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Mining the Manuals: Build Your Skills to Find Answers Michael J. Klug Senior Program Director, Training Health Assistance Partnership
© Health Assistance Partnership 2 Todays Goals 1.Discuss elevation procedure for help with your questions 2.Build your skills to find answers in SHIP Resource Guides 3.Understand changes coming in 2010
© Health Assistance Partnership 3 Why Should I Build Skills to Find Answers in the Manuals? You have the foundation in training It is empowering It saves time You become a stronger local resource It builds your credibility It builds statewide expertise You can do it!
© Health Assistance Partnership 4 Why Should I? What one knows is, in youth, of little moment: they know enough who know how to learn. –Henry Adams
© Health Assistance Partnership 5 Why Should I? SHIP Examples –Coordinator in TN Guaranteed issue for Medicare supplement plans –SHIP counselor in VA Caps on physical therapy and speech therapy –SHIP coordinator in GA Transition supplies of drugs in Part D plans
© Health Assistance Partnership 6 How Do I Start? Review SHIPTools Resources Tab –SHIP Resource Guides Medicare Basics Medicare Advantage Medicare Part D
© Health Assistance Partnership 7 How Do I Start? Activity Brainstorm questions that beneficiaries have asked you. Demonstration
© Health Assistance Partnership 8 Step-by-Step Process 1.Identify the main topic of the question; spot the issue (e.g., Part D enrollment or Medicare coverage) –How do you decide? –How do you sort through the extra details? –What if you dont know?
© Health Assistance Partnership 9 Step-by-Step Process 2.Decide which of the 3 SHIP Resource Guides to use –Medicare Basics (also contains sections on supplemental insurance, Coordination of Benefits, and long-term care insurance) –Medicare Advantage –Part D
© Health Assistance Partnership 10 Step-by-Step Process 3.Use the Table of Contents as a guide –Choose the chapter that best fits the main topic –Use the Search feature online, if needed Within a specific chapter Within the entire Resource Guide –No index in this first edition
© Health Assistance Partnership 11 Lets Practice Small Group Activity Use paper SHIP Resource Guides to look up the answers. Instructions: Refer to Activity Worksheet Use questions 1 through 4 on Worksheet Facilitator will assign one question to each table Use process described on Worksheet to find an answer 10 Minutes
© Health Assistance Partnership 12 Lets Practice Questions for Paper SHIP Resource Guides 1.A client enrolled in a Medicare Advantage plan and its not working out for him. Can he change back to Original Medicare? 2.How much notice is a nursing home required to give when a resident has nearly run out of Medicare days?
© Health Assistance Partnership 13 Lets Practice Questions for Paper SHIP Resource Guides 3.The cost-sharing for a Tier 3 drug is creating a financial hardship for your client. What can you do to help? 4.A client wants to know why her Part B late enrollment penalty keeps going up each year. How is that penalty calculated?
© Health Assistance Partnership 14 Lets Practice Small Group Activity Use SHIP Resource Guides online in SHIPTools to find the answers Instructions: Refer to Activity Worksheet Use questions 5 through 8 on Worksheet Facilitator will assign one question to each table Use process described on Worksheet to find an answer 10 Minutes
© Health Assistance Partnership 15 Lets Practice Questions for SHIPTools Resource Guides 5.A nursing home resident has depleted her assets and now qualifies for Medicaid. She has an MA-PD. Can she leave the MA plan and enroll in Original Medicare and Medicaid? 6.What are CMSs rules about home visits for plan agents? Accordingly, what is the process for reporting inappropriate agent behavior?
© Health Assistance Partnership 16 Lets Practice Questions for SHIPTools Resource Guides 7.A client had cataract surgery at an eye clinic that is not in the network of her Medicare plan. The client paid for the surgery out-of-pocket. Can she get reimbursed? 8.How does Big Sky Rx work with Medicare Advantage plans?
© Health Assistance Partnership 17 Lessons Learned Activity Discuss the two different ways to look up answers on the SHIP Resource Guides.
© Health Assistance Partnership 18 Who Writes the Guides? Each year, HAP produces 3 SHIP Resource Guides To be useful to SHIPs, we focus on what counselors need to know HAPs Resource Guides may not have answers to all the questions that come up So, where does HAP get the information?
© Health Assistance Partnership 19 Medicare Sources Constitution of the United States Statutes (Congress: legislative branch) Code of Federal Regulations (HHS: executive branch) CMS Online Manual System
© Health Assistance Partnership 20 Medicare Sources Sources move from general to specific language Also move from higher to lower levels of authority Constitution is supreme law of the land When CMS or contractor decisions conflict with Constitution or statute, federal courts can reverse it
© Health Assistance Partnership 21 Medicare Sources CMSs Medicare manuals are subject to change and revision –Court cases, for example Grijalva and Fox v. Bowen –MAC decisions –Informal discussions with providers and advocates CMS updates Internet-Only Manuals (IOM) regularly
© Health Assistance Partnership 22 Medicare Sources: Statutes The Medicare Statutes: Title XVIII of the Social Security Act Enacted in 1965, with many amendments Gives big picture –Scope of benefits –Definitions –Payment systems –Authorizes HHS Secretary to provide for such limitations as necessary.
© Health Assistance Partnership 23 Example: Statutes 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….
© Health Assistance Partnership 24 Medicare Sources: CFR 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) Medicare regulations: Title 42, Parts Organizes, summarizes, interprets statutes Binding on ALJ decisions
© Health Assistance Partnership 25 Example: Code of Federal Regulations Regulation on Part B coverage for medical supplies, appliances, and devices Summarizes scope of benefits for prosthetic devices in 3 short clauses See 42 CFR §410.36(a)(2) on next slide
© Health Assistance Partnership 26 § 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. Example: Code of Federal Regulations
© Health Assistance Partnership 27 Medicare Sources: CMS Manuals CMS Online Manual System 22 Internet Only Manuals (IOMs) Examples include: Medicare Benefit Policy Manual, Medicare Managed Care Manual Expands upon regulations; interprets and details Incorporates CMS guidance and transmittals Day to day operating instructions, policies, and procedures Informal comment process Binding on CMS payment contractors and MA plans
© Health Assistance Partnership 28 Example: CMS Manuals 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, is 262 pages long Section 120, Prosthetic Devices, has four pages of examples, rules, and clarifications
What Does It Mean? Activity Discuss the new SHIP elevation procedure and what it means for your work. © Health Assistance Partnership 29
© Health Assistance Partnership 30 What is SHIPhelp? is HAPs technical assistance address designed to support Questions come from SHIPs and beneficiaries 2 business days response time Range of Medicare-related questions, such as Medigap, LIS, and coverage denials
© Health Assistance Partnership 31 Questions?
© Health Assistance Partnership 32 Thank You ! Do you have suggestions or unanswered questions? If so, please contact us at: For more information, or to join the HAP community, visit HAPs website at:
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