations Manual System (POMS) Terms: RSI= Retirement, Survivors Insurance and HI= Hospital Insurance

A. Policy - RSI beneficiariesApplications for retirement age monthly benefits are also applications for HI. Thus, a separate HI application is not required if an individual: becomes entitled to monthly RSI benefits at age 65 or later (HI is effective with the

first month of RSI benefit entitlement), or was entitled to a reduced RSI benefit prior to age 65 (HI is effective with the month

the individual attains age 65).HI may begin earlier than the first month of RSI benefit entitlement if the individual was eligible for HI during any of the 6 months prior to the month of filing but RSI benefit entitlement is restricted to a later month. In such cases, HI begins with the first month during the 6 months prior to the month of filing in which the individual is age 65 and eligible for monthly RSI benefits.

Source: SSA POMS HI 00801.022

https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801022



Go to the Medicare General Information, Eligibility, and

Entitlement Manual

Chapter 2 - Hospital Insurance and Supplementary Medical Insurance Section 10.2 Hospital Insurance for the Aged

Premium-free HI for the aged begins with the month in which the individual attains age 65, provided he or she files an application for HI or for cash benefits and HI within 6 months of the month in which he or she attains age 65. If the application is filed later than that, HI entitlement can be retroactive for only 6 months.

Source: Medicare General Information, Eligibility, and Entitlement Manual Chp. 2

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS050111.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending


Case 4 Answers

1. Does my client owe a penalty?The client may owe a penalty based on the automatic, six

month Part A enrollment. It is important for those beyond age

65 and 6 months that contribute to an HSA to time their final

contribution carefully.

2. Can my client waive Part A retroactive

enrollment? No, the retroactive enrollment is automatic.


CMS Resources

Centers for Medicare & Medicaid Services DMEPOS Competitive Bidding PPT CMS NTP 2015 Train-the-Trainer Workshop

Materials. Select a city and hen agenda to access: Tax-favored Programs and Medicare Health Care

Costs 2015 Web Resources for Regulations and

Guidance

https://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/Training-Library-Items/CMS1247760.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending


Contact Us

Melissa Simpson [email protected] inquiries: State SHIP or [email protected]

SMP Inquiries: [email protected]

Visit us online at:www.ncoa.org

www.ncoa.org/centerforbenefitswww.mymedicarematters.org

www.facebook.com/NCOAgingwww.twitter.com/NCOAging

mailto:[email protected]



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Finding Medicare Answers When You Need Them · 2019-02-04 · Finding Medicare Answers When You...

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