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Medicare Coverage Database

Patient Advocacy Qs and As

Date
3/14/2008
 
Public Comment Period
N/A - N/A
 
Patient Advocacy Group Meeting
January 9, 2008 (10am-1pm)
Questions and Answers

Q1. Does Medicare cover breast cancer treatment?
A2. Generally, if Compendia says a drug is beneficial, then CMS may cover that drug under Part B or Part D. Other types of treatment such as surgery and/or radiation are often covered.

Three Compendia are listed in Section 1861 (t)(2)(B)(ii)(I) of the Social Security Act. At present they are:

American Hospital Formulary Service – Drug Information
American Medical Association - Drug Evaluations
United States Pharmacopoeia – Drug Information

Q2.How can patients receive coverage for off-label drugs?
A2. Under Section 1961 (t) (2) (B) (ii) of the Social Security Act, the term medically accepted indication” with respect to the use of a drug, includes any use which has been approved by the Food and Drug Administration (FDA) for the drug, and includes another use of the drug if – the drug has been approved by the FDA and such use is supported by one or more of the drug compendia. A Medicare contractor may also determine that such uses are medically accepted based on supportive clinical evidence in peer reviewed medical literature appearing in publications which have been identified by the Secretary in. a posted list of accepted cancer journals.

Q3. How can patients receive coverage for supplies, items, and transportation?
A3. The provider of the services must send a claim to the servicing Medicare contractor who determines if the services are reasonable and necessary. Call 1-800-Medicare (1-800-633-4227) for information on how to contact your servicing Medicare contractor. In addition, your Medicare Benefit Handbook can provide you with information on services provided under the Medicare program.

Q4. Does Medicare/Medicaid cover treatment for autism?
A4. Medicaid, as specified in the Omnibus Reconciliation Act of 1989, covers periodic screening, diagnostic, and treatment services for all children enrolled in the program under the age of 21. CAG only handles Medicare coverage requests and currently we have not had any formal requests to cover items or services for autistic spectrum of disorders specifically. Medicare will cover the same items or services for autistic individuals that it would cover for any Medicare beneficiary.

Q5. In what evidence priorities are CMS interested?
A5. A Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) meeting held on October 22, 2007 resulted in a list of “Top 100 Medicare Research Priorities.” That list can be viewed on our website at http://www.cms.hhs.gov/faca/downloads/id41a.pdf. CMS held a Federal workshop in February and will hold another MEDCAC meeting on April 30, 2008 to further refine and prioritize that list of evidentiary priorities.

Q6. What outcome is CMS expecting to achieve from the priorities MEDCAC?
A6. At the April meeting, we will task the MEDCAC panel to refine and prioritize the research topics developed by the Federal workshop. We then plan to publically release the final, prioritized list in the hopes of stimulating the research community, including government agencies, academia, and industry, to address the research questions that are identified as priorities for the Medicare program.

Q7. How does CMS train new MEDCAC members?
A7. Typically, CMS trains new MEDCAC members by offering a lay person’s view of how to examine evidence. MEDCAC members receive a training DVD at the time of invitation. The DVD is divided into sections that explain the MEDCAC process, the Medicare national coverage process, and evidence based medicine. It also includes an overview of the CMS website.

Q8. What is the time commitment for participating on a MEDCAC panel?
A8. Preparation for a meeting can take anywhere from 6 hours to 3 days, depending on both the experience of the particular MEDCAC member and the complexity of the topic. MEDCAC meetings are typically scheduled for 1 day, with an additional day allowed for travel.

Q9. How do patient advocates achieve access to optimal patient health care through out-of-network services?
Medicare Advantage Plans are health plan options (like HMOs and PPOs) approved by Medicare and run by private companies. These plans are part of the Medicare Program and are sometimes called “Part C” or “MA plans.”

Medicare Advantage Plans generally have provider networks. If enrollees use providers who aren’t in the network, they may have to pay the entire cost of the covered service. Some plans may allow use of out-of-network providers.

We suggest that patient advocates continue to work with the MA health plans to on access issues.

Q9. How is quality-of-life considered through the prism of effectiveness?
A9. When conducting a national coverage analysis, CMS examines the evidence for improvement in patient health outcomes and in many cases we consider this to include quality of life enhancements.

 
 


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