Supplemental Benefits Extending Original Medicare Benefits

30.2 – Supplemental Benefits Extending Original Medicare Benefits (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) In designing supplemental benefits that extend original Medicare benefits, MA plans should consider: • Medical Necessity: An MA plan may offer coverage of a supplemental benefit only if it is medically necessary and additional to the benefit covered by original Medicare. For example, an MA plan may offer additional inpatient hospital days as a supplemental benefit. An MA plan may not offer home health coverage or home health services beyond that covered by original Medicare, if the Home Health Agency Manual has classified those additional services as not covered by original Medicare because they are not considered medically necessary. The Home Health Agency Manual is located in chapter 7 of the Medicare Benefit Policy manual, located at: http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c07.pdf, publication 100-02. (All original Medicare manuals may be found in the Internet-only and paper-based manual links located at http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.) • Distinct Naming: An MA plan must be careful in the selection of terminology describing a supplemental benefit that furnishes coverage beyond that of original Medicare. The terminology should make clear what the supplemental benefit is. An MA plan offering a supplemental benefit for which there is no specified service category in the PBP must use CMS-specified terminology, if available. • Prohibition of Benefits for Non-enrollees: An MA plan may not offer as a benefit services furnished to a person other than the enrollee (unless original Medicare specifically allows such services, e.g., original Medicare coverage of a living donor for medical complications arising from a kidney transplant). Similarly, other than the original Medicare respite benefit, an MA plan may not offer other types of caregiver support as a supplemental benefit. However, an MA plan may, and is even encouraged, to include information about services available in the community to assist caregivers in obtaining relief so long as the MA plan does not refer to those services as plan benefits. Such information may be included in newsletters or other communications to enrollees, for example. For information on the original Medicare respite benefit see publication 100-02, the Medicare Benefit Policy Manual, chapter 9. • Benefit Naming Conventions: An MA plan should not single out specific aspects of the benefit, in its marketing materials and PBP descriptions of original Medicare benefits. For example: o An MA plan may state that it offers “ESRD services;” however, it need not further mention that “living donor expenses” are covered because “ESRD services” specifically includes “living donor expenses.” It would be misleading, from a marketing perspective, to single out only one aspect of the benefit. o While an MA plan must offer “Occupational Therapy,” it should not single out any particular aspect of this coverage in its marketing materials, such as massage therapy, or indicate that it offers “massage therapy” as a benefit. Similarly, although an MA plan may offer “chiropractic visits” as a benefit, the description of the benefit should not include the word “massage,” even though the chiropractor may use massage during the visit. Examples of benefits meeting these standards that are eligible for MA plans to offer as supplemental benefits include: • Additional days or sessions of certain original Medicare covered services such as inpatient days, sessions of smoking and tobacco cessation counseling, cardiac rehabilitation, pulmonary rehabilitation. • Expansion of coverage to allow enrollees to receive benefits for which they do not qualify under original Medicare such as medical nutrition therapy for enrollees that do not meet original Medicare coverage criteria and transportation services for non- emergency purposes. Table III: Medicare Covered Benefits with Related Supplemental Benefit Fields in the PBP Medicare Covered Benefits Benefits Eligible to be offered as a Supplemental Benefits Inpatient Hospital-Acute Additional Days Non-Medicare covered stays Upgrades Inpatient Hospital-Psych Additional Days Non-Medicare covered stays Skilled Nursing Facility Additional Days Emergency Care Worldwide Emergency/Urgent Coverage Chiropractor Routine Care/Other* Podiatry Routine Care Outpatient Blood Waiver of 3 pint deductible Medicare Part B Rx & Home Infusion Drugs Home Infusion Bundled Services $0 Cost-sharing Preventive Services Additional Smoking and Tobacco Use Cessation Counseling Comprehensive Dental Services Routine services, diagnostic services, restorative, endodontic/periodontal/extractive, prosthodontics, Other oral/maxillofacial surgery, other services Eye Exams Routine eye exams/Other* Eye Wear Contact lenses, eye glasses, lenses, frames, upgrades Non-routine Hearing Exams Routine hearing exams, fitting/evaluation for hearing aids *“Other” refers to any Non-Medicare covered service Table III identifies the Medicare-covered and other benefits for which supplemental benefits are coded into the PBP as options. Other supplemental benefits to extend original Medicare coverage may be entered in the PBP “Other Supplemental Benefit” fields. CMS will review these benefits during bid review.