Day 3

Advanced Case StudiesWorkbook

2018

ii

About This Workbook

This workbook provides job aids and corresponding case studies on advanced topics related to the Medicare Program. It’s a companion to the 2018 Understanding Medicare Workbook, which provides an overview of the basics of the Medicare Program and supplements a training module developed and approved by the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Federally-facilitated Health Insurance Marketplace. The information in that module was correct as of June 2018. To check for an updated version, visit CMSnationaltrainingprogram.cms.gov.

The CMS National Training Program (NTP) provides this as an informational resource for our partners. It’s not a legal document or intended for press purposes. The press can contact the CMS Press Office at press@cms.hhs.gov. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.

This training is provided by the CMS NTP.

To view all available NTP materials, or to subscribe to our email list, visit CMSnationaltrainingprogram.cms.gov.

Contact us at training@cms.hhs.gov.

Follow us on Twitter @CMSGov #CMSNTP.

July 2018

iii

iv

Contents

How to Use This Workbook .............................................................................................. vi

Job Aids & Related Case Study Scenario Worksheets

1—Vaccines & Medicare Prescription Drug Coverage under Part A, Part B, & Part D (Ms. Rosen) ...................................................................................................... 1

2—Skilled Nursing Facilities & Medicare Prescription Drug Coverage under Medicare Part A, Part B, & Part D (Mr. Henderson) .................................................... 7

3—End-Stage Renal Disease & Medicare Prescription Drug Coverage under Part A, Part B, & Part D (Ms. Williams) ........................................................................ 13

4—Medicare Coverage & Non-emergency Transportation (Mr. Richards) ........................ 19

5—Medicare & Group Health Plans (GHPs) (Bob & Ana) ................................................. 25

6—Health Savings Accounts (HSAs) & Medicare Considerations (Mr. Kingly) ................. 31

7—Considerations for People with Low Income Who Qualify for Medicare & Medicaid (Mr. Rutter) ................................................................................................................... 37

8—Hospital Observation Status, Skilled Nursing Facility Care, & Notification Requirements (Mr. James) ........................................................................................... 43

9—Income-Related Monthly Adjustment Amount (IRMAA) Appeals & Penalties (Ms. Zhang) .................................................................................................. 49

Appendixes

A—The MasterSolve Approach to Problem Solving .......................................................... A-1

B—Effective Questioning Techniques ............................................................................... B-1

C—2018 Medicare Amounts Job Aid ................................................................................. C-1

D—Case Study Scavenger Hunt Bingo Activity ................................................................. D-1

E—Case Studies ............................................................................................................... E-1

F—CMS National Training Program Resources ................................................................ F-1

v

vi

How to Use This Workbook

The Advanced Case Studies Workbook complements the Understanding Medicare Workbook and training module. The workbook includes 9 job aids. Each one summarizes key information and resources on an advanced topic, and is followed by a case study scenario and discussion questions. Appendix E includes detailed answers to the discussion questions. Other appendixes provide additional job aids on problem solving, effective questioning, 2018 Medicare amounts, case study scavenger hunt bingo questions and answer key, and information on training resources from the CMS NTP.

Ideas for Trainers

• Use the job aids on problem solving (Appendix A) and effective questioning techniques(Appendix B) to review strategies they can use in a variety of situations. Refer them toAppendix C for easy access to the CMS 2018 Medicare Amounts Job Aid.

• Use the case study scavenger hunt bingo activity (Appendix D) to introduce participantsto the topics covered in the job aids and case studies.

• Refer participants to the full set of 9 case studies (Appendix E) for detailed responses tothe discussion questions that follow each scenario. Explain that the appendix includesthe case studies discussed during the training session, plus additional case studies.

• Encourage participants to write notes in the workbook. Writing will help them rememberkey points.

• Encourage participants to keep the workbook as a reference tool and to use the job aidsand suggested resources to further their learning.

Ideas for Participants • Take notes in the workbook during the training event. Each job aid includes a section for

notes.

• Retain the workbook as a quick reference tool.

• Use the case study scavenger hunt bingo activity (Appendix D) as a self-assessment tocheck your understanding of advanced Medicare topics.

• Use the resources in the job aids to further your knowledge about Medicare. Theelectronic version of this workbook includes links to the online resources described ineach job aid.

These activities are designed to help learners understand how they can research answers to questions. The answers provided are representative and may not be comprehensive. The CMS National Training Program provides this as an informational resource for our partners. It’s not a legal document or intended for press purposes. The press can contact the CMS Press Office at press@cms.hhs.gov. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.

vii

After reading this job aid, you’ll know…

• Which part(s) ofMedicare cover vaccinesand their administration.

• Under whatcircumstances apharmacy mayadminister prescribedvaccines.

Medicare coverage for vaccines Medicare Part B covers most of the vaccines Medicare patients need that are reasonable and necessary for the treatment of an illness or injury. For example, Part B covers the Hepatitis B vaccine (for patients at high or intermediate risk), the influenza virus vaccine, the pneumococcal pneumonia vaccine, and vaccines directly related to the treatment of an injury or direct exposure to a disease or condition. Under Part B, providers administer these vaccines and submit a claim to the Medicare Administrative Contractor (MAC) for both the vaccine and its administration. For patients enrolled in Medicare Advantage (MA) Plans, network providers submit claims to the patient’s MA plan. Part D plans generally cover vaccines that Part B doesn’t cover. However, under Part D, the provider may or may not directly bill the Part D plan. If providers can’t bill directly, they may need to work with their patients’ Part D plans for payment. The Part D plan may request prior authorization to ensure appropriate payment under Part B vs. Part D.

Administration by participating pharmacy Patients get a prescription from their doctor and bring it to their local network retail pharmacy (or the doctor transmits it electronically. In some cases, a pharmacist administers the vaccine (unless prohibited by state law). The pharmacy bills the Part D plan, and patients pay the pharmacy the required Part D cost sharing amount. • The pharmacy must have a Medical billing number.• The patient must have a prescription from the

doctor.• Pharmacies, depending on state law, may

administer vaccines.

1

Pharmacy distribution to doctor Participating pharmacy: Patients get a prescription from their doctor and take it to the pharmacy (or the doctor submits it electronically). The pharmacy then fills the prescription, ships or delivers it to the doctor’s office, and bills the Part D plan for dispensing and providing the vaccine.

The doctor administers the vaccine. The patient (1) pays the pharmacy the required Part D cost sharing amount and (2) pays the doctor for administering the vaccine.

Non-participating pharmacy: The prescriber or patient contacts the patient’s Part D plan to obtain a vaccine-specific notice, which has information on coverage authorization, claims submission, patient cost sharing, and reimbursement rates. The prescriber agrees to accept Part D payment as payment in full.

Resources Medicare Part D Vaccines & Vaccine Administration This 6-page Medicare Learning Network fact sheet provides information for doctors, pharmacists, and other health care professionals about vaccine and vaccine administration coverage under the Medicare Part D Program, as well as how to submit claims for payment.

Medicare Drug Coverage Under Part A, Part B, & Part D This 6-page CMS tip sheet provides an overview of drug coverage under Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance), Medicare Part C (Medicare Advantage), and Medicare Part D (Medicare prescription drug coverage).

2

Use this space for key points you learn during training and on the job. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Glossary Cost sharing: The cost for medical care that you pay yourself like a copayment, coinsurance, or deductible.

Hepatitis B vaccination: A series of 3 shots covered only for people at high or medium risk for Hepatitis B. To determine if they’re eligible for coverage, people with Medicare should check with their doctor to see if they’re at high or medium risk for Hepatitis B.

High risk groups: Includes people with diabetes, End-Stage Renal Disease (ESRD), or hemophilia; people who live in the same household as a Hepatitis B virus (HBV) carrier; and clients of institutions for the mentally handicapped.

Intermediate risk groups: Includes staff of institutions for the mentally handicapped and workers in health care professions who have frequent contact with blood/blood-derived body fluids during routine work.

Medically necessary: Services or supplies that are proper and needed for the diagnosis or treatment of your medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of you or your doctor.

3

4

Case Study 1: Ms. Rosen

Vaccines & Medicare prescription drug coverage under Part A, Part B, & Part D

Ms. Rosen is 75 and has Medicare. She has high blood pressure, high cholesterol, diabetes, and a thyroid disorder. Ms. Rosen has Original Medicare (Part A and Part B) and a Medicare Prescription Drug Plan (Part D). Her doctor administered the first dose of the Hepatitis B vaccine in his office.

Discussion 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 Bvaccine 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?

______________________________________________________________________________________________________________________________________

Resources Medicare Drug Coverage Under Part A, Part B, & Part D (job aid) Medicare Part B Vaccines & Vaccine Administration (fact sheet)

5

6

After reading this job aid, you’ll know… • Key points about Medicare

prescription drug coverageduring SNF stays.

• Circumstances under whichcertain vaccines may becovered under Part B duringan SNF stay.

Medicare coverage for prescription drugs during a SNF stay People may get drugs as part of their treatment during a covered inpatient hospital or skilled nursing facility (SNF) stay. Medicare Part A payments made to hospitals and SNFs generally cover all drugs given during an inpatient stay, including preventive vaccines. If an inpatient doesn’t have Part A coverage, Medicare Part B can pay hospitals and SNFs for certain categories of Part B-covered drugs. If an inpatient has Part A, Part B may pay if the Part A coverage for the stay has run out, or if the stay isn’t covered by Part A. Also, when receiving Part A-covered SNF care, the SNF’s bundled per diem payment excludes certain costly and intensive chemotherapy drugs. They’re billed separately under Part B.

Medicare coverage for vaccines during a SNF stay Medicare Part B can cover vaccines when a patient’s stay in a SNF isn’t covered by Part A. Part B covers certain immunizations as part of Medicare-covered preventive services. If criteria are met, Part B covers the influenza virus vaccine (flu shot), a pneumococcal shot (to prevent certain types of pneumonia), a Hepatitis B shot (for individuals at high or intermediate risk), and other vaccines (like a tetanus shot) when someone gets it to treat an injury or has been exposed directly to a disease or condition. When a person getting covered care receives a preventive vaccine for which a specific Part B benefit category exists (i.e., pneumococcal pneumonia, Hepatitis B, or influenza), the vaccine would be covered under Part B. It wouldn’t be covered because the Part A SNF benefit doesn’t cover preventive

7

services, and it also wouldn’t be covered under Part D (because Part B already includes a specific benefit category that covers each of these three types of vaccines). Part B is primary to Part D. Similarly, a preventive vaccine (such as poliomyelitis) for which no Part B benefit category exists would be coverable under the Part D drug benefit when administered in the SNF, rather than being covered under the Part A SNF benefit.

Special circumstances for determining vaccine coverage under Medicare Part A, Part B, or Part D There are certain limited circumstances in which a vaccine would no longer be considered preventive in nature, and this can affect how the vaccine is covered. For example, a booster shot of tetanus vaccine wouldn’t be considered preventive when administered in response to an actual exposure to the disease (such as an animal bite, or a scratch on a rusty nail). In the latter situation, such a vaccine would be considered reasonable and necessary to treat an existing condition and, accordingly, would be included within the SNF’s global Part A per diem payment for the person’s Medicare-covered stay.

Resources Medicare Part D Vaccines and Vaccine Administration This 6-page Medicare Learning Network fact sheet provides information for doctors, pharmacists, and other health care professionals about vaccine and vaccine administration coverage under the Medicare Part D Program, as well as how to submit claims for payment. Skilled Nursing Facility Consolidated Billing & Preventive/Screening Services This 5-page Medicare Learning Network article describes SNF Consolidated Billing as it applies to preventative and screening services provided to SNF residents.

8

Use this space for key points you learn during training and on the job.

Glossary Consolidated billing: The SNF Consolidated Billing requirement makes the SNF itself responsible for including on the Part A bill that it submits to its Medicare intermediary almost all of the services that a resident receives during the course of a Medicare-covered stay, except for a small number of services that are specifically excluded from this provision. Medically necessary: Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine. Skilled nursing facility (SNF): A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9

10

Case Study 2: Mr. Henderson

Skilled nursing facilities & Medicare prescription drug coverage under Medicare Part A, Part B, & Part D

Mr. Henderson is at Bright Oaks, a skilled nursing facility (SNF). He may have been exposed to tetanus by a recent injury and was given a tetanus booster shot. He has Original Medicare (Part A and Part B) and a Part D Prescription Drug Plan.

Discussion 1. Which part of Medicare will cover Mr. Henderson’s shot, and why?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Under what circumstances would the shot not be covered?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Resources Medicare Drug Coverage Under Part A, Part B, & Part D (job aid) Skilled Nursing Facility Consolidated Billing & Preventive/Screening Services (article)

11

12

After reading this job aid, you’ll know…

• Which part(s) of Medicare covertransplant (immunosuppressive)drugs when an individual is Medicareeligible due to ESRD.

• How your age impactsimmunosuppressive drug coverageunder Medicare.

• How long a person previouslydiagnosed with ESRD is coveredunder Medicare after a successfultransplant.

• How immunosuppressive drugcoverage is affected if a transplanttakes place outside a Medicare-approved facility.

Medicare coverage for immunosuppressive drugs Medicare Part A covers transplant drugs (also called immunosuppressive drugs) and other drugs during a hospital stay when you’re enrolled in Part A at the time of a transplant. Part B covers self-administered immunosuppressive drugs outside of the hospital. In both instances, the transplant surgery must have taken place in a Medicare-approved facility, and you must be enrolled in Part B during the immunosuppressive drug therapy.

If you have ESRD and Original Medicare Part A or Part B, you may join a Part D Medicare drug plan. Part D may cover immunosuppressive and other drugs not covered by Part B, even if you weren’t enrolled in Part A at the time of the transplant and the transplant didn’t take place in a Medicare-approved facility.

Medicare Part B continues to pay for self-administered immunosuppressive drugs with no time limit when you become entitled to Medicare because of age (65) or disability after getting a transplant.

13

2

Period of coverage for services, items, and drugs after a kidney transplant If you’re entitled to Medicare only because of ESRD, Medicare coverage ends 36 months after the month of the successful transplant. Medicare won’t pay for any services or items, including immunosuppressive drugs, for patients who aren’t entitled to Medicare.

Medicare will pay for your transplant drugs with no time limit, however, if one of these conditions applies:

• You were already entitled toMedicare because of age ordisability before you gotESRD.

• You became eligible forMedicare because of age ordisability after getting atransplant that was paid forby one of these:

o Medicare

o Private insurance that paidprimary to your MedicarePart A (HospitalInsurance) coverage, in aMedicare-approved facility

Resources Drug Plan Coverage Rules This web page provides general guidance on coverage rules for Medicare drug plans.

I Have End-Stage Renal Disease (ESRD) This web page has links to information on signing up for Medicare with ESRD, how Medicare works with other coverage, kidney dialysis, transplants, children with ESRD, special needs plans, and other topics related to ESRD.

Medicare & You: End-Stage Renal Disease/Kidney Transplant Eligibility & Enrollment This 2-minute video provides an overview of how Medicare can help people who have ESRD.

Medicare Coverage of Kidney Dialysis and Kidney Transplant Services (CMS Publication 10128) This 60-page booklet has information about Medicare coverage for people with ESRD.

Medicare for People with ESRD This downloadable training module explains the Medicare Program for people with ESRD and can be easily adapted for presentations to groups of beneficiaries or people aging into Medicare. It includes information on eligibility and enrollment, coverage, health plan options, and additional sources of information. The module consists of 47 PowerPoint slides with corresponding speaker’s notes, activities, and check-your-knowledge questions. Also available in Spanish, this module is part of a series of classroom modules for trainers.

14

3

Use this space for key points you learn during training and on the job.

Glossary End-Stage Renal Disease (ESRD): Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

Immunosuppressive drugs: Drugs that prevent the body from rejecting a donor organ after an organ transplant; also called transplant drugs.

Medicare-approved facility: A Medicare-certified health care provider (like a home health agency, hospital, nursing home, or dialysis facility) that’s been approved by Medicare.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

15

16

End-Stage Renal Disease & Medicare prescription drug coverage under Part A, Part B, & Part D

Ms. Williams has Original Medicare (Part A and Part B), based on End-Stage Renal Disease (ESRD), which became effective in January 2017. In February 2018 (12 months after her Medicare became effective), she had a kidney transplant at a Medicare-approved facility. She was told that her coverage will end 36 months after her successful transplant. She’ll turn 65 in October 2018 (eight months after her transplant). If Ms. Williams is receiving Social Security or Railroad Retirement benefits, she’ll be automatically enrolled in Medicare due to her turning 65 and will continue with her Medicare Part A and Part B coverage. Also, she’ll have a new Initial Enrollment Period for Part D and an Open Enrollment Period for a Medigap policy. She’s not sure if she needs Part D coverage so she calls you for more information and to discuss her situation.

Discussion 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 thetransplant? Why or why not?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

17

Case Study 3: Ms. Williams

2. Which part of Medicare will pay for her immunosuppressive drugs when sheturns 65?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. If 36 months had passed following her successful transplant and she hadn’t turned65 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’tenroll in Part D when she turns 65?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Would her immunosuppressive drugs be covered if her transplant was done inanother country?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Resources Drug Plan Coverage Rules (web page) I Have End-Stage Renal Disease (ESRD) (web page) Medicare & You: End-Stage Renal Disease/Kidney Transplant Eligibility & Enrollment (video) Medicare Coverage of Kidney Dialysis and Kidney Transplant Services (CMS Publication 10128) (booklet) Medicare for People with ESRD (training module)

18

Case Study 3: Ms. Williams

The only transportation help that Medicare pays for is an ambulance. Medicare covers medically necessary non-emergency, scheduled, repetitive ambulance services if the ambulance provider or supplier, before furnishing the service to the person with Medicare, obtains a written order from the person with Medicare’s attending doctor certifying that the medical necessity requirements (e.g., bed confinement or a medical condition that makes transportation by ambulance medically required) are met. In this situation, the Medicare-covered person should contact both the ambulance provider and the doctor as soon as possible to start the approval process. Medicare Part B will generally cover up to 80%. The doctor’s order must be dated no earlier than 60 days before the date the service is provided. There are also origin and destination requirements. Medicare will typically cover only transports to the nearest appropriate medical facility that can provide the level of care necessary to treat the illness or injury. If a person has a Medicare Advantage (MA) Plan, the plan may cover some non-ambulance transportation to dialysis centers and doctors. Contact the plan for more information.

In a non-emergency situation, if the ambulance provider believes that the transport may be denied coverage by Medicare, the provider must issue an Advance Beneficiary Notice (ABN) to notify the beneficiary of his or her potential financial responsibility for the transport.

After reading this job aid, you’ll know…

• When Medicare providescoverage for non-emergency transportation.

• Alternative resources thatmight be available if anon-emergent transport isdenied.

19

People with Medicare who experience denials for non-emergency transportation requests may wish to explore local transportation assistance services. For example: • Local senior transportation services

often have specially equipped vans andpersonnel to help transport a frail personto and from a medical appointment. Usethe Eldercare Locator website to findresources, or call 1-800-677-1116.

• Another place to look for transportationassistance is the National Council onAging’s BenefitsCheckUp website.

• There are ambulance servicedemonstrations for people withMedicare in certain states that meetcertain criteria but still fall within thecurrent Medicare prior authorizationpolicies for this service. To see if ademonstration is available in your area,visit Medicare Coverage AmbulanceTransport.

Ambulance Services (Chapter 10, CMS Medicare Benefit Policy Manual) This chapter of the policy manual includes 5 sections on ambulance services (vehicle and crew requirements, necessity and reasonableness, the destination, air ambulance services, and joint responses), a section on coverage guidelines for ambulance service claims, and a section on implementation of the ambulance fee schedule. Medicare Coverage of Ambulance Services (CMS Publication 11021) This 16-page booklet explains ambulance coverage under Original Medicare. It provides information on coverage, payment, and rights and protection issues.

20

Glossary Advance Beneficiary Notice (ABN): A notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment. If you do not get an ABN before you get the service from your doctor or supplier, and Medicare does not pay for it, then you probably do not have to pay for it. If the doctor or supplier does give you an ABN that you sign before you get the service, and Medicare does not pay for it, then you will have to pay your doctor or supplier for it. ABNs only apply if you are in the Original Medicare Plan. They do not apply if you are in a Medicare Managed Care Plan or Private Fee-for-Service Plan. Ambulance: A land, air, or water vehicle specifically designed, equipped, and staffed for life saving and transporting the sick or injured. Bed confinement: A beneficiary is bed-confined if he/she is unable to get up from bed without assistance; unable to ambulate; and unable to sit in a chair or wheelchair.

Use this space for key points you learn during training and on the job. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

21

22

Case Study 4: Mr. Richards

Medicare coverage & non-emergency transportation

Mr. Richards is 72 and has Medicare Part A and Part B. He’s had type 2 diabetes for many years and now has End-Stage Renal Disease. He must get dialysis 3 times a week. He lives alone, doesn’t drive, is obese, and has to use a wheelchair, but needs help to get from his bed to his wheelchair, all of which makes it difficult for him to find transportation to dialysis.

Discussion 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?

_________________________________________________________________________________________________________________________________________________________________________________________________________

Resources Ambulance Services (Chapter 10, CMS Medicare Benefit Policy Manual) (chapter) Medicare Coverage of Ambulance Services (CMS Publication 11021) (fact sheet)

23

24

After reading this job aid, you’ll know…

• General requirementsand considerationsrelated to Medicareenrollment when GHPs(including FEHBs) orTRICARE is involved.

• Where to findadditional informationabout Medicarecoverage choices andhow Medicare workswith other insurance.

Medicare & Group Health Plan (GHP) coverage If you’re retired and have Medicare and employer group health plan (GHP) retiree coverage from a former employer, generally, Medicare pays first for your health care bills, and your group health plan (GHP) coverage pays second. How a retiree group health plan coverage works depends on the terms of the specific plan. Your employer or union, or your spouse’s employer or union, might not offer any health coverage after retirement. If you get group health plan coverage after retirement, it might have different rules, and it might not work the same way with Medicare. Contact your Benefits Administrator.

People who continue working beyond 65 and are covered by a GHP generally don’t need to enroll in Medicare Part B while they’re actively working. If upon retirement they’re no longer able to participate in the GHP, they may qualify for a Medicare Part B Special Enrollment Period (SEP). People whose employer has fewer than 20 employees may have to take Part B.

Federal Employees Health Benefits (FEHB) ProgramThe FEHB Program is a type of GHP. Federal employees who participate in an FEHB can choose to carry the plan into retirement. FEHB doesn’t require an individual to enroll in Part B upon retiring from the federal government. However, to carry FEHB coverage into retirement, people generally have to have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date their annuity

(Continued on next page)

25

starts, or for the full period(s) of service since their first opportunity to enroll (if less than 5 years). They also must be eligible for immediate annuity under a retirement system for civilian employees.

People with coverage through FEHB who don’t enroll in Part B during an SEP and want to enroll in Part B at a later time would have to wait until the Medicare General Enrollment Period (GEP)—January 1 through March 31—with coverage starting July 1, and would likely pay a lifetime Part B late enrollment penalty.

TRICARE TRICARE is a health care program for active-duty and retired uniformed services members and their families.

TRICARE for Life provides expanded medical coverage to Medicare-eligible uniformed services retirees 65 or older, to their eligible family members and survivors, and to certain former spouses. You must have Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) to get TRICARE for Life benefits.

For someone turning 65 whose spouse is under 65, the spouse can continue to use TRICARE Prime, TRICARE Select, or whatever plan they’re using now until they also become eligible for Medicare Part A and Part B.

Resources CMS National Training Program

This training module consists of a PowerPoint presentation with trainer’s notes. It explains the rules that govern the payers’ responsibility when people have Medicare and certain other types of health and/or prescription drug coverage.

How Medicare Works with Other Insurance This Medicare web page provides information about coordination of benefits for people who have Medicare and other health insurance or coverage.

The Federal Employees Health Benefits (FEHB) Program This Office of Personnel Management web page provides an overview of the FEHB program and enables users to compare the costs, benefits and features of different FEHB plans available in their state.

TRICARE This web page is the gateway to comprehensive information about TRICARE plans and eligibility, costs, what’s covered, finding a doctor, qualifying life events, claims, and forms.

Your Medicare Coverage Choices This Medicare web page explains coverage options and takes people through steps to help them decide what coverage they want.

26

Module 5: Coordination of Benefits

Use this space for key points you learn during training and on the job.

Glossary Federal Employees Health Benefits (FEHB) Program: A program through which federal employees, retirees, and their survivors have a wide selection of health plans available in their state.

Group Health Plan (GHP): A health plan that gives health coverage to employees, former employees, and their families, and is supported by an employer or employee organization.

TRICARE: A health care program for active-duty and retired uniformed services members and their families.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

27

28

Case Study 5: Bob & Ana

Medicare & Group Health Plans (GHPs)

Bob and Ana are married. Bob, 64, is a retired Marine who’s worked for ABC Company (a large employer with 5,000+ employees) for the past 5 years. He plans to work until full retirement age (66). Ana, 60, works for the federal government and doesn’t say when she’ll retire. Both currently have good, affordable health insurance through Bob’s employer.

Bob and Ana believe they’re getting conflicting information about their health coverage options as they get closer to retirement. At a financial planning seminar, Bob was told he should enroll in Medicare Part A when he’s first eligible, but could delay Part B as a way to save for his retirement. Later he got a note from the U.S. Department of Defense (DOD) indicating that if he doesn’t enroll in Part A and Part B, he and Ana will lose TRICARE. Meanwhile, Ana was told at a Federal Employees Health Benefits (FEHB) Program information fair to consider enrolling in FEHB, as it carries into retirement and doesn’t require enrollment in Medicare Part B upon retiring—and if certain conditions are met, enrolling Bob in the FEHB plan could be an option.

They ask you if the information they’ve received is accurate. They also ask you to help them sort out their options and make decisions about their health insurance.

29

Case Study 5: Bob & Ana

Discussion 1. Is the information Bob and Ana received correct? Is it complete?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. What advice would you give them about making decisions about their healthinsurance?

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

Resources How Medicare Works with Other Insurance (web page) The FEHB Program (web page) TRICARE (web page) Your Medicare Coverage Choices (web page)

30

After reading this job aid, you’ll know…

• When to stop making HSAcontributions based on enrollment inMedicare Part A or Part B.

• Potential Internal Revenue Service(IRS) penalties and repayments ifsomeone continues HSA contributionswhile receiving Medicare benefits.

• Options related to continuingparticipation in HSAs for people whoare eligible for Medicare.

How Medicare enrollment affects HSA contributions As people with HSAs approach retirement, it’s important for them to understand how enrolling in Medicare affects HSA contributions and withdrawals.

Contributions to an HSA aren’t taxed, as long as they’re used to pay for qualified medical expenses. However, if someone contributes to an HSA after his or her Medicare is effective, there may be a 6% IRS penalty on the excess contributions and any earnings until the funds are withdrawn from the account. For this reason, people who contribute to an HSA should make arrangements to stop their HSA contributions before their Medicare effective date. To avoid a tax penalty, they should stop contributing to their HSA at least 6 months before applying for Medicare.

People with HSAs generally may withdraw amounts from an HSA after reaching the age for Medicare eligibility to help pay for medical expenses without penalty if those funds are withdrawn prior to the due date for the current year federal text return (with extensions). They would include this amount as income on their federal tax return.

A spouse’s eligibility or enrollment in Medicare won’t impact the HSA owner’s ability to contribute to their HSA or incur any IRS penalties.

31

What if someone wants to continue HSA contributions after 65?People who qualify and would like to continue making contributions to their HSA shouldn’t apply for Medicare, Social Security, or Railroad Retirement Board (RRB) benefits. Because their enrollment date for Medicare (i.e., when their coverage starts) will generally be 6 months before their application date, they must stop contributing to their HSA 6 months before applying for Medicare. Premium-free Part A coverage begins 6 months back from the date someone applies for Medicare (or Social Security/RRB benefits), but no earlier than the first month the person was eligible for Medicare.

You can only enroll in Medicare Part B at certain times. If you have an HSA with a High Deductible Health Plan (HDHP) based on your or your spouse’s current employment, you may be eligible for a Special Enrollment Period (SEP) to enroll in Part B later without a lifetime Part B late enrollment penalty. If you qualify, you can wait to enroll in Medicare until you (or your spouse) stop working or lose your employer group health plan coverage based on that employment.

Speak to a financial advisor about your situation before making a decision.

Resources Social Security Benefits Planner: Retirement This web page provides general guidance on rules, penalties, and repayment requirements to consider before withdrawing Social Security benefits claims.

Enrolling in Medicare Part A & Part B This 36-page booklet provides general information about enrolling in Medicare Part A and Part B. It also provides detailed information in a Q&A format about Medicare enrollment and HSA coverage.

Medical & Dental Expenses (including the Health Coverage Tax Credit) IRS publication 502 explains the itemized deduction for medical and dental expenses claimed on Schedule A (Form 1040). It discusses what expenses people can and can’t include in figuring the deduction.

Original Medicare (Part A & B) Eligibility & Enrollment This CMS website has comprehensive information about Medicare eligibility and enrollment under Part A and Part B.

32

Use this space for key points you learn during training and on the job.

Glossary Health Savings Account (HSA): According to the IRS, an HSA is a tax-exempt trust or custodial account you set up with a qualified HSA trustee to pay or reimburse certain medical expenses you incur. You must be an eligible individual to qualify for an HSA. You set up an HSA with a trustee. A qualified HSA trustee can be a bank, an insurance company, or anyone already approved by the IRS to be a trustee of individual retirement arrangements (IRAs) or Archer MSAs.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

33

34

Case Study 6: Mr. Kingly

Health Savings Accounts (HSAs) & Medicare considerations

Mr. Kingly turned 65 and has been receiving Social Security retirement benefits for 9 months. He got his “Welcome to Medicare” packet and new Medicare card in the mail, and he’s been looking forward to having Medicare coverage. He also has an HSA with a high-deductible health insurance plan that he’s been contributing to for many years through an automatic deposit. Mr. Kingly went to file his federal income taxes for 2018 and was very confused when his accountant told him that he could be assessed a 6% penalty for excess contributions to his HSA. His accountant advised him that he was no longer eligible to contribute to his HSA because he now has Medicare, effective 4 months ago. He needs more information about why this happened, so he gives you a call.

Discussion 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?

______________________________________________________________________________________________________________________________________

35

Case Study 6: Mr. Kingly

Resources Enrolling in Medicare Part A & Part B (booklet) Medical and Dental Expenses, Including the Health Coverage Tax Credit (IRS publication 502) (booklet) Original Medicare (Part A and B) Eligibility and Enrollment (website) Social Security Benefits Planner: Retirement (website)

36

After reading this job aid, you’ll know…

• That Medicaid benefits vary by state

• That some people qualify for bothMedicare and Medicaid, and are called“dual eligibles”

• There are options for getting help fromyour state to pay out-of-pocketMedicare costs based on income andresources through Medicare SavingsPrograms (MSPs) or Extra Help

• About billing for people who areenrolled in both Medicare andMedicaid

Medicare-Medicaid eligible (dual eligible) The term includes people enrolled in Medicare Part A and/or Part B who get full Medicaid benefits and/or assistance with Medicare premiums or cost sharing through a Medicare Savings Program (MSP).

Medicare pays covered medical services first for dual-eligible beneficiaries because Medicaid is generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or partially covers (such as nursing home care, personal care, and home- and community-based services).

Medicare and Medicaid dual eligible benefits vary by state. Some states offer Medicaid through Medicaid managed care plans, while other states provide Fee-For-Service Medicaid coverage. Some states provide certain dual eligible beneficiary plans that include all Medicare and Medicaid benefits.

Federal law defines income and resource standards for full Medicaid and the MSPs, but states have discretion to effectively raise those limits above the federal floor. On an annual basis, the Centers for Medicare & Medicaid Services (CMS) releases dual eligible standards. See the glossary in the job aid for information on the types of MSPs.

37

Extra Help You automatically qualify for Extra Help if:

• You have both Medicareand Medicaid

• You’re in a MedicareSavings Program

• You get SupplementalSecurity Income (SSI)benefits

Balanced Billing People who are eligible for help in a state’s MSP as a Qualified Medicare Beneficiary (QMB) have special protection under federal law to prevent providers from billing them for Medicare cost-sharing.

To the extent consistent with the Medicaid state plan, QMBs may need to pay a nominal copayment in certain circumstances (like prescription drugs) even if payment isn’t available under the state plan for these charges.

Resources Low Income Subsidy for Medicare Prescription Drug Coverage

Limited Income & Resources

HI 03001.005 Medicare Part D Extra Help (Low Income Subsidy or LIS) The three web pages listed above provide information about the Low Income Subsidy (LIS) Program (also called Extra Help), which helps people with Medicare pay for prescription drugs. Topics include eligibility and enrollment.

Seniors & Medicare and Medicaid Enrollees This web page explains costs and services Medicaid covers when a person is also enrolled in Medicare. It includes the latest standards for qualifying for both Medicare and Medicaid.

Medicare Savings Program This web page describes MSPs. It also explains eligibility and how to apply for MSPs through a state Medicaid program, and provides general tips to keep costs down.

What to Do If You No Longer Automatically Qualify for Extra Help with Medicare Prescription Drug Costs This 4-page fact sheet provides guidance about options for people who don’t qualify for Extra Help based on income and resources.

38

GlossaryDual Eligibles: The following describes the various categories of people who, collectively, are known as dual eligibles. Medicare has 2 basic coverages: Part A, which pays for hospitalization costs; and Part B, which pays for physician services, lab and x-ray services, durable medical equipment, and outpatient and other services. Dual eligibles are people who are entitled to Medicare Part A and/or Part B and are eligible for some form of Medicaid benefit.

1. Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMBOnly): These people are entitled to Medicare Part A, have income of 100%federal poverty level (FPL) or less and resources that don’t exceed at least 3times the Supplemental Security Income (SSI) resource eligibility limit, and aren’totherwise eligible for full Medicaid. Medicaid pays their Medicare Part Apremiums, and, if any, Medicare Part B premiums. Federal FinancialParticipation (FFP) equals the Federal Medical Assistance Percentage (FMAP).

2. QMBs with full Medicaid (QMB Plus): These people are entitled to MedicarePart A, have income of 100% FPL or less and resources that don’t exceed atleast 3 times the SSI resource eligibility limit, and are eligible for full Medicaidbenefits. Medicaid pays their Medicare Part A premiums, and, if any, MedicarePart B premiums. FFP equals FMAP.

3. Specified Low-Income Medicare Beneficiaries (SLMBs) without otherMedicaid (SLMB Only): These people are entitled to Medicare Part A, haveincome of greater than 100% FPL but less than 120% FPL and resources thatdon’t exceed at least 3 times the SSI resource eligibility limit, and aren’totherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiumsonly. FFP equals FMAP.

4. SLMBs with full Medicaid (SLMB Plus): These people are entitled to MedicarePart A, have income of greater than 100% FPL but less than 120% FPL andresources that don’t exceed at least 3 times the SSI resource eligibility limit, andare eligible for full Medicaid benefits. Medicaid pays their Medicare Part Bpremiums and provides full Medicaid benefits. FFP equals FMAP.

5. Qualified Disabled and Working Individuals (QDWIs): These individualsattained Medicare eligibility based on their receipt of Social Security DisabilityInsurance (SSDI) benefits, but subsequently lost their SSDI benefits, and,consequently, their Medicare coverage, when they returned to work. They’reeligible to purchase Medicare Part A benefits, have income of 200% FPL or lessand resources that don’t exceed twice the limit for SSI eligibility, and aren’totherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiumsonly. FFP equals FMAP.

39

6. Qualifying Individuals (QIs): These people are entitled to Medicare Part A, haveincome of at least 120% FPL but less than 135% FPL and resources that don’texceed at least 3 times the SSI resource eligibility limit, and aren’t otherwiseeligible for Medicaid. Medicaid pays their Medicare Part B premiums only. There’san annual cap on the amount of money available, which may limit the number ofpeople in the group. FFP equals FMAP at 100%.

7. Medicaid Only Dual Eligibles (Non QMB, SLMB, QDWI, or QI): These peopleare entitled to Medicare Part A and/or Part B and are eligible for full Medicaidbenefits. They aren’t eligible for Medicaid as a QMB, SLMB, QDWI, or QI.Medicaid provides full Medicaid benefits and pays for Medicaid services providedby Medicaid providers, but Medicaid will only pay for services also covered byMedicare if the Medicaid payment rate is higher than the amount paid byMedicare, and, within this limit, will only pay to the extent necessary to pay thebeneficiary's Medicare cost-sharing liability. Payment by Medicaid of MedicarePart B premiums is a State option; however, states may not receive FFP forMedicaid services also covered by Medicare Part B for certain individuals whocould have been covered under Medicare Part B had they been enrolled. FFPequals FMAP.

Use this space for key points you learn during training and on the job. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

40

Case Study 7: Mr. Rutter

Considerations for people with low income who qualify for Medicare & Medicaid

Mr. Rutter has had coverage under his state’s Medicaid Program for many years. He’s turning 65 in a few months and knows he’ll need to enroll in Medicare, but he’s unsure what he should do or how his coverage will change.

Discussion 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 theproviders he currently sees?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. What other programs are available to help Mr. Rutter with his out-of-pocket healthand drug costs, considering his low income?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

41

Case Study 7: Mr. Rutter

3. Since Mr. Rutter will be a Medicare-Medicaid enrollee, how will the billing work nowthat he’ll have coverage under both programs?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Resources Limited Income & Resources (web page) Low Income Subsidy for Medicare Prescription Drug Coverage (web page) Medicare Part D Extra Help (Low Income Subsidy or LIS)—Section HI 03001.005d in Social Security Program Operations Manual (section of manual) Medicare Savings Program (web page) Seniors & Medicare and Medicaid Enrollees (web page) What to Do If You No Longer Automatically Qualify for Extra Help with Medicare Prescription Drug Costs (Medicare publication 11215) (fact sheet)

42

After reading this job aid, you’ll know…

• How to determine ifsomeone is an inpatientor outpatient

• How hospitalobservation statusaffects what people payfor care in a skillednursing facility (SNF)

• About some requirednotices

Medicare coverage for skilled nursing facility care Medicare doesn’t cover SNF care unless several conditions are met, including a qualifying 3-day hospital stay. The following conditions must also be met: • Patient has Part A and has days left in his or her

benefit period.• Doctor decides the patient needs daily skilled care

given by, or under the direct supervision of, skillednursing or therapy staff. (If in the SNF for skilledrehabilitation services only, care is considered dailycare even if these therapy services are offered just5 or 6 days a week, as long as therapy services areneeded and received each day they’re offered).

• Patient gets these skilled services in a SNF that’scertified by Medicare to help improve, maintain, orprevent his or her condition from getting worse.

• Patient needs these skilled services for a medicalcondition that was either a hospital-related medicalcondition or a condition that started while getting carein the SNF for a hospital-related medical condition.

Inpatient admittance to a hospital might be appropriate if a patient is expected to need two or more midnights of medically necessary hospital care. This is referred to as the 2-Midnight Rule. If you’re monitored overnight at a hospital prior to a doctor-recommended stay at a skilled nursing facility (SNF), Medicare deems such occurrences as outpatient observation services. Observation services are hospital outpatient services given to a patient to help the doctor decide if the patient needs to be admitted as an inpatient or can be discharged. Time spent as an outpatient under observation can’t be counted toward the three consecutive-day inpatient hospital stay also referred to as the 3-day inpatient qualifying stay requirement needed for Medicare Part A to cover a SNF stay. Observation services may be given in the emergency department or another area of the hospital.

43

How hospital observation status affects Medicare coverage for a subsequent SNF stay Observation services are hospital outpatient services that help the doctor decide if you need to be admitted as an inpatient, or if you can be discharged. These services may be given in the emergency department or another area of the hospital. If you aren’t formally admitted to the hospital as an inpatient, the observation is considered an outpatient service. This time can’t be counted toward the 3 consecutive-day inpatient hospital stay (also referred to as the 3-day inpatient qualifying stay) requirement needed for Medicare Part A to cover a SNF stay. An inpatient admission can be appropriate if you’re expected to need 2 or more midnights of medically necessary hospital care and your doctor formally admits you. Inpatient admissions will generally be payable under Medicare Part A in this situation. Medicare Part A payment is generally not appropriate, however, for hospital stays not expected to span at least 2 midnights. This is known as the 2-Midnight Rule.

Notification requirements If you’re receiving outpatient observation services at a hospital for least 24 hours, the hospital is required to give you a Medicare Outpatient Observation Notice (MOON) no later than 36 hours after observation begins. It explains why you’re an outpatient getting observation services, instead of an inpatient, and how this may affect what you pay while in the hospital, and what you pay for care you get after leaving the hospital. If you’re under observation status and your doctor recommends that you go directly to a SNF from the hospital, the hospital and SNF may also give you a SNF Advanced Beneficiary Notice of Non-Coverage (SNF ABN) advising you that Medicare Part A won’t pay for the SNF stay. People with Original Medicare may get a written notice called an ABN from a doctor, other health care provider, or supplier if they have Original Medicare and their doctor, other health care provider, or supplier thinks Medicare probably (or certainly) won’t pay for the items or services they got. The ABN lists the items or services Medicare isn’t expected to cover, an estimate of the costs for the items and services, and the reasons why Medicare may not pay.

44

Glossary 2-Midnight Rule: Rule that statesinpatient admissions will generallybe payable under Medicare Part Aif the admitting practitionerexpected the patient to require ahospital stay that crossed2 midnights and the medicalrecord supports that reasonableexpectation. Medicare Part Apayment is generally notappropriate for hospital stays notexpected to span at least2 midnights.Medicare Outpatient Observation Notice (MOON): A standardized notice that hospitals and Critical Access Hospitals are required to provide to individuals receiving observation services as outpatients for more than 24 hours explaining the status of the individual as an outpatient, not an inpatient, and the implications of such status. It must be delivered no later than 36 hours after observation services begin. Observation services: Hospital outpatient services given to a patient to help the doctor decide if the patient needs to be admitted as an inpatient or can be discharged.

Resources Advance Beneficiary Notice of Non-coverage (ABN) This web page explains notices of non-coverage that providers are required to provide, with links to downloadable forms. Are You a Hospital Inpatient or Outpatient: If You Have Medicare–Ask! (CMS Publication 11435)! This 8-page fact sheet explains how hospital status affects what a person pays for hospital services and whether their stay in a SNF will be covered. Beneficiary Notices Initiative (BNI) This web page has information about rights and protections available to people with Medicare and providers, as well as financial liability and appeals. Fee For Service ABN This web page includes a link to the FFS ABN form and instructions. Fee For Service SNF ABN This web page includes a link to the FFS SNF ABN form and instructions. Inpatient or Outpatient Hospital Status Affects Your Costs This web page gives examples of common hospital situations and describes how Medicare will pay.

45

Use this space for key points you learn during training and on the job. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

46

Case Study 8: Mr. James

Hospital observation status, skilled nursing facility care, & notification requirements

Mr. James has Original Medicare (Part A and Part B). Recently, he went to the emergency room at his local hospital for severe back spasms. The doctor monitored Mr. James overnight and recommended physical therapy (PT) to help him regain function. Because of Mr. James’ weakened state, the doctor recommended he go to a skilled nursing facility (SNF) that day for PT. Mr. James received a week of inpatient PT at the SNF and was discharged home.

Since Mr. James didn’t read all the paperwork he received from Medicare and the hospital, he was surprised to receive a bill from the SNF indicating he didn’t meet Medicare Part A requirements for coverage. He thought he understood that Medicare pays 100% for the first 20 days of SNF care. Since he only received 7 days of SNF care, he thought it would be covered.

He also received a bill indicating he’s responsible for a coinsurance related to the doctors’ services and tests associated with this hospital visit.

Discussion 1. Are these charges correct? Why or why not?

_________________________________________________________________________________________________________________________________________________________________________________________________________

47

Case Study 8: Mr. James

2. What are the notification requirements that the hospital and SNF should provide toMr. James advising him how Medicare will or won’t pay for his hospital/doctorservices, SNF stay, and PT?

_________________________________________________________________________________________________________________________________________________________________________________________________________

Resources Are You a Hospital Inpatient or Outpatient? If you have Medicare–Ask! (CMS Publication 11435) (fact sheet) Inpatient or outpatient hospital status affects your costs (web page) Beneficiary Notices Initiative (BNI) (web page) Advance Beneficiary Notice of Noncoverage (web page) Fee For Service SNF Advance Beneficiary Notice of Non-coverage (Form CMS-100-55) (web page with link to form)Fee For Service Advance Beneficiary Notice of Non-coverage (Form CMS-R-131)(web page with link to form)

48

After reading this job aid, you’ll know…

• How Social Security determines if income-related monthly adjustment amounts(IRMAA) for Part B and/or Part Dpremiums apply to you

• How to request a new initial determinationif you think your Medicare premium isn’taccurate based on Social Security’sIRMAA determination

• Potential penalties for non-payment duringan IRMAA appeal

• Options for making IRMAA payments tocover Medicare monthly premiums

IRMAA determination notices, amounts, & appeals You may get an Initial IRMAA Determination Notice from Social Security if you have Medicare Part B and/or Part D, and Social Security determines that any income-related monthly adjustment amounts apply to you. The notice includes information about Social Security’s determination and appeal rights.

Social Security uses your modified adjusted gross income (MAGI) from income reported to the Internal Revenue Service 2 years prior to determine what you pay for Medicare Part B and Part D. About 5% of people with Medicare are affected by IRMAA. The 2019 IRMAA for Part B and Part D will differ from the 2018 IRMAA, and there will be an additional IRMAA level.

If you had a life changing event (LCE) that affected your income, you can file a request for a new initial determination by mailing a completed Form SSA-44 to Social Security, or you can schedule an interview with your local Social Security office by calling 1-800-772-1213; TTY 1-800-325-0778. The form provides detailed instructions about what’s needed to submit the request.

49

IRMAA Payments and Penalties You’re required by law to pay any IRMAA you owe to keep your Part B and/or Part D coverage, even if you disagree with the amount or request a new initial determination. Failure to pay may result in disenrollment from Part B and/or Part D and loss of health insurance coverage. If you’re disenrolled, you may have to wait until the next available enrollment period to reenroll and may be subject to a monthly Late Enrollment Penalty. If Social Security determines that your IRMAA should be reduced or eliminated, any IRMAA you pay while waiting for an appeal won’t be reimbursed directly. The amount(s) will be applied to future bills, first to Part B, then to any applicable Part A premium, and finally to Part D IRMAA. Part B and Part D IRMAA are separate amounts, but have similar payment options: automatic deduction from Social Security or RRB benefit payments, or for people who don’t get monthly Social Security or RRB benefits, from a savings or checking account through Medicare Easy Pay or their bank’s online bill payment services, or by check, money order, or credit card.

Resources 2018 Medicare Parts A & B Premiums & Deductibles This CMS fact sheet provides 2018 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs. CMS also provides a job aid with information on 2018 Medicare Amounts for Parts A, B, and D.

The Medicare Premium Bill (CMS-500) is a bill for people who pay Medicare directly for their Part A, Part B, and/or Part D IRMAA. Medicare Easy Pay (MEP) is a free, electronic payment option that allows people to have their Medicare premium payments automatically deducted from a savings or checking account each month.

Medicare Income-Related Monthly Adjustment Amount (IRMAA) – Life Changing Event (Form SSA-44) People who get an Initial IRMAA Determination Notice can use this form to appeal if they had a life changing event that may reduce their IRMAA.

Social Security Program Operations Systems Manual See the following sections: • Initial IRMAA Determination Notices• Beneficiary Questions an IRMAA

Determination or Decision• Life Changing Events• The Reconsideration Process for the

IRMAA• Description of the Medicare Part D

Prescription Drug Program, Sections G–CMS’s Part D responsibilities & H.2–Payment options

50

Use this space for key points you learn during training and on the job.

Glossary Income-related monthly adjustment amount (IRMAA): Any additional amount you pay for monthly Medicare Part B and/or Part D premiums, based on your modified adjusted gross income as reported to the Internal Revenue Service 2 years prior.

Initial IRMAA Determination Notice: A notice Social Security sends to people who have Medicare Part B and/or Part D if Social Security determines that any IRMAA applies to you. This notice includes information about Social Security’s determination and appeal rights.

Medicare Easy Pay (MEP): A free, electronic payment option that allows people to have their Medicare premium payments automatically deducted from a savings or checking account each month.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

51

52

Case Study 9: Ms. Zhang

Income-related monthly adjustment amount (IRMAA) appeals & penalties

Ms. Zhang recently turned 65 and enrolled in Original Medicare (Part A and Part B) and a Medicare Prescription Drug (Part D) Plan. She’s still working at an advertising agency and has decided to delay receiving Social Security retirement for a few years. When she was 64, she got divorced and changed from filing a joint federal tax return to filing as an individual. Her modified adjusted gross income (MAGI) was $75,000 in 2017. At 63, when she was still married, the MAGI listed on her joint federal tax return was $250,000. Based on a meeting with a financial advisor, her income is projected to remain at about $75,000 per year for the next few years. She recently received an “Initial IRMAA Determination Notice” for 2018 from the Social Security Administration (SSA). The letter stated that her Part B monthly premium is $267.90, and she’ll pay an additional $33.60 for her Part D monthly premium because of her high income.

Discussion 1. Based on the scenario, what would you tell Ms. Zhang about the IRMAA information

in her Initial IRMAA Determination Notice?

_________________________________________________________________________________________________________________________________________________________________________________________________________

53

Case Study 9: Ms. Zhang

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 isreviewed? What would happen if she doesn’t pay the IRMAA?

_________________________________________________________________________________________________________________________________________________________________________________________________________

Resources 2018 Medicare Amounts (job aid) 2018 Medicare Parts A & B Premiums and Deductibles (fact sheet) Understanding the “Medicare Premium Bill” Form (CMS-500), Pub 11659 (brochure) HI 01101.035 Initial IRMAA Determination Notices (Social Security Program Operations Systems Manual) HI 01101.050 Beneficiary Questions an IRMAA Determination or Decision (Social Security Program Operations Systems Manual) HI 01120.005 Life Changing Events (Social Security Program Operations Systems Manual) HI 01140.005 The Reconsideration Process for the Income-Related Monthly Adjustment Amount (Social Security Program Operations Systems Manual) HI 03001.001 Description of the Medicare Part D Prescription Drug Program (Social Security Program Operations Systems Manual), see Sections G–CMS’ Part D responsibilities & H.2–Payment options Initial IRMAA Determination (web page) Monthly premium for drug plans (web page) Medicare Easy Pay (web page) Medicare Premium Bill (CMS-500) (web page) Part B costs (web page)

54

Appendix A The MasterSolve© Approach to

Problem Solving

The MasterSolve© Approach to Problem Solving This job aid shows the seven-step MasterSolve© approach for working through complicated issues to solve a problem. Use it to help you generate the right questions, explore options, and test answers or solutions to achieve the desired results.

STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Determine your understanding of the problem.

Decide what specifically you want to happen (desired state).

Observe and note in detail what’s happening instead (current state).

Create a solution (goal) that describes what you and others will…

a. see

b. hear

c. feel

d. know

when the problem or issue is resolved.

Determine what’s preventing the desired result from occurring now.

Brainstorm and record possible solutions.

Analyze and test options, noting benefits and drawbacks for each, and rank/order the options to help you select a solution.

STEP 6 Confirm that the selected solution will produce the results described in Step 2. If not, make adjustments.

STEP 7 Implement the solution and monitor what happens. If the desired result is achieved, congratulations! If not, re-enter the data and run again until you get the desired results.

Reference Hughes, M., and Terrell, J.B. (2012). Emotional Intelligence in Action: Training and Coaching Activities for Leaders, Managers, and Teams (2nd ed.). New York: Pfeiffer. The MasterSolve© Problem Solving Model is copyrighted and used with permission of Collaborative Growth, LLC.

A-1

A-2

Appendix B Effective Questioning

Techniques

B-1

Effective Questioning Techniques The ability to ask the right questions, at the right time, in the right way, is essential to communicating effectively and working efficiently to resolve problems. Developing your questioning skills can help you (1) gather the information you need; (2) avoid misunderstandings; (3) learn more and help others learn, too; (4) build stronger relationships; (5) persuade people; and sometimes (6) defuse heated situations (for example, by using the“funneling” technique described below to get at a frustrated person’s grievance).

Use this job aid (1) to remind yourself and your colleagues of effective questioning techniques, and (2) to reflect on and improve your proficiency.

QUESTIONING TECHNIQUE PROFICIENCY LEVEL USES LOW MODERATE HIGH

1. Using close-endedquestions to get alimited response suchas “yes” or “no.”

Close-ended questions are good for… Testing one’s understanding: “So, if he gets this administered at a pharmacy, I can submit this under Part B?" Concluding a discussion or making a decision: “Now that we know the situation, do we all agree this is the right course of action?” Frame setting: “Are you happy with the service from your provider?” Tip: Be careful about using closed questions when a conversation is in full flow because doing so can shut down the discussion.

2. Using open-endedquestions to ask forexpanded responses.They usually begin withwhat, why, or how.They ask people toshare their knowledge,opinions, feelings, orexperiences. They canalso be stated asprompts, such as “Tellme what happenednext” or “Describe the

Open-ended questions are good for… Opening a conversation: “What new questions do you have about Part D?” Getting details: “What else do we need to know about your current situation?” Soliciting opinions: “What do you think about these options?”

B-2

QUESTIONING TECHNIQUE PROFICIENCY LEVEL USES LOW MODERATE HIGH

circumstances in more detail.”

3. Using a funnelingtechnique that startswith general questionsand uses follow-upquestions to getadditional details.

The funneling technique is good for… Helping people provide detailed information: “How many times were you admitted to the hospital in May?” Helping people weigh their options: Instead of asking “What details you can give me about the pharmacies you prefer?,” use funneling: • “How many are near your

neighborhood?”• “What are their hours of operation?”• “Which provider will you contact?”

4. Using neutral probes toget additionalinformation when initialresponses aresuperficial orincomplete.

Probes are good for… Following up on a vague or limited response: “Can you show me your insurance cards?” Clarifying your understanding: “So you have prescription drug coverage. Is that right?” Prompting deeper thinking: “Does your current plan cover the drugs you need?” Generating forward movement when someone seems “stuck” on a response: “Should we look at the formulary?” Encouraging full participation in group discussions: “What do others say about their experience?”

5. Being comfortable with,and capitalizing onsilence. A 3-secondpause is a good rule ofthumb.

Silence is good for… Giving people time to process the question: “Think time” can lead to more complete, accurate responses. Signaling that you’re comfortable waiting for a response: A 3-second pause is a good rule of thumb. Longer silences might be required for complex or sensitive questions.

QUESTIONING TECHNIQUE PROFICIENCY LEVEL USES LOW MODERATE HIGH

6. Explaining the “why”behind a series of in-depth questions.

Explaining “why” is good for… Establishing rapport: Providing context up front shows respect and can help people understand how they can benefit from responding. “To help you with your Medicare questions it will be necessary for me to ask you about your prior employer, your health and the circumstances that led to today’s conversation.”

7. Affirming the otherperson’s participation inthe dialogue.

Affirming is good for… Encouraging a two-way conversation: Nods or vocal affirmations like “I see” show genuine interest and encourage two-way conversation. “Please” and “thank you” go a long way, too.

8. Using active listeningskills.

Active listing is good for… Focusing on the other person’s response rather than your own internal monologue: “So you were assuming you wouldn’t qualify because you’re under 65.”

9. Monitoring your bodylanguage and tone ofvoice.

Monitoring your body language and tone is good for… Showing interest: People are more likely to respond fully if you don’t appear to be rushed, frustrated, or distracted.

10. Watching andresponding to theother person’s bodylanguage and tone ofvoice.

Responding to the other person’s body language and tone is good for… Acknowledging and following up on nonverbal cues: If the respondent remains open and engaged, keep going. If you see or sense confusion, concern, or frustration, ask questions to clear things up—or agree to table questioning for now, and return to the discussion at another time.

B-3

Appendix C 2018 Medicare Amounts Job Aid

2018 MEDICARE AMOUNTS

Part A ‐ Hospital Insurance

Part A Standard Premium No charge for most people (at least 40 work quarters) $422 per month for people with less than 30 work quarters $232 per month for people with 30-39 work quarters

Part A Late Enrollment Penalty - If you aren’t eligible for premium-free Part A, and you don’t buy it when you’re first eligible, your monthly premium may go up 10%. You’ll have to pay the higher premium for twice the number of years you could’ve had Part A, but didn’t sign up.

Cost for You Pay Part A Deductible for Each Benefit Period

Hospital Inpatient Stay for Each Benefit Period

$1,340

$0 for days 1-60 $335 a day for days 61-90 $670 a day for days 91-150 (lifetime reserve days) All costs for all days after 150

Skilled Nursing Facility Stay $0 for days 1-20 $167.50 a day for days 21-100 All costs for all days after 100

Home Health Care $0 for home health care services 20% of the Medicare-approved amount for durable

medical equipment

Hospice Care $0 for hospice care. You may need to pay a copayment of no more than $5 for

each prescription drug and other similar products for painrelief and symptom control while you’re at home. In therare case your drug isn’t covered by the hospice benefit,your hospice provider should contact your Medicare drugplan to see if it’s covered under Part D. You may need to pay 5% of the Medicare-approved amount

for inpatient respite care. Medicare doesn’t cover room and board when you get

hospice care in your home or another facility where youlive (like a nursing home).

C-1

Part B ‐ Medical Insurance

Part B Deductible - $183 per year

Part B Coinsurance - After your deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you’re a hospital inpatient), outpatient therapy, and durable medical equipment.

Part B Standard Premium - The standard Part B premium amount in 2018 is $134 (or higher depending on your income). However, some people who get Social Security benefits pay less than this amount ($130 on average).

Since 2007, people with Medicare with higher incomes have paid higher Medicare Part B monthly premiums. These income-related monthly adjustment amounts (IRMAA) affect roughly 5% of people with Medicare.

Your Part B premium in 2018 based on your 2016 tax return:

File individual tax return File joint tax return File married and separate

You pay

$85,000 or less $170,000 or less $85,000 or less $134.00

above $85,000 up to $107,000 above $170,000 up to $214,000 Not applicable $187.50

above $107,000 up to $133,500 above $214,000 up to $267,000 Not applicable $267.90

above $133,500 up to $160,000 above $267,000 up to $320,000 Not applicable $348.30

above $160,000 above $320,000 above $85,000 $428.60

Part B Late Enrollment Penalty ‐ If you don’t sign up for Part B when you’re first eligible, or if you drop Part B and then get it after you’re first eligible, you may have to pay a late enrollment penalty for as long as you have Medicare. Your monthly premium for Part B may go up 10% (.10) for each full 12-month period that you could’ve had Part B, but didn’t sign up for it.

C-2

Part D – Medicare Prescription Drug Coverage

Part D Base Beneficiary Premium - $35.02 (used to determine any late enrollment penalty amount).

Listed below are the 2018 Part D monthly income-related premium adjustment amounts to be paid by people with Medicare who file an individual tax return (including those who are single, head of household, qualifying widow(er) with dependent child, or married filing separately who lived apart from their spouse for the entire taxable year), or a joint tax return.

Your Part D premium in 2018 based on your 2016 tax return:

File individual tax return

File joint tax return File married and separate tax return

You pay Income‐related monthly adjustment amount + your plan premium (YPP)

$85,000 or less $170,000 or less

$85,000 or less $0.00 + YPP above $85,000 up to

$107,000 above $170,000 up to $214,000

Not applicable $13.00 + YPP

above $107,000 up to $133,500

above $214,000 up to $267,000

Not applicable $33.60 + YPP

above $133,500 up to $160,000

above $267,000 up to $320,000

Not applicable $54.20 + YPP

above $160,000 above $320,000 above $85,000 $74.80 + YPP

Part D Deductibles, Copayments, and Coinsurance - The amount you pay for Part D deductibles, copayments, Look for specific Medicare drug plan costs, and then call the plans you’re

interested in to get more details. and/or coinsurance varies by plan.

Part D Late Enrollment Penalty - If you don’t sign up for Part D when you’re first eligible, or if you drop Part D and then get it after you are first eligible, you may have to pay a late enrollment penalty for as long as you have Part D. The cost of the late enrollment penalty depends on how long you didn’t have creditable prescription drug coverage. The late enrollment penalty is calculated by multiplying 1% (.01) of the national base beneficiary premium ($35.02 in 2018) times the number of full, uncovered months that you were eligible but didn’t join a Medicare Prescription Drug Plan and went without other creditable prescription drug coverage. This final amount is rounded to the nearest $.10 and added to your monthly premium. The national base beneficiary premium may increase each year, so the penalty amount may also increase each year.

C-3

C-4

Appendix D Case Study Scavenger Hunt

Bingo Activity

Case study scavenger hunt bingo activity This activity helps learners understand how to use the Day 3 Workbook to prepare them for the Advanced Casework Session. You can also use this bingo game to check your knowledge on topics covered in the Advanced Case Studies Workbook, or as a group assessment activity. The answer key tells which job aid in the workbook has the answer to each question.

Prepare for this activity: 1. Print the questions and answers for each person or each table, along with a

bingo card for each person or table. A template is available atcmsnationaltrainingprogram.cms.gov.

2. Distribute one bingo card and one set of questions per person or per table,depending on whether you want this to be an individual or group activity.

3. Provide directions (see below).4. Distribute the answer key and encourage the group to review all questions later

and use the answer key to self-assess their knowledge. Direct them to theAdvanced Case Studies Workbook to further their understanding.

Directions for group: 1. See “Case Study Scavenger Hunt Questions” for scavenger hunt questions,

numbered 1-24.2. Write the answer to each question in the bingo block that has the corresponding

number and include the job aid number that had the answer. See the casestudies and related job aids in the Advanced Case Studies Workbook, availableat cmsnationaltrainingprogram.cms.gov.

3. When you have written answers/job aid numbers in 5 squares across, down, ordiagonally, call out “Bingo!”

Case study scavenger hunt bingo

D-1

Case study scavenger hunt questions 1. What type of vaccine is covered under Part B for intermediate to high-risk

beneficiaries?

2. Which part (or parts) of Medicare would cover a tetanus booster shot administered toan inpatient in a skilled nursing facility (SNF) for therapeutic purposes, assuming theperson has Original Medicare (Part A and Part B) and a Part D Prescription DrugPlan, and the SNF facility stay is covered by Part A?

3. What kind of drugs are covered under Medicare Part A during a hospital stay after akidney transplant, assuming the beneficiary was enrolled in Part A at the time of thetransplant?

4. What percentage of medically necessary non-emergency, scheduled, repetitiveambulance services does Medicare Part B generally cover, if the ambulance provideror supplier completes the appropriate approval process before the service isprovided?

5. What’s the IRS penalty on contributions you make to a Health Savings Account afteryour Medicare becomes effective?

6. What term is used for people who are entitled to Medicare Part and/or B and are alsoeligible for some form of Medicaid benefit?

7. The MOON is a notice that hospitals and Critical Access Hospitals are required toprovide in certain situations. What does “MOON” stand for?

8. What percentage of people with Medicare are affected by the income-related monthlyadjustment amount (IRMAA)?

9. What’s a condition that puts someone in a high-risk group for Hepatitis B?

10. When receiving Part A-covered skilled nursing facility (SNF) care, the SNF’s bundledper diem payment excludes certain costly and intensive chemotherapy drugs, whichare billed separately under which part (or parts) of Medicare?

11. ESRD is permanent kidney failure that requires a regular course of dialysis or akidney transplant. What does ESRD stand for?

12. The Uniformed Services Health Benefits Program is also known by what other title?

13. If someone has both Medicare and Medicaid, and receives servicesthat are covered by Medicare, does Medicare or Medicaid pay first?

D-2

14. What do you call hospital outpatient services given to someone to help the doctordecide if the patient needs to be admitted as an inpatient or can be discharged?

15. Social Security uses your modified adjusted gross income from incomereported to the Internal Revenue Service to determine if any income-related monthly adjustment amounts apply to you. Does Social Securityuse information from 1 year prior or 2 years prior?

16. Does cost sharing mean (a) the cost for medical care that you pay yourself like acopayment, coinsurance, or deductible, or (b) the amount Medicare pays if you haveadditional health insurance coverage?

17. How many months after the month of a successful kidney transplant would yourMedicare coverage end if you are entitled to Medicare only because of End-StageRenal Disease?

18. To be eligible for TRICARE when you turn 65, and are eligible for Medicare, what part(or parts) of Medicare must you enroll in to maintain TRICARE coverage?

19. If you have a Health Savings Account (HSA), should you arrange to stop contributionsto the HSA before or after your Medicare effective date?

20. Medicare Part A payment is generally not appropriate for hospital stays not expectedto span at least how many midnights?

21. If you receive an Initial IRMAA Determination Notice from Social Security, and youappeal the decision, should you pay the income-related monthly adjustment amountwhile you wait on a decision?

22. If transportation other than an ambulance could be used to take a Medicarebeneficiary to and from dialysis 3 times a week, but such transportation is not actuallyavailable, how many dollars will Medicare pay for ambulance services?

23. For people who are retired and have Medicare and employer group health plan (GHP)retiree coverage from a former employer, does Medicare generally pay first orsecond?

24. What’s another term for the Low-Income Subsidy, which helps people with Medicarewho have low income and resources pay for prescription drugs?

D-3

Case study scavenger hunt answer key

1. Hepatitis B (job aid 1)2. Part A (job aid 2)3. Immunosuppressive drugs (job aid 3)4. 80 (job aid 4)5. 6% (job aid 6)6. Dual eligible (job aid 7)7. Medicare Outpatient Observation Notice (job aid 8)8. 5% (job aid 9)9. Any of the following are correct: Diabetes, ESRD, Hemophilia, clients of

institutions for the mentally handicapped, or those who live in the samehousehold as a Hepatitis B virus carrier (job aid 1)

10. Part B (job aid 2)11. End-Stage Renal Disease (job aid 3)12. TRICARE (job aid 5)13. Medicare (job aid 7)14. Observation services (job aid 8)15. 2 years (job aid 9)16. a (job aid 1)17. 36 (job aid 3)18. Parts A & B (job aid 5)19. Before (job aid 6)20. 2 (job aid 8)21. Yes (job aid 9)22. 0 (job aid 4)23. First (job aid 5)24. Extra Help (job aid 7)

D-4

Appendix E Case Studies

Case Study 1—Ms. Rosen Vaccines & Medicare prescription drug coverage under Part A, Part B, & Part D

Case Study 2—Mr. Henderson Skilled nursing facilities & Medicare prescription drug coverage under Medicare Part A, Part B, & Part D

Case Study 3—Ms. Williams End-Stage Renal Disease & Medicare prescription drug coverage under Part A, Part B, & Part D

Case Study 4—Mr. Richards Medicare coverage & non-emergency transportation

Case Study 5—Bob & Ana Medicare & Group Health Plans (GHPs)

Case Study 6—Mr. Kingly Health Savings Accounts (HSAs) & Medicare considerations

Case Study 7—Mr. Rutter Considerations for people with low income who qualify for Medicare & Medicaid

Case Study 8—Mr. James Hospital observation status, skilled nursing facility care, & notification requirements

Case Study 9—Ms. Zhang Income-related monthly adjustment amount (IRMAA) appeals & penalties

E-1

E-2

Case Study 1: Ms. Rosen

Vaccines & Medicare prescription drug coverage under Part A, Part B, & Part D

Ms. Rosen is 75 and has Medicare. She has high blood pressure, high cholesterol, diabetes, and a thyroid disorder. Ms. Rosen has Original Medicare (Part A and Part B) and a Medicare Prescription Drug Plan (Part D). Her doctor administered the first dose of the Hepatitis B vaccine in his office.

Discussion 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 Bvaccine 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?

______________________________________________________________________________________________________________________________________

Resources Medicare Drug Coverage Under Part A, Part B, & Part D (job aid) Medicare Part B Vaccines & Vaccine Administration (fact sheet)

E-3

Case Study 1: Ms. Rosen

Discussion points 1. Which part of Medicare covers the vaccine?

• Medicare Part B covers most of the vaccines Medicare patients need that arereasonable and necessary for the treatment of an illness or injury. Under Part B,immunizers administer these vaccines and submit a claim to the MedicareAdministrative Contractor (MAC) for both the vaccine and its administration. Forpatients enrolled in Medicare Advantage (MA) Plans, in-network doctors submitclaims to the patient’s MA Plan.

• Part D plans generally cover vaccines that Part B doesn’t cover. However, underPart D, the provider may or may not directly bill the Part D plan. If providers can’tbill directly, they may need to work with their patients’ Part D plans for payment.

2. If her doctor gave her a prescription to go to her local pharmacy to get theHepatitis B vaccine series, would the pharmacy be able to administer thevaccine?

• In-network administration by pharmacy: Patients get a prescription from theirdoctor and bring it to their local network retail pharmacy (or the doctor transmits itelectronically). In some cases, a pharmacist administers the vaccine (unlessprohibited by state law). The pharmacy bills the Part D plan, and patients pay thepharmacy the required Part D cost sharing amount.

o The pharmacy must have a Medicare billing number.

o The patient must have a prescription from the doctor.

o Pharmacies, depending on state law, may administer vaccines.

• In-network pharmacy distribution to doctor: Patients get a prescription fromtheir doctor and bring it to the pharmacy (or the doctor transmits it electronically).The pharmacy then fills the prescription, ships or delivers it to the doctor’s office,and bills the Part D plan for dispensing and providing the vaccine. The pharmacybills the Part D plan, and patients pay the pharmacy the required Part D costsharing amount and pay the doctor for administering the vaccine.

E-4

Case Study 1: Ms. Rosen

3. If so, which part of Medicare should the pharmacy bill for the Hepatitis Bvaccine?

• The pharmacy should bill Medicare Part B because Ms. Rosen has diabetes andit places her in a “high risk” category. The Hepatitis B vaccine is covered underPart B for intermediate to high risk beneficiaries.

o Intermediate risk groups:

Staff of institutions for the mentally handicapped

Workers in health care professions who have frequent contact withblood/blood-derived body fluids during routine work

o High risk groups:

End-Stage Renal Disease (ESRD)

Hemophilia

Clients of institutions for the mentally handicapped

Those who live in the same household as a Hepatitis B virus (HBV)carrier

Diabetes

E-5

E-6

Case Study 2: Mr. Henderson

Skilled nursing facilities & Medicare prescription drug coverage under Medicare Part A, Part B, & Part D

Mr. Henderson is at Bright Oaks, a skilled nursing facility (SNF). He may have been exposed to tetanus by a recent injury and was given a tetanus booster shot. He has Original Medicare (Part A and Part B) and a Part D Prescription Drug Plan.

Discussion 1. Which part of Medicare will cover Mr. Henderson’s shot, and why?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Under what circumstances would the shot not be covered?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Resources Medicare Drug Coverage Under Part A, Part B, & Part D (job aid) Skilled Nursing Facility Consolidated Billing & Preventive/Screening Services (article)

E-7

Case Study 2: Mr. Henderson

Discussion points 1. Which part of Medicare will cover the shot, and why?

• Medicare Part A would cover the shot (if Mr. Henderson's SNF stay is coveredby Part A), because in this situation, the tetanus booster shot wasadministered for therapeutic purposes since he was an inpatient.

2. Under what circumstances would the shot not be covered?

• Medicare wouldn’t cover the shot unless Henry met the criteria for coverage,i.e., it was medically necessary. For example, if Henry didn’t have an injury,the shot wouldn’t be considered a treatment, and thus not covered by Part B.

• Medicare Part B would cover the vaccine if Henry’s stay in the SNF wasn’tcovered by Part A. Part B covers certain immunizations as part of Medicare-covered preventive services. If you meet the criteria, Part B covers theinfluenza virus vaccine (flu shot), a pneumococcal shot (to prevent certaintypes of pneumonia), a Hepatitis B shot (for individuals at high or intermediaterisk), and other vaccines (like a tetanus shot) when you get it to treat an injuryor if you’ve been exposed directly to a disease or condition.

• Here are some points to remember about how Medicare Part A and Part Bcover prescription drugs in a SNF.

o You may get drugs as part of your treatment during a covered inpatienthospital or SNF stay. Medicare Part A payments made to hospitals andSNFs generally cover all drugs given during an inpatient stay.

If you don’t have Part A coverage, Medicare Part B can payhospitals and SNFs for certain categories of Part B-covered drugs.If you do have Part A, Part B may pay if the Part A coverage foryour stay has run out, or if your stay isn’t covered by Part A.

Also, when receiving Part A-covered SNF care, the SNF’s bundledper diem payment excludes certain costly and intensivechemotherapy drugs. They’re billed separately under Part B.

E-8

End-Stage Renal Disease & Medicare prescription drug coverage under Part A, Part B, & Part D

Ms. Williams has Original Medicare (Part A and Part B), based on End-Stage Renal Disease (ESRD), which became effective in January 2017. In February 2018 (12 months after her Medicare became effective), she had a kidney transplant at a Medicare-approved facility. She was told that her coverage will end 36 months after her successful transplant. She’ll turn 65 in October 2018 (eight months after her transplant). If Ms. Williams is receiving Social Security or Railroad Retirement benefits, she’ll be automatically enrolled in Medicare due to her turning 65 and will continue with her Medicare Part A and Part B coverage. Also, she’ll have a new Initial Enrollment Period for Part D and an Open Enrollment Period for a Medigap policy. She’s not sure if she needs Part D coverage so she calls you for more information and to discuss her situation.

Discussion 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 thetransplant? Why or why not?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

E-9

Case Study 3: Ms. Williams

2. Which part of Medicare will pay for her immunosuppressive drugs when sheturns 65?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. If 36 months had passed following her successful transplant and she hadn’t turned65 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’tenroll in Part D when she turns 65?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Would her immunosuppressive drugs be covered if her transplant was done inanother country?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Resources Drug Plan Coverage Rules (web page) I Have End-Stage Renal Disease (ESRD) (web page) Medicare & You: End-Stage Renal Disease/Kidney Transplant Eligibility & Enrollment (video) Medicare Coverage of Kidney Dialysis and Kidney Transplant Services (CMS Publication 10128) (booklet) Medicare for People with ESRD (training module)

E-10

Case Study 3: Ms. Williams

Discussion points 1. Were her transplant (immunosuppressive) drugs covered under Part A or

Part B when she was eligible for Medicare due to ESRD at the time of thetransplant? Why or why not?

• Medicare Part A covers her transplant drugs (also called immunosuppressivedrugs) and other drugs during the hospital stay since she was enrolled in Part Aat the time of the transplant. Part B covers self-administered immunosuppressivedrugs outside of the hospital. In both instances, the transplant surgery must havetaken place in a Medicare-approved facility, and she must be enrolled in Part Bduring the immunosuppressive drug therapy.

• If you have ESRD and Original Medicare Part A or Part B, you may join a Part Dplan. If Ms. Williams enrolls in a Part D plan, Part D may coverimmunosuppressive and other drugs not covered by Part B, even if she wasn’tenrolled in Part A at the time of the transplant and the transplant didn’t take placein a Medicare-approved facility.

2. Which part of Medicare will pay for her immunosuppressive drugs when sheturns 65?

• Medicare Part B continues to pay for her self-administered immunosuppressivedrugs with no time limit when she becomes entitled to Medicare because of ageor disability after getting a transplant.

3. If 36 months had passed following her successful transplant and she hadn’tturned 65 yet, would she have Medicare drug coverage through Part A, Part B,or Part D?

• If a person is entitled to Medicare only because of ESRD, Medicare coverageends 36 months after the month of a successful transplant. Medicare won’t payfor any services or items, including immunosuppressive drugs, for patients whoaren’t entitled to Medicare. Therefore, she wouldn’t have Medicare drugcoverage once she was no longer entitled to Medicare. She would need to gether drug coverage through a different source like the Health InsuranceMarketplace, or other coverage. Therefore, she wouldn’t have Medicare drugcoverage once she was no longer entitled to Medicare. She would need to gether drug coverage through a different source like the Health InsuranceMarketplace, or other coverage.

E-11

Case Study 3: Ms. Williams

4. What would happen to the coverage of her immunosuppressive drugs if shedidn’t enroll in Part D when she turns 65?

• Her transplant drugs would be covered because she was enrolled in Part A at thetime of the transplant, the transplant took place in a Medicare-approved facility,and she was still enrolled in Part B at the time the drugs were purchased. As longas she’s enrolled in Part B, she’ll continue to have coverage of herimmunosuppressive transplant drugs.

5. Would her immunosuppressive drugs be covered if her transplant was donein another country?

• Part D would cover her immunosuppressive drugs provided she enrolls in aPart D plan.

Note: Transplant drugs can be very costly. People who are worried about paying for them after Medicare coverage ends are encouraged to talk to their doctor, nurse, or social worker. There may be other ways to help pay for these drugs.

E-12

Case Study 3: Ms. Williams

Case Study 4: Mr. Richards

Medicare coverage & non-emergency transportation

Mr. Richards is 72 and has Medicare Part A and Part B. He’s had type 2 diabetes for many years and now has End-Stage Renal Disease. He must get dialysis 3 times a week. He lives alone, doesn’t drive, is obese, and has to use a wheelchair, but needs help to get from his bed to his wheelchair, all of which makes it difficult for him to find transportation to dialysis.

Discussion 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?

_________________________________________________________________________________________________________________________________________________________________________________________________________

Resources Ambulance Services (Chapter 10, CMS Medicare Benefit Policy Manual) (chapter) Medicare Coverage of Ambulance Services (CMS Publication 11021) (fact sheet)

E-13

Case Study 4: Mr. Richards

Discussion points 1. Will Medicare consider paying for an ambulance to take him to and from

dialysis 3 times a week? If so, what’s the process for getting thetransportation approved?

• Medicare covers medically necessary non-emergency, scheduled, repetitiveambulance services if the ambulance provider or supplier, before furnishing theservice to the person with Medicare, obtains a written order from the person withMedicare’s attending doctor certifying that the medical necessity requirementsare met. Medicare Part B will generally cover up to 80%.

• The doctor’s order must be dated no earlier than 60 days before the date theservice is provided.

• Mr. Richards should contact both the ambulance provider and the doctor as soonas possible to start the approval process.

• If transportation other than an ambulance could be used without endangering theperson’s health, whether or not this transportation is actually available, nopayment may be made for ambulance services.

2. If the transportation request is denied, what resources could be suggested?

• There may be local transportation assistance services that he could use. Localsenior transportation services often have specially equipped vans and personnelto help transport a frail person to and from a medical appointment. You can usethe Eldercare Locator website to find resources, or you can call them toll free at1-800-677-1116. You can also look for transportation assistance at the NationalCouncil on Aging’s BenefitsCheckUp website.

Additional supporting information

• People with Medicare frequently experience denials for non-emergent transportsbecause Medicare regulations require that either the beneficiary be “bed-confined” and that the person’s condition is such that other methods oftransportation are contraindicated, or, if his or her medical condition, regardlessof bed confinement, is such that transportation by an ambulance is medicallyrequired.

E-14

Case Study 4: Mr. Richards

• Medicare regulations consider “bed confinement” to mean that the person with Medicare is

o Unable to get up from bed without assistance;

o Unable to ambulate; and

o Unable to sit in a chair or wheelchair.

• There are also origin and destination requirements. Medicare will typically only cover transports to the nearest appropriate medical facility that can provide the level of care necessary to treat the illness or injury.

• If a person has a Medicare Advantage Plan (Part C), the plan may cover some non-ambulance transportation to dialysis centers and doctors. The person should contact his or her plan for more information.

• In a non-emergency situation, if the ambulance provider believes that the transport may be denied coverage by Medicare, the provider must issue an Advance Beneficiary Notice (ABN) to notify the beneficiary of his or her potential financial responsibility for the transport.

• The only transportation help that Medicare pays for is an ambulance. There are ambulance service demonstrations for people with Medicare in certain states that meet certain criteria but still fall within the current Medicare prior authorization policies for this service. To see if a demonstration is available in your area, visit Medicare Coverage Ambulance Transport.

E-15

E-16

Case Study 5: Bob & Ana

Medicare & Group Health Plans (GHPs)

Bob and Ana are married. Bob, 64, is a retired Marine who’s worked for ABC Company (a large employer with 5,000+ employees) for the past 5 years. He plans to work until full retirement age (66). Ana, 60, works for the federal government and doesn’t say when she’ll retire. Both currently have good, affordable health insurance through Bob’s employer.

Bob and Ana believe they’re getting conflicting information about their health coverage options as they get closer to retirement. At a financial planning seminar, Bob was told he should enroll in Medicare Part A when he’s first eligible, but could delay Part B as a way to save for his retirement. Later he got a note from the U.S. Department of Defense (DOD) indicating that if he doesn’t enroll in Part A and Part B, he and Ana will lose TRICARE. Meanwhile, Ana was told at a Federal Employees Health Benefits (FEHB) Program information fair to consider enrolling in FEHB, as it carries into retirement and doesn’t require enrollment in Medicare Part B upon retiring—and if certain conditions are met, enrolling Bob in the FEHB plan could be an option.

They ask you if the information they’ve received is accurate. They also ask you to help them sort out their options and make decisions about their health insurance.

E-17

Case Study 5: Bob & Ana

Discussion 1. Is the information Bob and Ana received correct? Is it complete?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. What advice would you give them about making decisions about their healthinsurance?

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

Resources How Medicare Works with Other Insurance (web page) The FEHB Program (web page) TRICARE (web page) Your Medicare Coverage Choices (web page)

E-18

Case Study 5: Bob & Ana

Discussion Points 1. Is the information Bob and Ana received correct? Is it complete?

The information the financial planner provided to Bob is correct. While Bob’sactively working and covered by his GHP at ABC Company, he doesn’t need toenroll in Medicare Part B. He does qualify for a Medicare Part B Special EnrollmentPeriod (SEP) while he has GHP coverage, and qualifies for an SEP if he loses hisEHP coverage upon retirement—which isn’t likely, since he works for a largecompany with more than 5,000 employees.

The information the DOD provided to Bob is correct. To be eligible for TRICAREwhen you turn 65, and are eligible for Medicare, you must enroll in Medicare Part Aand Part B to maintain TRICARE coverage.

The information the FEHB fair provided to Ana is correct. FEHB is a GHP thatcarries into retirement if you so choose, and doesn’t require enrollment in Part Bupon retiring from the federal government. To carry FEHB coverage into retirement,Ana generally has to have been continuously enrolled (or covered as a familymember) in any FEHB plan(s) for the 5 years of service immediately before the dateher annuity starts, or for the full period(s) of service since her first opportunity toenroll (if less than 5 years). She also must be eligible for immediate annuity under aretirement system for civilian employees.

Note: The 5-year requirement period can include the time you’re covered under theUniformed Services Health Benefits Program (also known as TRICARE) as long asyou were covered under an FEHB enrollment at the time of your retirement.

2. What advice would you give them about their health insurance options?

Bob and Ana have several options. You can’t make the decision for them, but here’sa possible response:

First, you could point out some of their options and related considerations:

• Keep their current coverage unchanged until Bob retires.

• Keep Ana on Bob’s GHP for now and look into enrolling Ana and Bob into theFEHB program during the open enrollment season the year before Bob plansto retire. If she and Bob enroll in an FEHB plan, he wouldn’t need to enroll inPart B for as long as she’s working and they’re covered by FEHB. He canenroll in Medicare Part B at any time while Ana is working and enrolled inFEHB, or 8 months after the month she retires without a waiting period or

E-19

Case Study 5: Bob & Ana

Part B late enrollment penalty. However, if they don’t enroll in Part B during the prescribed SEP, and want to enroll in Part B at a later time, they would have to wait until the Medicare General Enrollment Period (GEP) from January 1 through March 31, with coverage starting July 1, and may pay a Part B late enrollment penalty.

• Bob could also opt to enroll in Medicare upon retiring and have Medicare andTRICARE and not enroll in the FEHB.

Second, you could explain that there might not be one right answer. To make an informed decision, they’ll probably need to get more information about their options, weigh the pros and cons, and agree on their personal retirement plans and goals. Bob and Ana will likely need to do the following:

• Gather additional information about their current and future health insurancecoverage options.

For example: What kind of coverage does ABC Company offer to retirees andtheir spouses? How might the coverage or the costs change over time? Whichoptions include prescription drug coverage, and would it be considered“creditable”? (This will help them avoid possible Part D late enrollmentpenalties in the future.)

• Understand how Medicare works with other insurance.

For example: How will Medicare work with retiree insurance through a GHP?How will it work with TRICARE?

• Identify how their individual actions now might affect the options available toeach of them upon retirement.

For example: If they decide Ana should enroll in her FEHB at work, and mightwant to continue that coverage into retirement, when should she enroll?

• Discuss their retirement plans and priorities with each other.

For example: Do they plan to travel abroad? If so, which options providecoverage outside the United States? What about other lifestyleconsiderations?

• Determine which option(s) they want to keep open, and which options (if any)they won’t consider.

E-20

Case Study 5: Bob & Ana

For example: If they read the summary plan description of ABC Company’s retiree health insurance and find the coverage is more limited than they thought, this could influence their decision.

• Identify which actions each will need to take, and when, to keep their desiredoption(s) open.

For example: If they want to keep TRICARE coverage for both of them, whenwill Bob need to enroll in Medicare Part B? While TRICARE offers good healthcare coverage, they have good health insurance through Bob’s employer, andenrolling in Part B to keep TRICARE might not be cost effective. Once Bobretires, if he enrolls in Part B, TRICARE will be reinstated.

You might even sketch a simple chart like this one to help them get started:

Options & Considerations for Bob & Ana

Option* Cost Coverage Lifestyle Considerations

Timing (Who needs to

do what, & when?)

ABC Company’s GHP FEHB TRICARE Original Medicare Part A & Part B Medicare Part B only

*These are the basic options, but various combinations of these options are possible.

E-21

E-22

Case Study 6: Mr. Kingly

Health Savings Accounts (HSAs) & Medicare considerations

Mr. Kingly turned 65 and has been receiving Social Security retirement benefits for 9 months. He got his “Welcome to Medicare” packet and new Medicare card in the mail, and he’s been looking forward to having Medicare coverage. He also has an HSA with a high-deductible health insurance plan that he’s been contributing to for many years through an automatic deposit. Mr. Kingly went to file his federal income taxes for 2018 and was very confused when his accountant told him that he could be assessed a 6% penalty for excess contributions to his HSA. His accountant advised him that he was no longer eligible to contribute to his HSA because he now has Medicare, effective 4 months ago. He needs more information about why this happened, so he gives you a call.

Discussion 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?

______________________________________________________________________________________________________________________________________

E-23

Case Study 6: Mr. Kingly

Resources Enrolling in Medicare Part A & Part B (booklet) Medical and Dental Expenses, Including the Health Coverage Tax Credit (IRS publication 502) (booklet) Original Medicare (Part A and B) Eligibility and Enrollment (website) Social Security Benefits Planner: Retirement (website)

E-24

Case Study 6: Mr. Kingly

Discussion points 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?

• Because of IRS rules, Mr. Kingly was no longer eligible to contribute to his HSAonce his Medicare became effective in October. Since he contributed to his HSAonce his Medicare was effective, there may be a 6% IRS penalty on the excesscontributions and any earnings until the funds are withdrawn from the account.For this reason, he should’ve made arrangements to stop his HSA contributionsbefore his Medicare effective date.

• Mr. Kingly generally may withdraw amounts from an HSA after reaching the agefor Medicare eligibility without penalty if those funds are withdrawn prior to thedue date for the current year federal tax return (with extensions). He wouldinclude this amount as income on his federal tax return.

Note: A spouse’s eligibility or enrollment in Medicare won’t impact HSA owners’ability to contribute to their HSA or incur any IRS penalties.

2. What options does Mr. Kingly have concerning his Medicare enrollment, andwhy?

• If Mr. Kingly decided that he wants to keep contributing to his HSA, he does havean option, but it may not be practical. Because he hasn’t been receiving SocialSecurity retirement benefits for a full year, he could request to terminate hisMedicare enrollment. He would have to contact Social Security and ask towithdraw his entire claim for benefits. Before Social Security can withdraw hisclaim, he would have to repay all of the benefits he or his family received fromSocial Security and Medicare. (Those receiving Railroad Retirement Board [RRB]and/or Veterans benefits should check with the RRB and the Department ofVeterans Affairs separately about how a withdrawal affects those benefits.) He’slimited to one withdrawal of claims per lifetime.

The cost of repaying his Social Security and Medicare benefits may be muchgreater than the IRS penalty he’s being assessed for contributing to his HSAwhile he had Medicare. He should speak to a financial advisor about his situationbefore making a decision.

E-25

E-26

Case Study 7: Mr. Rutter

Considerations for people with low income who qualify for Medicare & Medicaid

Mr. Rutter has had coverage under his state’s Medicaid Program for many years. He’s turning 65 in a few months and knows he’ll need to enroll in Medicare, but he’s unsure what he should do or how his coverage will change.

Discussion 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 theproviders he currently sees?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. What other programs are available to help Mr. Rutter with his out-of-pocket healthand drug costs, considering his low income?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

E-27

Case Study 7: Mr. Rutter

3. Since Mr. Rutter will be a Medicare-Medicaid enrollee, how will the billing work nowthat he’ll have coverage under both programs?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Resources Limited Income & Resources (web page) Low Income Subsidy for Medicare Prescription Drug Coverage (web page) Medicare Part D Extra Help (Low Income Subsidy or LIS)—Section HI 03001.005d in Social Security Program Operations Manual (section of manual) Medicare Savings Program (web page) Seniors & Medicare and Medicaid Enrollees (web page) What to Do If You No Longer Automatically Qualify for Extra Help with Medicare Prescription Drug Costs (Medicare publication 11215) (fact sheet)

E-28

Case Study 7: Mr. Rutter

Discussion points 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 touse the providers he currently sees?

• Once Mr. Rutter enrolls in Original Medicare Part A (Hospital Insurance) and PartB (Medical Insurance) and his coverage becomes effective, he’ll continue to haveaccess to the same Medicaid providers that he’s used and all of his state’sMedicaid plan services, provided that he continues to be eligible for his state’sMedicaid Program. He’ll also be able to use providers that accept Medicare. Insome cases, his Medicaid providers may also be Medicare providers. He shouldcontinue to ask his providers if they accept Medicaid and/or Medicare. He cancall 1-800-MEDICARE for information about Medicare providers in his area. Tofind Medicaid providers in his area, he should call his state’s Medicaid office.

• The options for Mr. Rutter to receive Medicare and Medicaid benefits vary bystate. In some states, Mr. Rutter would receive Medicaid through Medicaidmanaged care plans, and in other states, Medicaid coverage may be provided ona fee-for-service basis. In some states, Mr. Rutter may be able to join plans thatinclude all Medicare and Medicaid benefits.

• Mr. Rutter will also need to consider whether or not he needs to enroll in aMedicare Prescription Drug (Part D) Plan.

2. What other programs are available to help Mr. Rutter with his out-of-pockethealth and drug costs, considering his low income?

• Depending on his income, Mr. Rutter may be eligible for his state’s MSPs, whichpay a person’s Medicare premiums, copayments, and coinsurance at differentlevels depending on how their income and resources fall into set categories ofneed. MSPs also eliminate the Medicare Part D coverage gap, reduce out-of-pocket costs, and provide additional flexibilities to change enrollment in Medicarehealth and drug plans.

o Federal law defines income and resource standards for full Medicaid andthe MSPs, but states have discretion to raise those limits above the federalfloor.

• If Mr. Rutter meets certain income and resource limits, he may qualify for ExtraHelp, also called the Low Income Subsidy (LIS), from Medicare to pay the costsof Medicare prescription drug coverage.

E-29

Case Study 7: Mr. Rutter

o In 2018, Mr. Rutter may qualify if he has up to $18,210 in yearly income($24,690 for a married couple) and up to $14,100 in resources ($28,150 fora married couple).

o With full Extra Help, prescription drug costs in 2018 are no more than $3.35for each generic/$8.35 for each brand-name covered drug. (Based on theirincome level, some people pay only a portion of their Medicare drug planpremiums and deductibles.)

o Mr. Rutter has full Medicaid coverage, but then could also automaticallyqualify if he has Medicare and meets any of these conditions:

Has full Medicaid coverage;

Gets help from his state Medicaid Program paying his Part Bpremiums (in an MSP); and/or

Gets Supplemental Security Income (SSI) benefits.

If he loses his eligibility for Medicaid and no longer automatically qualifies, he could apply for Extra Help. If Mr. Rutter thinks he qualifies but isn’t sure, he should still apply. Mr. Rutter can apply for Extra Help at any time, and if he’s denied, he can reapply if his circumstances change.

o He can apply for Extra Help by:

Applying through Social Security online at Extra Help with MedicarePrescription Drug Plan Costs;

Completing a paper application he can get by calling Social Securityat 1-800-772-1213. TTY: 1-800-325-0778;

Applying through his state’s Medicaid agency; and/or

Working with a local organization, like a State Health InsuranceAssistance Program (SHIP).

Note: If you apply for Extra Help, Social Security will transmit the data from your application to your state Medicaid agency to also initiate an application for MSP, which can help you pay for your Medicare premiums. You can opt out if you don’t want your application sent.

E-30

Case Study 7: Mr. Rutter

o Mr. Rutter can apply on his own behalf, or someone with the authority toact on his behalf can file his application (like a person acting through amedical Power of Attorney). He can ask someone else to help him apply.

3. Since Mr. Rutter will be a Medicare-Medicaid enrollee, how will the billing work now that he’ll have coverage under both programs?

• As a Medicare-Medicaid enrollee, Mr. Rutter will receive full Medicaid benefits and may also qualify for Medicaid assistance with Medicare premiums or cost sharing. Mr. Rutter must meet certain income and resource requirements to be eligible for either full Medicaid or any level of the MSPs.

If Mr. Rutter is eligible for help in his state’s MSPs at the Qualified Medicare Beneficiary (QMB) level, he’ll have special protection under federal law to prevent providers from billing him for Medicare cost-sharing. To the extent consistent with the Medicaid state plan, QMBs may need to pay a nominal Medicaid copayment in certain circumstances (like prescription drugs) even if payment isn’t available under the state plan for these charges; QMBs aren’t liable for balanced billing.

• Mr. Rutter may choose coverage under Original Medicare or a Medicare Advantage Plan, if one is available in his area. Medicare-covered services are paid first by Medicare because Medicaid is always the payer of last resort. Medicaid may cover the cost of prescription drugs and other care that Medicare may not cover or may partially cover (such as nursing home care, personal care, and home- and community-based services).

E-31

Note: Federal regulations allow states discretion on how they implement Medicaid programs.

E-32

Case Study 8: Mr. James

Hospital observation status, skilled nursing facility care, & notification requirements

Mr. James has Original Medicare (Part A and Part B). Recently, he went to the emergency room at his local hospital for severe back spasms. The doctor monitored Mr. James overnight and recommended physical therapy (PT) to help him regain function. Because of Mr. James’ weakened state, the doctor recommended he go to a skilled nursing facility (SNF) that day for PT. Mr. James received a week of inpatient PT at the SNF and was discharged home.

Since Mr. James didn’t read all the paperwork he received from Medicare and the hospital, he was surprised to receive a bill from the SNF indicating he didn’t meet Medicare Part A requirements for coverage. He thought he understood that Medicare pays 100% for the first 20 days of SNF care. Since he only received 7 days of SNF care, he thought it would be covered.

He also received a bill indicating he’s responsible for a coinsurance related to the doctors’ services and tests associated with this hospital visit.

Discussion 1. Are these charges correct? Why or why not?

_________________________________________________________________________________________________________________________________________________________________________________________________________

E-33

Case Study 8: Mr. James

2. What are the notification requirements that the hospital and SNF should provide toMr. James advising him how Medicare will or won’t pay for his hospital/doctorservices, SNF stay, and PT?

_________________________________________________________________________________________________________________________________________________________________________________________________________

Resources Are You a Hospital Inpatient or Outpatient? If you have Medicare–Ask! (CMS Publication 11435) (fact sheet) Inpatient or outpatient hospital status affects your costs (web page) Beneficiary Notices Initiative (BNI) (web page) Advance Beneficiary Notice of Noncoverage (web page) Fee For Service SNF Advance Beneficiary Notice of Non-coverage (Form CMS-100-55) (web page with link to form)Fee For Service Advance Beneficiary Notice of Non-coverage (Form CMS-R-131)(web page with link to form)

E-34

Case Study 8: Mr. James

Discussion points 1. Are these charges correct? Why or why not?

• Yes, the charges are correct. Mr. James was at the hospital for an emergencyvisit and was never admitted as an inpatient while there. He would’ve beenconsidered an inpatient if the doctor had formally admitted him to the hospital. Aninpatient admission would’ve been appropriate if Mr. James had been expectedto need 2 or more midnights of medically necessary hospital care and his doctorformally admitted him.

The 2-Midnight Rule states that:

o Inpatient admissions will generally be payable under Medicare Part A if theadmitting practitioner expected the patient to require a hospital stay thatcrossed 2 midnights, and the medical record supports that reasonableexpectation.

o Medicare Part A payment is generally not appropriate for hospital stays notexpected to span at least 2 midnights.

• Mr. James received outpatient observation services because he wasn’t formallyadmitted to the hospital as an inpatient. Observation services are hospitaloutpatient services given to a patient to help the doctor decide if the patientneeds to be admitted as an inpatient or can be discharged. This time can’t becounted toward the 3 consecutive-day inpatient hospital stay (also referred to asthe 3-day inpatient qualifying stay) requirement needed for Medicare Part A tocover a SNF stay. Observation services may be given in the emergencydepartment or another area of the hospital.

• Medicare doesn’t cover SNF care unless all these conditions are met:

o Patient has Part A and has days left in his or her benefit period.

o Patient has a qualifying hospital stay.

o Doctor decides the patient needs daily skilled care given by, or under thedirect supervision of, skilled nursing or therapy staff. (If in the SNF forskilled rehabilitation services only, care is considered daily care even ifthese therapy services are offered just 5 or 6 days a week, as long astherapy services are needed and received each day they’re offered.)

E-35

Case Study 8: Mr. James

o Patient gets these skilled services in a SNF that’s certified by Medicare tohelp improve, maintain, or prevent his or her condition from getting worse.

o Patient needs these skilled services for a medical condition that was either:

A hospital-related medical condition, or

A condition that started while getting care in the SNF for a hospital-related medical condition.

2. What are the notification requirements that the hospital and SNF shouldprovide to Mr. James advising him how Medicare will or won’t pay for hishospital/doctor services, SNF stay, and PT?

• Hospitals are required to give Mr. James a Medicare Outpatient ObservationNotice (MOON). The MOON is a standardized notice to inform him that he’s anoutpatient receiving observation services and isn’t an inpatient of a hospital orCritical Access Hospital. He must get this notice if he’s getting outpatientobservation services for at least 24 hours. The MOON document must bedelivered any time up to, but no later than, 36 hours after observation servicesbegin.

o The MOON will tell Mr. James why he’s an outpatient getting observationservices, instead of an inpatient. It will also let him know how this mayaffect what he pays while in the hospital, and what he pays for care he getsafter leaving the hospital.

o The MOON is mandated by the federal Notice of Observation Treatmentand Implication for Care Eligibility Act (NOTICE Act), passed on August 6,2015. The NOTICE Act requires all hospitals and Critical Access Hospitalsto provide written and oral notification under specified guidelines.

• Medicare Part B will pay for the doctors’ services, but Mr. James is responsiblefor any Medicare Part B deductibles and copayments for the outpatient care hereceived.

• Mr. James didn’t meet the qualifying 3-day hospital stay and therefore, doesn’tmeet the requirement of the SNF benefit. The hospital and the SNF may alsogive Mr. James a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN), Form CMS-10055, advising him that Medicare Part Awon’t pay for his SNF stay. Although the SNF isn’t required to give a SNF ABN totransfer financial liability to Mr. James, Medicare recommends giving Mr. Jamesa SNF ABN to inform him of his potential liability.

E-36

Case Study 8: Mr. James

• People with Original Medicare may get a written notice called an ABN (FormCMS-R-131) from a doctor, other health care provider, or supplier if both of theseapply:

o They have Original Medicare.

o Their doctor, other health care provider, or supplier thinks Medicareprobably (or certainly) won’t pay for the items or services they got.

The ABN lists:

The items or services Medicare isn’t expected to cover. As anexample, if Mr. James’ treatment plan included TranscutaneousElectrical Nerve Stimulation (TENS) for lower chronic back pain(which isn’t covered, as a National Coverage Decision determined),an MSN would work as notification that subsequent items or serviceswould also be denied by Medicare for similar conditions in the future.

An estimate of the costs for the items and services.

E-37

The reasons why Medicare may not pay.

The SNF must use ABN Form CMS-R-131 to transfer potential financial liability to Mr. James for items or services expected to be denied under Medicare Part B only. For example, if Mr. James is getting care during a non-covered SNF stay (i.e., doesn’t require skilled services), and during the stay decides he’d like PT 3 times a week to remain active, this could be considered a non-covered Part B service in a SNF because it may not be medically necessary for Mr. James and wasn’t ordered by a provider.

E-38

Case Study 9: Ms. Zhang

Income-related monthly adjustment amount (IRMAA) appeals & penalties

Ms. Zhang recently turned 65 and enrolled in Original Medicare (Part A and Part B) and a Medicare Prescription Drug (Part D) Plan. She’s still working at an advertising agency and has decided to delay receiving Social Security retirement for a few years. When she was 64, she got divorced and changed from filing a joint federal tax return to filing as an individual. Her modified adjusted gross income (MAGI) was $75,000 in 2017. At 63, when she was still married, the MAGI listed on her joint federal tax return was $250,000. Based on a meeting with a financial advisor, her income is projected to remain at about $75,000 per year for the next few years. She recently received an “Initial IRMAA Determination Notice” for 2018 from the Social Security Administration (SSA). The letter stated that her Part B monthly premium is $267.90, and she’ll pay an additional $33.60 for her Part D monthly premium because of her high income.

Discussion 1. Based on the scenario, what would you tell Ms. Zhang about the IRMAA information

in her Initial IRMAA Determination Notice?

_________________________________________________________________________________________________________________________________________________________________________________________________________

E-39

Case Study 9: Ms. Zhang

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 isreviewed? What would happen if she doesn’t pay the IRMAA?

_________________________________________________________________________________________________________________________________________________________________________________________________________

Resources 2018 Medicare Amounts (job aid) 2018 Medicare Parts A & B Premiums and Deductibles (fact sheet) Understanding the “Medicare Premium Bill” Form (CMS-500), Pub 11659 (brochure) HI 01101.035 Initial IRMAA Determination Notices (Social Security Program Operations Systems Manual) HI 01101.050 Beneficiary Questions an IRMAA Determination or Decision (Social Security Program Operations Systems Manual) HI 01120.005 Life Changing Events (Social Security Program Operations Systems Manual) HI 01140.005 The Reconsideration Process for the Income-Related Monthly Adjustment Amount (Social Security Program Operations Systems Manual) HI 03001.001 Description of the Medicare Part D Prescription Drug Program (Social Security Program Operations Systems Manual), see Sections G–CMS’ Part D responsibilities & H.2–Payment options Initial IRMAA Determination (web page) Monthly premium for drug plans (web page) Medicare Easy Pay (web page) Medicare Premium Bill (CMS-500) (web page) Part B costs (web page)

E-40

Case Study 9: Ms. Zhang

Discussion points 1. Based on the scenario, what would you tell Ms. Zhang about the IRMAA

information in her Initial IRMAA Determination Notice?

• The 2018 IRMAA amounts for Part B and Part D are based on her 2016 federaltax return. SSA uses MAGI from income reported to the IRS from 2 years prior.Her income has changed since 2016 to a level that doesn’t require her to payhigher premiums.

• The Initial IRMAA Determination Notice includes information about her appealrights.

• The charts below summarize how Social Security determines the IRMAAamount.

Part B premium in 2018 based on your 2016 tax return:

File individual tax return File joint tax return File married and

separate tax return You pay

$85,000 or less $170,000 or less $85,000 or less $134.00 above $85,000 up to $107,000

above $170,000 up to $214,000

Not applicable $187.50

above $107,000 up to $133,500

above $214,000 up to $267,000

Not applicable $267.90

above $133,500 up to $160,000

above $267,000 up to $320,000

Not applicable $348.30

above $160,000 above $320,000 above $85,000 $428.60

Part D premium in 2018 based on your 2016 tax return:

File individual tax return

File joint tax return

File married and separate

tax return

You pay Income‐related monthly adjustment amount + your plan

premium (YPP) $85,000 or less $170,000 or less $85,000 or less $0.00 + YPP above $85,000 up to $107,000

above $170,000 up to $214,000

Not applicable $13.00 + YPP

above $107,000 up to $133,500

above $214,000 up to $267,000

Not applicable $33.60 + YPP

above $133,500 up to $160,000

above $267,000 up to $320,000

Not applicable $54.20 + YPP

E-41

Case Study 9: Ms. Zhang

File individual tax return

File joint tax return

File married and separate

tax return

You pay Income‐related monthly adjustment amount + your plan

premium (YPP) above $160,000 above $320,000 above $85,000 $74.80 + YPP

Note: In 2019, the IRMAA amounts change. There will be an additional tier that requires IRMAA payments. The 2019 IRMAA information will be posted as part of the Medicare Amounts Job Aid when 2019 amounts are available.

2. Can she request a new initial determination? If so, how would she do it?

• Yes, Ms. Zhang can file a request for a new initial determination. In this scenario,because her income has changed since she filed her joint 2016 federal taxreturn, she can file a request for a new initial determination. She needs to fill out

Form SSA-44. She can mail the completed form to Social Security, or schedulean interview with her local Social Security office by calling 1-800-772-1213. TTYusers can call 1-800-325-0778. Form SSA-44 provides detailed instructionsabout what’s needed to accurately file the request.

• The type of information she needs to provide for the appeal includes:

o Date and type of life changing event (LCE)

o Details of the reduction of income in the tax year her income was reducedby the LCE:

Adjusted gross income

Tax-exempt interest

Tax filing status for the tax year provided

Details of the change in MAGI

Tax year

o Documentation of her MAGI and the LCE

A signed copy of her filed federal tax return or a signed copy of anamended federal income tax return. She can provide an estimate ofher MAGI. However, SSA will ask her to provide a signed copy of herfederal tax return when she files her taxes.

E-42

Case Study 9: Ms. Zhang

Since Ms. Zhang is now divorced, she’d need a certified copy of thedivorce decree. In some cases, SSA may be able to accept anothertype of evidence if she doesn’t have the certified copy of the divorcedecree. She’ll need to ask a Social Security representative to explainwhat documents can be accepted.

3. How do people submit payment for IRMAA?

Part B and Part D IRMAA are separate amounts but have similar payment options.

• Automatic Deduction from Benefit Payments: If a person with Medicare isreceiving monthly Social Security or Railroad Retirement Board (RRB) benefitpayments, the Part B and Part D premiums and any IRMAA amounts, and LateEnrollment Penalties (LEPs), if applicable, would automatically be deducted fromthe monthly payment, provided the person receives enough to cover the paymentamounts. The person would still have the option to pay the Part D plan monthlypremium separately, if he or she chooses.

o Direct Bill: If a person with Medicare doesn’t get a monthly Social Securityor RRB payment (like Ms. Zhang), or if the amount of the payment doesn’tcover the amount of the premium, the person will receive a MedicarePremium Bill (Medicare Form-CMS 500). The Part B premium (including B-IRMAA) is direct billed quarterly. Since Ms. Zhang also has to pay Part DIRMAA, she’ll be billed for her Part B premium, and Part B and Part DIRMAA, on the same direct bill.

If her bank offers an online bill payment service, she can use it to payher Medicare premiums electronically. She can also pay by check,money order, or credit card.

• She can also sign up for Medicare Easy Pay (MEP). MEP is a free, electronicpayment option that allows her to have her Medicare premium paymentsautomatically deducted from a savings or checking account each month. Theinformation about these payment options can be found on the Medicare PremiumBill or can be reviewed at Medicare.gov.

E-43

Case Study 9: Ms. Zhang

4. Should Ms. Zhang pay her IRMAA while her new initial determination requestis reviewed? What would happen if she doesn’t pay the IRMAA?

• Ms. Zhang should continue to pay the amount calculated in the Initial IRMAADetermination Notice, even though she disagrees with the amount. Ms. Zhang isrequired by law to pay any IRMAA amount(s) to keep her Medicare Part B and/orPart D coverage. If she fails to pay any applicable Medicare IRMAA, she may bedisenrolled from Medicare Part B and/or Part D (as applicable) and lose herhealth insurance coverage. She would have to wait until her next availableenrollment period to re-enroll in Part B and/or Part D, and she may be subject toa monthly LEP.

• If Social Security determines that her IRMAA should be reduced or eliminated,any IRMAA she pays while waiting for her appeal won’t be reimbursed directly toher. The overpayments of IRMAA will be applied to her future bills: first to Part B,then to any applicable Part A premium, and finally Part D IRMAA.

E-44

Appendix F CMS National Training

Program Resources

F-1

CMS National Training Program Resources

The Centers for Medicare & Medicaid Services (CMS) National Training Program (NTP) develops materials and leads training opportunities to help people make informed health care decisions. We also provide resources, PowerPoints, and job aids that can be used to educate others.

See the CMS NTP website to access all of our materials and educational opportunities that will help you better understand and educate others about Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Federally-facilitated Health Insurance Marketplace.