Mining the Manuals: Build Your Skills to Find Answers Michael J. Klug Senior Program Director,...

Mining the Manuals:Build Your Skills to

Find Answers

Michael J. KlugSenior Program Director, Training

Health Assistance Partnership

© Health Assistance Partnership

2

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


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!


4

Why Should I?

“What one knows is, in youth, of little moment: they know enough who know how to learn.” – Henry Adams


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


6

How Do I Start?

• Review SHIPTools

• Resources Tab– SHIP Resource

Guides• Medicare Basics

• Medicare Advantage

• Medicare Part D


7

How Do I Start?

ActivityBrainstorm questions

that beneficiaries have asked you.

Demonstration


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 don’t know?


9


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


10


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


11

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


12

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?


13

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?


14

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


15

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?


16

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?


17

Lessons Learned

Activity

Discuss the two different ways to

look up answers on the SHIP Resource

Guides.


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”

• HAP’s Resource Guides may not have answers to all the questions that come up

• So, where does HAP get the information?


19

Medicare Sources

Constitution of the United States

Statutes (Congress: legislative branch)

Code of Federal Regulations (HHS: executive branch)

CMS Online Manual System


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


21

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


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.”

http://images.google.com/imgres?imgurl=http://www.planetware.com/i/photo/washington-united-states-capitol-washington-d-c-dccap1.jpg&imgrefurl=http://www.planetware.com/picture/washington-d-c-washington-united-states-capitol-us-dccap1.htm&usg=__XTTfb0UzgRFz_WutkDeezQn4n5Q=&h=334&w=500&sz=177&hl=en&start=13&um=1&tbnid=1ssXms4QL6Qh5M:&tbnh=87&tbnw=130&prev=/images%3Fq%3Dcapitol%2Bbuilding%2Bwashington%2Bdc%26hl%3Den%26sa%3DN%26um%3D1


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….”

http://images.google.com/imgres?imgurl=http://law.sc.edu/library/tour/images/34-us_code.jpg&imgrefurl=http://law.sc.edu/library/tour/&usg=__GJGGnoyX7MDmgY_pgiX6OKJJBec=&h=512&w=768&sz=94&hl=en&start=7&um=1&tbnid=zX7SgjNLrGCB1M:&tbnh=95&tbnw=142&prev=/images%3Fq%3Dunited%2Bstates%2Bcode%2Bannotated%26hl%3Den%26sa%3DN%26um%3D1


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 400-429• Organizes, summarizes, interprets statutes• Binding on ALJ decisions


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

http://images.google.com/imgres?imgurl=http://www.hhs.gov/about/hhh.jpg.gif&imgrefurl=http://www.hhs.gov/about/hhh.html&usg=__uQRNOFkqp32WxE7zhrWjx2ddB6o=&h=300&w=380&sz=82&hl=en&start=2&um=1&tbnid=nB5J1UB4FN6AbM:&tbnh=97&tbnw=123&prev=/images%3Fq%3DHumphrey%2BBuilding%26hl%3Den%26sa%3DN%26um%3D1


26

§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


27

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


28

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.


29


30

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


31

Questions?


32

Thank You !

• Do you have suggestions or unanswered questions? If so, please contact us at:

[email protected]

• For more information, or to join the HAP community, visit HAP’s website at:www.hapnetwork.org

Date post:	27-Mar-2015
Category:	Documents
Upload:	stephanie-clark
View:	215 times
Download:	0 times

Mining the Manuals: Build Your Skills to Find Answers Michael J. Klug Senior Program Director,...

Documents