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2015 Web Resources for Regulations and Guidance
For Those Who Counsel People With Medicare
June 2015
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
06/01/2015 2015 Web Resources for Regulations and Guidance 2
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
06/01/2015 2015 Web Resources for Regulations and Guidance 3
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 stakeholders06/01/2015 2015 Web Resources for Regulations and Guidance 4
Medicare.gov and CMS.govMedicare.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
Regulations.gov and eCFR.gpoaccess.govRegulations.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 CFR2015 Web Resources for Regulations and Guidance 6
SSA.gov and HealthCare.govSSA.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
Marketplace.cms.govMarketplace.cms.gov
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 Counselors06/01/2015
2015 Web Resources for Regulations and Guidance 8
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
06/01/2015 2015 Web Resources for Regulations and Guidance 9
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 Guidance 10
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
a. Coordination of Benefits (COB)
b. Eligibility/Enrollmentc. COB and
Eligibility/Enrollmentd. COB and Appeals
To address Ralph’s concerns what topic(s) do we need to research?
a. b. c. d.
0% 0%0%0%
06/01/2015 2015 Web Resources for Regulations and Guidance 12
Check Your Knowledge – Question 1
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
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
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 questionsthat relate to Medicareentitlement, seek answers by accessing Medicare eligibility and enrollment provisions
06/01/2015 2015 Web Resources for Regulations and Guidance 15
a. SSA.gov (POMS) & CMS.gov (Manuals)
b. eCFR & CMS.gov (Manuals)
c. SSA.gov (POMS) & eCFRd. eCFR
What resources should be used to determine if Ralph’s EGHP will remain primary?
a. b. c. d.
0% 0%0%0%
06/01/2015 2015 Web Resources for Regulations and Guidance 16
Check Your Knowledge – Question 2
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 primary1. 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
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
amendmentsNOTE: Official legal guidance is contained in the statutes, regulations, and rulings
06/01/2015 2015 Web Resources for Regulations and Guidance 18
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 status06/01/2015 2015 Web Resources for Regulations and Guidance 19
“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
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 working06/01/2015 2015 Web Resources for Regulations and Guidance 21
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?
06/01/201506/01/2015 2015 Web Resources for Regulations and Guidance 22
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
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, 2015o 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 SEP06/01/2015 2015 Web Resources for Regulations and Guidance 24
a. SSA.gov Program Operating Manuals
b. Medicare.govc. CMS.gov (manuals)d. Regulations.gov
What resources should be used to determine if Ralph gets an SEP?
a. b. c. d.
0% 0%0%0%
06/01/2015 2015 Web Resources for Regulations and Guidance 25
Check Your Knowledge – Question 3
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
Case Scenario 2—Medicare CoverageContinued
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
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
a. CMS.gov (Manuals)b. eCFR & CMS.gov
(Manuals)c. SSA.gov (POMS) &
CMS.govd. eCFR
What resource(s) should be used to determine Marion’s Medicare coverage?
a. b. c. d.
0% 0%0%0%
Check Your Knowledge – Question 4
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
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
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
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 [email protected]
06/01/2015 2015 Web Resources for Regulations and Guidance 33