Press Releases

CMS UPDATES AND IMPROVES ITS MEDICARE COVERAGE DECISION PROCESS

The Centers for Medicare & Medicaid Services (CMS) today announced an updated and improved process for making Medicare coverage decisions to ensure the highest quality of care for beneficiaries of the program of health care for the elderly and disabled.

"As we strive for continuous improvement, we are revising our procedures for developing a National Coverage Determination to be more efficient and to ensure that we have access to all relevant information to make fully informed decisions," CMS Administrator Tom Scully said.

"Our goal is to make the latest advances in medical care available to Medicare beneficiaries more rapidly, while making evidence-based decisions that safeguard the health and safety of patients," Scully said.

A notice to be published in the Federal Register on Friday, September 26, 2003 incorporates lessons learned over the past three years and implements certain requirements of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection act of 2000 (BIPA). The notice went on display today at the Office of the Federal Register. It replaces an April 27, 1999 notice and will be effective on October 27, 2003.

The notice outlines the process CMS will use to make an NCD under the Medicare program. It establishes the steps CMS is taking to be more efficient, while maintaining an open and transparent process.

Some of the improvements included in this notice are:

• Establishing a separate process, with more rigid time frames, for beneficiaries who qualify as aggrieved parties under section 522 of BIPA,
• Revising, formalizing, and updating the elements that constitute a complete, formal request to reflect best practices,
• Updating and clarifying the conditions for acceptance of a complete, formal request, and
• Making it clear that all evidence currently available must be adequate for us to conclude that the item or service is reasonable and necessary.

In addition, CMS will continue to pursue an ongoing effort to work with various sectors of the scientific and medical community to develop and publish on the CMS web site documents that describe the agency's approach when analyzing scientific and clinical evidence to develop an NCD. Interested parties will be able to offer comments. Making these documents available will make the coverage process more open and offer the public a better understanding.

These improvements add to Health and Human Services Secretary Tommy G. Thompson's initiative to improve the quality of care provided Medicare's 41 million beneficiaries. Already, CMS has introduced initiatives to assure higher quality of care in hospitals and nursing homes, and released research published in the Journal of the American Medical Association indicating that the quality of care for Medicare beneficiaries has improved and pointing to areas in which further improvement can be made.