Description

Medicare is the federal health insurance plan for those 65 and over, younger people with certain disabilities, and for individuals with renal failure. In order to effectively use the plan, the treatments and procedures ordered by a physician must be covered under the scope of Medicare’s benefits. Coverage of Medicare is bound to treatments and procedures that are reasonable and required for the diagnoses or treatment of ailments, injuries or diseases.

The Medicare coverage determination process uses national coverage determinations - NCDs - that are made through an evidence-based process, with opportunities for public participation. The criteria for establishing NCDs are forever changing, with the most recent modifications made by CMS in the Medicare Modernization Act. If there is no national coverage policy, an item or procedure (service) may be covered at the “discretion of the Medicare contractors” on a local coverage determination - LCD. (CMS.gov). The U.S. Centers for Medicare & Medicaid Services, which governs the process, offers a wide range of educational resources to make sure health care practitioners understand Medicare coverage. (American Optometric Association)


Applications

Clinicians must communicate with their patients over what processes &medications are covered under Medicare. Medicare is the primary insurance for most individuals over 65, and the guidelines of who it can cover and what it covers change frequently. Administrative review may be needed to determine Medicare Coverage under the SS Act. It is often a long and arduous process that can be reduced & improved with the ongoing implementation of new HIT technology.

CMS recently made some provisions to make the coverage process faster, and more uniform. The CMS “implemented draft Coverage with Evidence Development (CED)” guidance to make sure that Medicare “beneficiaries” have access to new emerging technologies through “expanded coverage criteria”, while gathering data that can be useful to the physicians who treat them. (Straube, B. M.) CMS continues to improve the process by making it a priority to improve the evidence used for better care and simplification.


Resources

Medicare Coverage Determination Process
Medicare Coverage Database
Medicare Coverage Center
Section 1861 of The Act
Medicare NCDs Revised


Terminology

Medicare Advantage Plan
National Coverage Determination
Local Coverage Determination
Claim



Citations/references:
Medicare Coverage Determination Process. (n.d.). Retrieved October 28, 2014.

American Optometric Association, Medicare coverage, Optometry - Journal of the American Optometric Association, Volume 81, Issue 12, December 2010, Pages 702-705, ISSN 1529-1839, http://dx.doi.org/10.1016/j.optm.2010.10.008.
(http://www.sciencedirect.com/science/article/pii/S1529183910005464)

Straube, B. M. (2005). How changes in the medicare coverage process have facilitated the spread of new technologies. Health Affairs, 24, W5-314-W5-316. Retrieved from http://search.proquest.com/docview/204640527?accountid=4840

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