The Medicare Modernization Act of 2003 required the Secretary of Health and Human Services to make the national coverage determination (NCD) process a public and transparent process, with the intent of making the NCD process one that would be better serve Medicare providers and beneficiaries. On April 11, 2006, CMS issued two documents related to “Guidance for The Public, Industry and CMS Staff,” i.e.:
1.Factors CMS Considers In Opening A National Coverage Determination, and
2.Factors CMS Considers In Commissioning External Technology Assessments.
Both articles are available on the CMS Web site.
National coverage determinations, i.e., NCDs, are just what the name implies; they are decisions made by CMS controlling the coverage of benefits and services that might be available to Medicare beneficiaries on a national scope. These new releases define the NCD processes as a three step process, i.e., initiation, review and completion. NCDs can be requested by external parties (e.g., manufacturers, providers, health plans, professional associations, etc.), aggrieved parties (individuals who have been denied benefits), and internally by CMS. When CMS opens an NCD, a tracking sheet is posted on the CMS website so that the public can follow the NCD process. Federal rules require the completion of the NCD process within 6 months after a formal request.
Technology assessments (TAs) are an adjunct process to the NCD, and can add 3 months to the available time period.
Coverage determinations can also be made by local or regional Medicare contractors. These decisions are now referred to as local coverage determinations (LCDs). The LCD process was mandated by the Benefit Improvement Protection Act of 2000, which required all Medicare contractors to convert local medical review policies (LMRPs) into LCDs. By way of example, HGSAdminstrators (HGSA) issues the LCDs for partly Medicare providers in Pennsylvania. Those LCDs are posted on the HGSA website at www.hgsa.com/professional/lcd. HGSA issues ongoing revisions to those LCDs. By way of further example, the April 17, 2006 posting to the HGSA Web site indicates that five LCDs have been revised effective April 17, 2006:
*M-52E-external counter pulsation (ECP)
*S-13C-intradiscal electro thermal therapy (IDET)
*Y-1AA-physical therapy and rehabilitation services
*Y-2P-occupational therapy services
Those policies can be accessed on the Web site.