Mining the Manuals: Build Your Skills to Find Answers Michael J. Klug Senior Program Director, Training Health Assistance Partnership
Mar 27, 2015
Mining the Manuals:Build Your Skills to
Find Answers
Michael J. KlugSenior Program Director, Training
Health Assistance Partnership
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Today’s 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
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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!
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Why Should I?
“What one knows is, in youth, of little moment: they know enough who know how to learn.” – Henry Adams
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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
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How Do I Start?
• Review SHIPTools
• Resources Tab– SHIP Resource
Guides• Medicare Basics
• Medicare Advantage
• Medicare Part D
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How Do I Start?
ActivityBrainstorm questions
that beneficiaries have asked you.
Demonstration
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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 don’t know?
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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
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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
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Let’s PracticeSmall 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
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Let’s Practice
Questions for Paper SHIP Resource Guides
1.A client enrolled in a Medicare Advantage plan and it’s 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?
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Let’s 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?
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Let’s PracticeSmall 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
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Let’s 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 CMS’s rules about home visits for plan agents? Accordingly, what is the process for reporting inappropriate agent behavior?
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Let’s 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?
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Lessons Learned
Activity
Discuss the two different ways to
look up answers on the SHIP Resource
Guides.
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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”
• HAP’s Resource Guides may not have answers to all the questions that come up
• So, where does HAP get the information?
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Medicare Sources
Constitution of the United States
Statutes (Congress: legislative branch)
Code of Federal Regulations (HHS: executive branch)
CMS Online Manual System
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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
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Medicare Sources
• CMS’s 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
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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.”
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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….”
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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 400-429• Organizes, summarizes, interprets statutes• Binding on ALJ decisions
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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
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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 lensesfurnished after each cataract surgery during which an intraocular lens is inserted.
Example: Code of Federal Regulations
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Medicare Sources: CMS Manuals
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 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
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Example: CMS Manuals
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,” 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.
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What is SHIPhelp?
[email protected] is HAP’s technical assistance email address designed to support SHIPs.
• Questions come from SHIPs and beneficiaries
• 2 business days response time• Range of Medicare-related questions,
such as Medigap, LIS, and coverage denials
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Questions?
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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 HAP’s website at:www.hapnetwork.org