Welcome to HAPs April Webinar

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• Welcome to HAPs 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 Medicares 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 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

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What is SHIPhelp?

• SHIPhelp_at_hapnetwork.org is HAPs 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

• Identify topic
• Spotting issues
• Determine the resource information likely to be
  referenced
• CMS Manuals
• State law or regulations
• Research authority for answer
• Respond to SHIPhelp
• Include authority language
• 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
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.
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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/MedicareMangCareEligEnrol/D
  ownloads/2009MAenrollmentguidance.pdf

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How Did We Find the Answer?

• Go to CMSs 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

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

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Thanks for Joining HAPs Webinar!

• Do you have any suggestions, or unanswered
  questions? If so, please contact us at
• SHIPhelp_at_hapnetwork.org
• 202-737-6340
• For more information, or to join the HAP
  community, visit HAPs website at
• www.hapnetwork.org