2015 Web Resources for Regulations and Guidance For Those Who Counsel People With Medicare June...

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


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


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


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


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.


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?


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.

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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


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


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


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%



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


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


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.”


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.”


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%



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


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


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


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%


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


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.”


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


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]


http://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/index.html

http://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/index.html

mailto:[email protected]

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