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Medicare puts its coverage decision process up for review

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Insurance agents, insurers, patients, doctors and others who hate how traditional Medicare managers decide what to cover now have a good chance to complain about the decisionmaking process.

The Centers for Medicare & Medicaid Services (CMS) is putting the information collection processes at the heart of the Medicare program’s national coverage determination system through a routine paperwork review.

The review covers only the paper forms, electronic forms and information-handling methods CMS officials use to run the determination system, not the underlying standards governing which medical service and devices Medicare should cover.

Related: 10 Medicare facts for agents who know everything

But members of the public now have a chance to give CMS advice about ways to make the determination system cheaper, easier or faster for them use, or for CMS to administer.

CMS estimates it gets about 200 requests for national coverage determination decisions every year. Recently, for example, Medicare program managers have been conducting a national coverage analysis for a proposed coverage determination process for gender reassignment surgery.

The Medicare coverage determination team formally accepted a request for a gender reassignment surgery coverage review in December, collected public comments for a month, posted a draft decision memo June 2, and collected public comments on the draft memo until July 2. 

The determination team received 106 public comments before it posted the draft memo, including a reply from Kaiser Permanente favoring a national standard and complaints from anonymous consumers who said Medicare money could be better spent on other things.

The draft memo attracted 38 comments.

CMS published the paperwork review notice today in the Federal Register. Comments on the national coverage determination system information collection processes are due Sept. 23.

Federal law requires CMS to put many of its information collection efforts through a public review every three years. CMS last put the national coverage determination system efforts through a public review in 2013.

Changes to the Medicare determination system would not have a direct effect on commercial health insurance, but CMS is so big and influential that any changes it makes could affect how commercial insurers make their own decisions about what to cover.

When CMS conducted the last determination system paperwork review, officials said in a response to the comments it received that most dealt with the underlying determination system standards, not ways to improve the processes for collecting and handling the information used to develop the standards. 


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