Regional Office Casework Process Case Studies Samuel J

Regional Office Casework Process & Case Studies Samuel J. Howard Division of Medicare Health Plans Operations

Casework Process Getting Beneficiaries Help with Medicare problems (or “I’m just a case. ”) The place to start: 1‐ 800‐Medicare (1‐ 800‐ 633‐ 4227) This presentation is an informal informational resource for our partners. It’s not a legal document or intended for press purposes. Official Medicare program legal guidance is contained in the relevant statutes, regulations, and rulings.

Casework Process What are the 4 Types of Medicare? Original Medicare Advantage Part C Part A Hospital Insurance Medicare Prescription Drug Coverage Part B Medical Insurance Part D (Usually) Part D Medicare prescription drug coverage This presentation is an informal informational resource for our partners. It’s not a legal document or intended for press purposes. Official Medicare program legal guidance is contained in the relevant statutes, regulations, and rulings.

Casework Process Help from 1‐ 800‐Medicare The national toll‐free number can is available 24/7 and can give beneficiaries help with problems with all parts of Medicare. 1‐ 800‐Medicare can refer issues to the Regional Offices if they are unable to resolve a particular issue. Remember that entitlement to Medicare Part A and Medicare Part B is adjudicated by the Social Security Administration, so to resolve entitlement problems contact SSA at 1‐ 800‐ 772‐ 1213. (Exception: the Railroad Retirement Board handles Medicare entitlement for some RRB retirees. Contact them at 1‐ 877‐ 772‐ 5772. ) This presentation is an informal informational resource for our partners. It’s not a legal document or intended for press purposes. Official Medicare program legal guidance is contained in the relevant statutes, regulations, and rulings.

Casework Process Help Picking Medicare Options If a beneficiary needs help deciding how to receive their Medicare coverage, for example, what Medicare Advantage or prescription drug plan to enroll in or whether to choose Medigap coverage, they can get information, they can contact the State Health Insurance Assistance Program (SHIP) for free individualized counseling. The New York State SHIP is called HIICAP, the Health Insurance Information, Counseling and Assistance Program. Their general New York State contact number is 1‐ 800‐ 701‐ 0501. They’ll get a referral from there to a local HIICAP program office. This presentation is an informal informational resource for our partners. It’s not a legal document or intended for press purposes. Official Medicare program legal guidance is contained in the relevant statutes, regulations, and rulings.

Casework Process Help with Part C & Part D For Part C Medicare Advantage and/or Part D prescription drug problems, 1‐ 800‐Medicare can tell you what plan(s) a beneficiary is enrolled in and give you contact information for that plan. Beneficiaries should work with their plans directly to resolve issues. Beneficiaries can file an appeal or a grievance with the plan. 1‐ 800‐Medicare can also escalate cases to the regional office via the Complaints Tracking Module (CTM). This presentation is an informal informational resource for our partners. It’s not a legal document or intended for press purposes. Official Medicare program legal guidance is contained in the relevant statutes, regulations, and rulings.

Casework Process Help with Part C & Part D What's the difference between a grievance and an appeal? Part C and Part D grievances are complaints about the quality of service a beneficiary got or is getting. For example, a beneficiary may file a grievance for one of these reasons: • They have a problem calling the plan. • They are unhappy with how a staff person at the plan treated them. A beneficiary should file an appeal if they have an issue with a plan's refusal to cover a service, supply, or prescription. The HIICAP program can provide help with filing appeals and grievances. This presentation is an informal informational resource for our partners. It’s not a legal document or intended for press purposes. Official Medicare program legal guidance is contained in the relevant statutes, regulations, and rulings.

Casework Process Quality of Care Complaints If beneficiaries have a complaint about the quality of care they received from a Medicare provider such as a doctor, nurse practitioner, hospital, etc. , they should contact the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC‐QIO) for their area. In New York, the BFCC‐QIO is Livanta, LLC. Contact information: Toll Free: 1‐ 866‐ 815‐ 5440 Toll Free TTY: 1‐ 866‐ 868‐ 2289 Web Site: https: //www. bfccqioarea 1. com/ This presentation is an informal informational resource for our partners. It’s not a legal document or intended for press purposes. Official Medicare program legal guidance is contained in the relevant statutes, regulations, and rulings.

Casework Process Contacting the New York Regional Office Complex Part C and D cases for NY, NJ, PR and VI that are not successfully resolved by 1‐ 800‐Medicare or the beneficiary’s plan can be referred to the Division of Medicare Health Plans Operations at the New York Regional Office. We can be contacted in a variety of ways: This presentation is an informal informational resource for our partners. It’s not a legal document or intended for press purposes. Official Medicare program legal guidance is contained in the relevant statutes, regulations, and rulings.

Casework Process Regional Office Process Overview (simplified) This presentation is an informal informational resource for our partners. It’s not a legal document or intended for press purposes. Official Medicare program legal guidance is contained in the relevant statutes, regulations, and rulings.

Day 3 Advanced Casework Studies 2018 NTP Workshops

Casework Scenarios Using resources listed in the workbook on both the casework and the job aids. Each table will answer the questions for an assigned scenario.

• 75 • High blood pressure, high cholesterol, diabetes, & a thyroid disorder • Doctor administered first dose of Hepatitis B vaccine in his office • Has Original Medicare (Part A & Part B) & Part D

1. Which part of Medicare covers Ms. Rosen’s vaccine? 2. If her doctor gave her a prescription to go to her local pharmacy to get the Hepatitis B vaccine series, would the pharmacy be able to administer the vaccine? 3. If so, which part of Medicare should the pharmacy bill for the Hepatitis B vaccine?

1. Which part of Medicare will cover Mr. Henderson’s shot, and why? 2. Under what circumstances would the shot not be covered?

1. Were Ms. Williams’ transplant (immunosuppressive) drugs covered under Part A or Part B when she was eligible for Medicare due to ESRD at the time of the transplant? Why or why not? 2. Which part of Medicare will pay for immunosuppressive drugs when she turns 65? 3. If 36 months had passed following her successful transplant and she hadn’t turned 65 yet, would she have Medicare drug coverage through Part A, Part B, or Part D? 4. What would happen to the coverage of her immunosuppressive drugs if she didn’t enroll in Part D when she turns 65? 5. Would her immunosuppressive drugs be covered if her transplant was done in another country?

1. Will Medicare consider paying for an ambulance to take Mr. Richards to dialysis 3 times a week? If so, what’s the process for getting the transportation approved? 2. If the transportation request is denied, what resources could be suggested?

Review of Ambulance Coverage 2018

When Does Medicare Cover Ambulance Services? § Requests for coverage are always considered on a case‐by‐case basis § To be covered, ambulance services must be medically necessary and reasonable § Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated § An ambulance transport is covered to the nearest appropriate facility to obtain necessary services

Coverage Considerations § Transport must meet the definition of an ambulance q Ground, air, and water transport can be used q Each have different criteria q States have different rules q Medicare payment is based on the level of service furnished § Emergency or approved non‐emergency transport that meets specific criteria

What is Medical Necessity? § Medical condition is such that use of any other method of transportation is contraindicated § Transportation other than an ambulance couldn’t be used without endangering the beneficiary’s health • Whether or not such other transportation is actually available § The presence (or absence) of a physician’s order for a transport by ambulance doesn’t necessarily prove (or disprove) whether the transport was medically necessary § The ambulance service must meet all program coverage criteria for payment to be made

Examples of Medical Conditions that May Justify the Use of Ground Ambulance Transportation § You can get emergency ambulance transportation when • You’ve had a sudden medical emergency, and your health is in serious danger • You can’t be safely transported by other means, like by car or taxi § These are some examples of when Medicare might cover emergency ambulance transportation: • You’re in shock, unconscious, or bleeding heavily • You need skilled medical treatment during transportation § Air and water transport have unique coverage criteria

Non-Emergency Transport Coverage Conditions § Non‐emergency transportation by ambulance is appropriate if either • The person with Medicare is bed‐confined, and it’s documented that their condition is such that other methods of transportation are contraindicated; or, • Transportation by ambulance is medically required § Medicare covers medically necessary, non‐emergency, scheduled, repetitive ambulance services if • Ambulance provider/supplier obtains a written order from the beneficiary's attending physician certifying the medical necessity • Physician's order must be dated no earlier than 60 days before the date the service is furnished

1. Is the information Bob and Ana received correct? Is it complete? 2. What advice would you give them about making decisions about their health insurance?

1. What would you advise Mr. Kingly about why he could be penalized by the IRS? What should he have done earlier to prevent a penalty? 2. What options does Mr. Kingly have concerning his Medicare enrollment, and why?

Tax‐Favored Programs and Medicare Health Care Costs 2018

Regulation of Tax‐Favored Health Accounts § Regulated by the Internal Revenue Service (IRS) • Medicare Medical Savings Accounts are the only exception q Medicare has oversight § “Qualified medical expenses”—Types of medical costs eligible to be covered by funds in these accounts • Defined and regulated by the IRS June 2018 Tax‐Favored Programs and Medicare Health Care Costs 44

Qualified Medical Expenses § Defined by the IRS • Costs of diagnosis, cure, mitigation, treatment, or prevention of disease, and the costs for treatments affecting any part or function of the body • Must be primarily to alleviate or prevent a physical or mental defect or illness § Qualified medical expenses are those specified in the plan that would generally qualify for the medical and dental expenses deduction • These are explained in IRS Publication 502 June 2018 Tax‐Favored Programs and Medicare Health Care Costs 45

More Qualified Medical Expenses § A medicine or drug is a qualified medical expense only if the medicine or drug • Requires a prescription • Is available without a prescription (an over‐the‐counter medicine or drug) and the consumer gets a prescription for it, or • Is insulin § Generally non‐prescription medicines (other than insulin) aren’t considered qualified medical expenses § Qualified medical expenses are those incurred by the following persons • The consumer and their spouse • All dependents the consumer can claim on their tax return q Any person the consumer could’ve claimed as a dependent on their return (with some exceptions) June 2018 Tax‐Favored Programs and Medicare Health Care Costs 46

What’s a Health Savings Account (HSA)? § HSA or sometimes generally called a “Medical Savings Account” § Account funds used for qualified medical expenses § High‐deductible health plan (HDHP) and tax‐ sheltered account • Generally, not considered a group health plan for people with Medicare § Funded by any eligible individual • Eligibility based on the type of HSA June 2018 Tax‐Favored Programs and Medicare Health Care Costs 47

Benefits of an HSA § Account can accumulate tax‐free interest § Used to pay current and future qualified medical expenses § Account funds are fully vested and not subject to forfeiture § Once a person is 65, they can use HSA funds to pay for • Qualified expenses including q q June 2018 Medicare premiums (Part A, Part B, Part C, and Part D) Long‐term care insurance‐subject to limits based on age and are adjusted annually Tax‐Favored Programs and Medicare Health Care Costs 48

Medicare Considerations and HSAs § Can’t have another source of health insurance • Including Medicare § Use funds after retirement to pay qualified medical expenses including Medicare premiums, deductibles, coinsurance, and copayments § Can’t use funds after retirement for Medicare Supplement Insurance (Medigap) Policy premiums § A person with Medicare may only withdraw funds • Can no longer contribute to the account or will have penalties q 6% tax penalty on any contributions and their interest until they withdraw the amount from their account June 2018 Tax‐Favored Programs and Medicare Health Care Costs 49

More Medicare Considerations and HSAs § Decide whether to enroll in Medicare or delay § If a person gets Social Security retirement benefits, they’re automatically enrolled in Medicare when they turn 65 • Stop contributing to the HSA prior to their Medicare effective date to avoid any IRS penalties • Generally, can’t opt‐out of Medicare if getting Social Security retirement benefits q They’d have to withdraw from monthly Social Security retirement benefits and repay any retirement benefits paid to date § Payments made to a person’s HSA once their Medicare is effective have a tax penalty • Even if due to retroactive Medicare enrollment June 2018 Tax‐Favored Programs and Medicare Health Care Costs 50

Medicare Enrollment Reminders Related to HRAs and HSAs § Allowed 63 days to join a Part D plan if a person loses current employer drug coverage or if it’s no longer creditable § A person may be eligible for a Medicare Part B Special Enrollment Period (SEP) if they’re over 65 and they (or their spouse) are still working and have health insurance through active employment § SEPs for Part B and Part D have different enrollment time frames • The Part B SEP lasts for 8 months and begins the month after coverage ends • The Part D SEP lasts for only 63 days after the month coverage ends NOTE: A person can enroll in Part A at anytime after their Initial Enrollment Period, if they’re entitled to premium‐free Part A June 2018 Tax‐Favored Programs and Medicare Health Care Costs 51

1. How would you advise Mr. Rutter about how his coverage will work under Medicaid and Medicare? How will his Medicare enrollment affect his ability to use the providers he currently sees? 2. What other programs are available to help Mr. Rutter with his out‐of‐pocket health and drug costs, considering his low income? 3. Since Mr. Rutter will be a Medicare‐Medicaid enrollee, how will the billing work now that he’ll have coverage under both programs?

I stayed in a skilled nursing facility for only a week. Why wasn’t it covered under Medicare Part A? I thought Medicare would pay 100% for my first 20 days? FB SN are M ic ed ill Pa rt A X

Please look at your Errata Sheet

1. Are these charges correct? Why or shy not? 2. What are the notification requirements that the hospital and SNF should provide to Mr. James advising him how Medicare will or won’t pay for his hospital/doctor services, SNF stay, and PT?

1. Based on the scenario, what would you tell Ms. Zhang about the IRMAA information in her Initial Determination Notice? 2. Can she request a new initial determination? If so, how would she do it? 3. How do people submit payment for IRMAA? 4. Should Ms. Zhang pay her IRMAA while her new initial determination request is reviewed? What would happen if she doesn’t pay the IRMAA?