Member Resources
National Coverage Determinations

The Centers for Medicare & Medicaid Services (CMS) sometimes change the coverage rules that apply to an item or service under Medicare. When they do make changes, they share them as a National Coverage Determination (NCD) – and we make sure our members are aware of the changes, too.

About National Coverage Determinations

NCDs tell you:

  • What benefits and services are covered
  • What benefits and services are changing
  • What Medicare will pay for these items or services

 

CMS has issued the following National Coverage Determinations since 2022. Visit the CMS website to learn about determinations prior to 2022.

Effective 5/16/2023

Effective for services performed on or after May 16, 2023, power seat elevation equipment is reasonable and necessary for individuals using complex rehabilitative power-driven wheelchairs, when the following conditions are met:

The individual has undergone a specialty evaluation that confirms the individual’s ability to safely operate the seat elevation equipment in the home. This evaluation must be performed by a licensed/certified medical professional such as a physical therapist (PT), occupational therapist (OT), or other practitioner, who has specific training and experience in rehabilitation wheelchair evaluations; and,

At least one of the following apply:

  • The individual performs weight bearing transfers to/from the power wheelchair while in the home, using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a sit to stand transfer. Transfers may be accomplished with or without caregiver assistance and/or the use of assistive equipment (e.g., sliding board, cane, crutch, walker, etc.); or,
  • The individual requires a non-weight bearing transfer (e.g., a dependent transfer) to/from the power wheelchair while in the home. Transfers may be accomplished with or without a floor or mounted lift; or,
  • The individual performs reaching from the power wheelchair to complete one or more mobility related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in customary locations within the home. MRADLs may be accomplished with or without caregiver assistance and/or the use of assistive equipment.

In accordance with the Centers for Medicare & Medicaid Services guidance, Jefferson Health Plans will cover this service when the conditions apply.

Effective 4/7/2022

Alzheimer’s disease (AD) is a currently irreversible brain disorder that progressively degrades memory, cognitive function, and ability to carry out tasks of daily living. AD is the number one cause of dementia in older Americans. Antiamyloid-beta monoclonal antibodies (antiamyloid mAbs) are laboratory-made proteins designed to bind a specific substance in the body, with the goal of marking it for destruction by the body’s immune system. Scientists design various mAbs as treatments with the goal of targeting and neutralizing or clearing infections (like the COVID-19 virus), cancer cells, and in the case of AD, amyloid accumulation in the brain.

Effective April 7, 2022, the Centers for Medicare & Medicaid Services (CMS) covers Food and Drug Administration (FDA) approved monoclonal antibodies directed against amyloid for the treatment of AD when furnished in accordance with Section B under coverage with evidence development (CED) for patients who have a clinical diagnosis of mild cognitive impairment (MCI) due to AD or mild AD dementia, both with confirmed presence of amyloid beta pathology consistent with AD.

Effective 2/10/2022

The Centers for Medicare & Medicaid Services (CMS) has determined that evidence is sufficient to expand the eligibility criteria for Medicare beneficiaries receiving low dose computed tomography (LDCT) for lung cancer screening when the following criteria are met. This final decision lowers the starting age for screening from 55 to 50 years and reduces the tobacco smoking history from at least 30 packs per year to at least 20 packs per year.

Beneficiary eligibility criteria:

  • Age 50 – 77 years;
  • Asymptomatic (no signs or symptoms of lung cancer);
  • Tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes);
  • Current smoker or one who has quit smoking within the last 15 years; and
  • Receive an order for lung cancer screening with LDCT

In accordance with the CMS guidance, Jefferson Health Plans Medicare will cover this service when the conditions apply. Copays are waived when services provided are in-network.

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Need Additional Information?

For help with questions about benefits or using your plan, please call Member Relations at 1-866-901-8000 (TTY 1-877-454-8477).

From October 1 to March 31, we’re available 8 a.m. to 8 p.m., 7 days a week (closed on Thanksgiving and Christmas). And from April 1 to September 30, we’re available 8 a.m. to 8 p.m., Monday to Friday.

Page last updated: 10/1/2024 - Y0170_MCE‐220S05‐4991_M