Medicare’s Coverage Process Gets the Spotlight


“Obamacare” has stimulated a revolution throughout the health insurance industry, including Medicare.

One of the greatest issues with medical care today is the irregularities in insurance coverage. The Affordable Care Act, also known as “Obamacare”, was signed into law in hopes of not only expanding access to medical coverage for the uninsured but also to address many of the coverage issues that the insured were experiencing. Even people covered by Medicare often found themselves unsure what procedures and prescriptions would be covered and to what extent.

Traditionally, Medicare managers have been the ones responsible for deciding what gets covered, often leaving patients, doctors, and even other insurers puzzled about their decision-making process and unable to explain the lack of coverage for particular medical treatments.

The Centers for Medicare & Medicaid Services (CMS) have decided that the national coverage determination (NCD) system needs to be the focus of a routine paperwork review. This will give them an opportunity to reveal the processes they use to collect information and, based on that information, make their determinations regarding healthcare coverage. The review will not cover any actual governing standards, but it will illustrate the operation of the determination system, covering both electronic and paper forms, as well as other information-handling methods.

What is the Medicare Coverage Determination Process?

Generally, Medicare coverage is limited to only those medical services and specific items that are determined to be necessary for the proper diagnosis and treatment of a particular illness or injury. These medical services also have to be included within the scope of one of Medicare’s benefit categories.

When a new proposed medical service is put forward for coverage, an evidence-based review process begins. This is a process that not only reviews the evidence for and against coverage but also allows for the public to have an opportunity to participate. Members of the public can now submit their comments and suggestions about the Medicare program, suggesting ways for CMS to make the review and determination system less expensive and easier to use. The public also frequently suggests ways for CMS to better administrate Medicare and the determination system.

Sometimes these suggestions are very general, while other times they relate to a specific coverage issue with which CMS is being faced.While the reviews only occur every three years, an annual report is always issued which lists any NCD that was made during the previous year. It also includes ways for people to obtain more information about the determinations that have been made.

How Does the CMS Determination Process Work?

According to CMS, around 200 requests are made for national coverage determination decisions every year. But what exactly is this process? The best way to look at the step-by-step of a coverage determination process is to follow proposed coverage through.

Recently, a national coverage analysis was conducted by Medicare program managers addressing the possible coverage of gender reassignment surgery. The formal request for a review to consider coverage for gender reassignment surgery was forwarded to the Medicare coverage determination team in December of 2015. Over the course of the next month, the determination team collected 106 comments made by the public, including comments favoring the establishment of a national standard. There were also some complaints from consumers, mostly anonymous, who believed that the money Medicare was allotted could be spent on services that they believed were more important. The draft memo collected another 38 comments.

Currently, the paperwork review notice has been published in the Federal Register, and the public may continue to comment on the national coverage determination system information collection processes until September 13, 2016.

Updates to the National Coverage Determinations Process

CMS addressed the need for more clarity and transparency in the coverage process in 2013 as it updated the process for making NCDs. CMS addressed some topics including the procedures that are followed to request an NCD; what constitutes a formal request for an NCD; and an outline of the protocols for public participation in the national coverage determination process.

Of particular note is the attention paid to expediting the administrative process by which CMS determines which NCDs are no longer needed. This enables the Medicare contractors to more quickly and effectively determine Medicare coverage as technology and clinical science continues to advance, bringing new treatments and medications. CMS reviews the inventory of NCDs every three years, paying close attention to any NCDs that are 10 years or older and reviewing whether they need to be maintained or discontinued.


The process of promoting national coverage of a treatment or procedure begins with a review.


There have been a great many changes to the health insurance industry in recent years, all designed to increase the effectiveness of the industry’s coverage of medical services. The Affordable Care Act was an added impetus for this, pushing insurance companies to refine their coverage assessments as they strive to keep up with technological advancements and new treatments. Government health insurance, namely Medicare, is also trying to refine its coverage process and is paying closer attention to the functionality and transparency of the entire process.

For many people utilizing Medicare, whether as a supplement or as their primary health care coverage, the way that treatments and procedures are covered is often a mystery. Medicare managers are most often the people in charge of deciding who gets treatment for what and what treatments are covered, in whole or in part, by Medicare. For the average person, understanding this process has become more and more important.

Now, as Medicare shines the spotlight on the inner workings of how coverage issues are decided and becomes even more open to input through comments and complaints, the general public is getting the opportunity to start a dialogue about the medical issues they care about. As new possible treatments and services come into being, brought about by medical research and technology, CMS will continue its review process, isolating new possible treatments and procedures that could be covered on a national basis.

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