Medicare Coverage and Payment Policy
AdvaMed develops strategies for improving Medicare coverage and payment systems and methodologies impacting patients, providers, and suppliers.
The Centers for Medicare & Medicaid Services (CMS) is the largest provider of health insurance in the United States, covering care for more than 170 million individuals nationwide. Within CMS’ coverage, the Medicare program is the nation’s single largest health program with over 60 million beneficiaries. CMS governs Medicare coverage and reimbursement for medical services through a series of payment systems, each governed by a unique set of statutory and regulatory requirements.
Medicare enrollment growth, budget pressures, and rapid technological change will continue to shape the Medicare program’s future. Using a consensus-based approach, the AdvaMed Payment and Health Care Delivery Policy Team develops strategies for improving Medicare coverage and payment systems and methodologies that impact patients, providers, and suppliers of Medicare-covered items and services, including hospitals, doctors, durable medical equipment suppliers, and others.
Key Areas of Focus
Improving Medicare Reimbursement Policies
Medicare uses several different payment systems and reimbursement methodologies for paying for services provided to the program’s beneficiaries. CMS generally publishes annual updates to payment amounts determined under these methodologies using the notice-and-comment rulemaking process. The Payment & Health Care Delivery Policy Team proactively advocates for changes in and responds to specific issues arising through these proposed rules for the following major benefit categories:
- Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System
- Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System
- Physician Fee Schedule (PFS)
- End-Stage Renal Disease (ESRD) Prospective Payment System
- Durable Medical Equipment, Prosthetics/Orthotics & Supplies (DMEPOS) Competitive Bidding Program and Fee Schedules
Improving Access to Innovative Technologies
New and innovative technologies face many hurdles establishing Medicare coverage. The Payment & Health Care Delivery Policy Team pursues policies within Medicare’s existing benefit categories and reimbursement methodologies to streamline and accelerate adoption of new technologies, such as:
- New Technology Add-On Payments (NTAP)
- Transitional Pass-Through Payments (TPT)
- Transitional Payments for New and Innovative Equipment and Supplies (TPNIES)
The Payment & Health Care Delivery Policy Team also advocates for broader improvements to Medicare coverage for new and innovative technologies. An alternative expedited pathway to coverage and payment for these devices and diagnostics (currently referred to as Transitional Coverage of Emerging Technologies, or TCET) would bolster the innovation ecosystem and provide Medicare patients swift access to these technologies.
Policy
Transitional Coverage of Emerging Technologies (TCET)
Creating a clear and consistent pathway to coverage for new and innovative medical technologies will ensure Medicare patients’ access to life-saving and life-enhancing care.
Transforming Coverage for Digital Health Technologies
The COVID-19 pandemic has highlighted the role of digital health in transforming care delivery and making the health system nimbler and more responsive to changing needs. The Payment & Health Care Delivery Policy Team advocates for adoption of coverage policies within CMS’ existing statutory authority in order to realize the game-changing potential of digital health technologies across each of Medicare’s benefit categories.
Developing and Evaluating Alternative Payment Models
In response to growing financial pressures and limitations within Medicare’s existing reimbursement methodologies, CMS has begun testing new approaches to Medicare payment. An Alternative Payment Model (APM) is a payment approach that provides added incentive to provide high-quality and cost-efficient care. The Center for Medicare & Medicaid Innovation (CMMI) has developed a variety of different APMs to test these goals in the context of specific clinical conditions, care episodes, or populations. The Payment & Health Care Delivery Policy Team both independently develops concepts for and provides feedback to CMS on model concepts in order to ensure implemented APMs appropriately reflect the importance and value of Medtech innovation.
