CMS Pub. 100-16, ch. 4, § 30.2

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.