Medicare coverage and payment - Reimbursement

The Centers for Medicare & Medicaid Services (CMS) issues new regulations each year adjusting payment levels and payment policies for providers. It also makes changes from time-to-time in the medical procedures and technologies it will cover.

2019 Regulations
2019 Regulations
2019 Regulations

Inpatient Hospital

Outpatient Hospital and Ambulatory Surgery Center

Physician Services
2018 Regulations
2018 Regulations
2018 Regulations

Significant changes came about as the result of Medicare payment regulations for 2018. These include adjustments in the Medicare Access and CHIP Re-Authorization Act (MACRA), the new system for updating physician payment rates; changes in reimbursement for hospital outpatient departments that acquire off-campus physician practices; and further adjustments in Medicare's push toward value-based payments.

For more detail:

MACRA

Inpatient hospital

Hospital outpatient department and physician services
2017 Regulations
2017 Regulations
2017 Regulations

The Centers for Medicare & Medicaid Services (CMS) made changes in the rates and policies for hospital outpatient departments and physician services for calendar year 2017. It also finalized the rates and policies for hospital inpatient care for Fiscal Year 2017. In November, 2017, CMS issued a final regulation implementing the new system for updating physician payment rates that was authorized by the Medicare Access and CHIP Re-Authorization Act (MACRA). Here are links to summaries:

MACRA

Inpatient hospital

Hospital outpatient department

Physician services
CT Lung Cancer Screening
CT Lung Cancer Screening
CT Lung Cancer Screening

In February 2015, a long process of review and evaluation of low-dose CT scans for lung cancer screening concluded when the Centers for Medicare & Medicare Services decided to cover the scans for Medicare beneficiaries who are heavy smokers.

Medicare will cover LDCT lung cancer screening once per year for beneficiaries who meet all of the following criteria:

Age 55-77 and are either current smokers or have quit smoking within the last 15 years

Smoked for at least 30 “pack years” (an average of one pack a day for 30 years)

Received a written order from a physician or qualified non-physician practitioner that meets certain requirements.

CMS also set additional requirements: Screening is allowed only once per year and requires a doctor's order. The patient must also undergo "shared decisionmaking" counseling in which a medical professional explains screening benefits and harms. In addition, screening facilities must submit scan data to a registry approved by CMS. The agency also set the billing codes and payment levels for low-dose CT for cancer screening and counseling.

Two of the important factors leading up to the decision was a clinical study by the National Institute of Health and a recommendation in favor of screening by a key federal health task force.

United States Preventive Services Task Force (USPSTF)

In December, 2013, the USPSTF recommended annual low-dose CT screening for people between 55 and 80 years of age who are at high risk for lung cancer because they are heavy smokers or were previously, but quit within the past 15 years. The recommendation was based on a comprehensive review of the available evidence, including results of the 2011 NIH National Lung Screening Trial. The task force found that low-dose CT scans more accurately identify early stage lung cancer than do other screening tests. The group also found that many lung cancer deaths can be prevented by screening high-risk people every year.

NIH National Lung Cancer Screening Trial

In 2011, the National Institutes of Health reported the results of its long-term, randomized controlled clinical trial which found that LDCT led to a 20% relative reduction in mortality from lung cancer. The authors of the study, which began in 2002 and enrolled more than 50,000 patients, concluded that “screening with the use of low-dose CT reduces mortality from lung cancer.”

Click to read final CMS coverage decision
Coverage Policies
Coverage Policies

Coverage Policies

Most decisions about whether to cover technologies and services under the Medicare program are done locally by the private and commercial insurance companies that process Medicare claims. But some Medicare decisions are considered to be of such importance that they are done at the national level.

In recent years, national decisions have focused in two important areas -- low-dose CT scans for high risk lung cancer patients (see "CT Lung Cancer Screening") and use of PET scans for various aspects of cancer care and treatment planning. In 2013, CMS allowed broader use of PET to guide anti-tumor treatment strategy -- expanding one allowed scan to three -- and allowing coverage of any additional scans to be left to local Medicare contractors.

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Medicare coverage
and payment

2019 Regulations

2018 Regulations

2017 Regulations

CT Lung Cancer Screening

Coverage Policies

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