HCFA releases details of new process for national Medicare coverage decisions

HCFA releases details of new process for national Medicare coverage decisions

Agency's changes intended to address long-time delays, confusion, lack of openness
IN AN APRIL 27 Federal Register notice (p. 22619) outlining changes in the national Medicare coverage process, the Health Care Financing Administration (HCFA) announced that it is establishing targeted timeframes for itself in completing key elements of the coverage decision-making process.
According to the notice, HCFA will attempt to:

Approve, reject, or take other action on coverage requests within 90 days of receiving them;
Act upon coverage recommendations from the newly formed Medicare Coverage Advisory Committee (MCAC) within 60 days of receiving MCAC's recommendation.

The agency said that it expects most national coverage requests to require referral to MCAC or to outside third parties for an independent technology assessment. MCAC, too, has authority to request outside assessments. HCFA said it expects any assessments of this kind to normally take no longer than 12 months.
HCFA's notice also outlines other key changes in how the agency plans to conduct coverage decisionmaking. For example, it intends to publish extensive information about coverage reviews on the Internet and permit local HCFA contractors to cover a technology, even if Medicare has decided not to make a coverage decision on the device at the national level. With regard to implementing national coverage decisions, HCFA said, "Generally, we expect to make a payment change effective within 180 calendar days of the first day of the next full calendar quarter that follows the date we issue the national coverage decision." The notice gives no indication of the mechanics of how that would take place.
The changes in the coverage process announced by HCFA come about in response to strong criticism during recent years from Congress, HIMA, and other groups-and from concerns among top agency officials themselves-about historic delays, lack of openness, and confusion in Medicare's system of deciding whether to cover technologies at the national level. Although HCFA officials have been discussing the changes publicly and implementing some of them gradually, the notice will not take effect until 60 days after the Federal Register publication date.
For more information, member companies can contact Greg Raab at HIMA at graab@himanet.com.
The HCFA notice can be accessed on the agency's Web site at http://www.hcfa.gov/quality/8b2-a.htm .