Member materials and benefits

2024 Member Materials

Member Handbook

Annual Notice of Change

Summary of Benefits

List of Covered Drugs

Prior Authorization Criteria

Manual del Miembro

Aviso Anual de Cambios (Annual Notice of Changes, Spanish)

Resumen de Beneficios (Summary of Benefits, Spanish)

Lista de Medicamentos Cubiertos/Formulario (List of Covered Drugs, Spanish)

Step Therapy Criteria

Medicare-Medicaid benefits

Stay in-network and save
You must receive services covered by the health plan, from facilities and/or providers in the Aetna Better Health of Ohio network. The only time you can use providers that are not in the Aetna Better Health of Ohio provider network is for:

• Emergency services
• Federally qualified health centers/rural health clinics
• An out-of-panel provider that Aetna Better Health of Ohio has approved you to see during or after your transition of care time period
• Members that choose both their Medicare and Medicaid benefits through Aetna Better Health of Ohio can also receive urgently needed care and hospice services from non-contracting providers.

We provide services in only certain counties in Ohio. When you are out of our service area, you are only covered for emergency services. If you are out of the service area and need non-emergency services, call your PCP or Member Services.

Out-of-network and emergency care
Except in certain cases, like emergencies, you cannot visit a care provider outside of our network. “In network” providers are listed in our directory. These care providers have agreed to charge less for many services. If you do not use in-network providers, you may be responsible for these charges.

If you have questions about this, call Member Services at 1-855-364-0974 (TTY: 711), 24 hours a day, seven days a week. You also can use the Find a Provider tool. 

How do I know if it’s an emergency?
For more information about emergency care, please review your Member Handbook. You can also call your PCP or our 24/7 Nurse Advice Line at 1-855-364-0974.

Behavioral health 
Your mental health is important
Behavioral health benefits cover services to help you improve your mental health. For example, if you suffer from mental illness, alcohol or drug addiction, you may need therapy or medicine. Your Aetna Better Health of Ohio covers many kinds of services for mental health. For more information, view your Summary of Benefits.

Care management
As a member of Aetna Better Health of Ohio, you will have your own care manager as part of our care management program. Your care manager can help you find the right care and services. Your care manager will contact you soon after you are enrolled with Aetna Better Health of Ohio.

A care manager will work with you, your doctors and other providers to make sure you receive the right care and services, with your needs in mind. The goal is to build a treatment plan just for you to help you live a healthier life. Your care manager will meet with you by phone or where you live as often as needed.

A care manager can help guide you if you have had any of these or other issues:

• You are having to go to the ER a lot
• You are having trouble getting things your doctor has ordered
• Your doctor just told you that you have a disease like CHF (congestive heart failure) or diabetes but you would like to get more information about a disease or treatment
• You need services to help you at home and need help getting long term services and support
• Your doctor wants you to see a specialist, but you don't know what to do

If you want to discuss your health care needs and questions with your case manager, call Member Services to ask to speak to your care manager. Your care manager is there for you!

Disease management
Extra support to care for you

Our disease management programs are designed just for members with chronic (ongoing) conditions. This may include things like asthma, diabetes, lung disease or a heart issue.

What is a disease management program?

These programs provide education and outreach to you based on your medical needs. The goal is to help you be healthier and get quality care. If you choose to be part of our program, we work with the doctor to create a plan for your care. This plan will include goals that will help you and your doctor track your results. We will also provide education to you about how to stay well.

We have disease management programs for:

• Asthma
• Diabetes
• Depression
• Chronic Obstructive Pulmonary Disorder (COPD)
• Congestive Heart Failure (CHF)

When you sign up for one of our disease management programs, we give you all the help we can. We will also connect you with other resources to help you manage your condition.

If you want to know more about our disease management programs, talk to your care manager or call the 24-hour Care Management line at 1-855-364-0974 (TTY: 711), 24 hours a day, seven days a week. The call is free.

Additional benefits

Extra Benefits Card*

 

Members with specific chronic conditions have access to an Extra Benefits Card. This card can be used to pay for utilities, rent or healthy foods. The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify.

• $50 allowance every month to help with utilities, rent, and healthy foods for qualifying members. Funds do not roll over. The funds will automatically be added to your Nations Benefits prepaid debit cardif you qualify. The card can be used:
  • Online at AetnaMMP.com
  • Over the phone at 1-833-838-1307 (TTY: 711)or
  • At partner grocer locations
• Check if you are eligible for the Extra Benefits Card by calling Member Services at 1-855-364-0974 (TTY: 711).

Click here to view the 2024 Healthy Foods catalog

SilverSneakers^®

SilverSneakers^® membership to members at no additional cost. SilverSneakers is the nation’s leading community fitness program specifically designed for older adults, promotes greater health engagement and accountability by providing members with regular exercise (strength training, aerobics, flexibility) and social opportunities. Benefit includes:

• Access to thousands of participating fitness locations, use of basic amenities (weights, treadmills, pools, etc.), fitness classes, group activities and classes outside the traditional gym setting (Community FLEX classes).
• Online resources including a member portal, live classes, on-demand classes, SilverSneakers app with reminders to move and more.
• One Home kit or Steps kit available each calendar year.

Visit SilverSneakers.com to learn more, or call Member Services at 1-855-364-0974 (TTY:711) .

Federal Free Cell Phone Program

Aetna Better Health of Ohio members who are interested in the Lifeline, federal free cell phone program, are provided our contracted Lifeline vendor’s website, phone number and application to complete in order to determine if they qualify. The vendor notifies Aetna Better Health of Ohio of those members who are approved and opt-in to the program.

• Qualified members are then eligible to receive a smartphone with voice minutes, unlimited texts, data, voicemail, call waiting, caller ID and 911 access. Aetna Better Health of Ohio members receive unlimited free calls to the plan’s Member Services toll-free number that has been zero rated so these calls do not apply to monthly minute allotment and as appropriate, free health-related texts and free texts from the plan.

Please visit the Lifeline website to see how you qualify.

Non-Emergency Transportation

• Transportation for 30 round trips or 60 one-way trips to plan-approved health-related locations.

Aetna Better Health of Ohio requires that you call 1-855-364-0974 (TTY: 711) at least 3 days before your appointment to schedule a trip.

Dental services  

• 1 exam, cleaning, x-rays, fluoride every six months

To access these services, go to a dentist in the Aetna Better Health of Ohio network and show your Aetna Better Health of Ohio ID card.  If you have questions or need help finding a dentist call Member Services at 1-855-364-0974 (TTY: 711). This benefit is available to both Duals (Medicare and Medicaid) and Medicaid-Only members.

Over-the-counter allowance

 

$35 monthly allowance to purchase OTC items. Funds do not roll over. Members can buy items with their OTC benefit in three ways:

• Online at NationsBenefits.com
• Over the phone by calling 1-833-838-1307 (TTY: 711)
• Using their Nations Benefits Prepaid debit card at participating retail locations that include: 
  • CVS
  • Walmart
  • Kroger
  • Giant Eagle and more

Click here to view the 2024 OTC Catalog

For more information about the benefit, call Member Services at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week.

If you do not already have an OTC prepaid debit card, you can call 1-833-838-1307 (TTY: 711)

 

Podiatry

6 routine foot care visits each year.

 

Meals after Hospitalization

The plan offers 10 home-delivered nutritional meals after an in-patient hospitalization.

Smoking cessation counseling

• 42 additional smoking cessation counseling sessions each year.

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National Coverage Determination Member Notification

Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease (NCD) 220.6.20

Effective October 13, 2023, the Centers for Medicare and Medicaid (CMS) removed NCD 220.6.20 from Publication 100-03, the National Coverage Determination (NCD) Manual. This ended coverage with evidence development (CED) for positron emission tomography (PET) beta amyloid imaging and permitting Medicare coverage determinations for PET beta amyloid imaging to be made by the Medicare Administrative Contractors under section 1862(a)(1)(A) of the Social Security Act. 

This summarizes CMS Transmittal 12364

NCD 260.18 Power Seat Elevation Equipment on Power Wheelchairs

Effective for items 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.

1. 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,
2. At least one of the following apply:
3. 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,
4. 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,
5. 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.

This summarizes CMS Transmittal 12183 (NCD 280.16)

Cochlear Implantation - Manual Update of National Coverage Determination (NCD) 50.3

Effective for services performed on or after September 26, 2022, the Centers for Medicare and Medicaid expanded coverage for treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence cognition. The policy also provides coverage of cochlear implants when performed in the context of FDA-approved category B investigational device exemption clinical trials or as a routine cost in clinical trials under section 310.1 of the National Coverage Determination (NCD) Manual titled Routine Costs in Clinical Trials. 

This summarizes CMS Transmittal 11875 (NCD 50.3) 

Ambulatory Electroencephalographic (EEG) Monitoring (Retired) - Removal of National Coverage Determination (NCD) 160.22

Effective January 1, 2023, the Centers for Medicare and Medicaid removed the NCD for Ambulatory EEG Monitoring. In absence of an NCD, coverage determinations will be made by the Medicare Administrative Contractors.

Sections affected: Refer to CMS Publication 100-03, NCD Manual, Chapter 1, part 2, section 160.22

This summarizes CMS Transmittal 11824 (NCD 160.22)

Expanded Coverage of Colorectal Cancer Screening Tests – NCD 210.3

Effective for claims with dates of service on or after January 1, 2023, contractors shall be aware that NCD 210.3 Colorectal Cancer Screening Tests has been revised to reduce the minimum age limitation from 50 to 45 years and older for Fecal Occult Blood Tests (FOBT), Multi-target Stool DNA (sDNA) Tests and Blood-based Biomarker Tests. There is also no frequency limitations when the screening coloscopy follows a positive result from a stool-based test. 

 

This summarizes CMS Transmittal 11824 (NCD 210.3) 

Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease (AD)

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.

 

This summarizes CMS Transmittal 11692 NCD 200.3

Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)

Effective February 10, 2022, CMS expanded Medicare eligibility for screening for lung cancer with LDCT to closely align with the United States Preventive Services Task Force's recommendation. CMS is lowering the minimum age for screening from 55 to 50 years and reducing the smoking history from at least 30 pack-years to at least 20 pack-years.

 

This summarizes CMS Transmittal 11388 (NCD 210.14)

Home Use of Oxygen revision

CMS is revising NCD 240.2, Home Use of Oxygen, to nationally expand patient access to oxygen and oxygen equipment in the home. The revised NCD also identifies circumstances of non-coverage of home oxygen and oxygen equipment.

 

In addition, CMS is removing NCD 240.2.2, ending coverage with evidence development for home use of oxygen to treat cluster headache, and allowing the coverage determinations regarding the use of home oxygen and oxygen equipment for patients with cluster headaches.

Medicare removed two National Coverage Determinations (NCD's)

Effective January 1, 2022

 

NCD 180.2 Enteral/Parenteral Nutritional Therapy

NCD 220.6 Positron Emission Tomography (PET) Scans

 

CMS also made coverage updates to the Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilitation (ICR) policies resulting from changes specified in the calendar year 2022 Physician Fee Schedule (PFS) final rule published on November 19, 2021.

 

This summarizes CMS Transmittal R11272NCD

Blood-Derived Products for Chronic, Non-Healing Wounds

For services performed on or after April 13, 2021, Medicare will cover autologous Platelet-Rich Plasma (PRP) for the treatment of chronic, nonhealing diabetic wounds. Coverage is up to 20 weeks when prepared by devices whose FDA-cleared indications include the management of exuding, cutaneous wounds, such as diabetic ulcers.

This summarizes CMS Transmittal R10981NCD. (NCD 270.3)

Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation

Transcatheter Edge-to-Edge Repair (TEER) of the mitral valve (previously named Transcatheter Mitral Valve Repair (TMVR) is used in the treatment of mitral regurgitation (MR). TEER approximates the anterior and posterior mitral valve leaflets by grasping them with a clipping device in an approach similar to a treatment developed in cardiac surgery called the Alfieri stitch.

Effective January 19, 2021, Medicare expanded coverage of mitral valve TEER procedures for the treatment of functional mitral regurgitation (MR) and maintained coverage of TEER for the treatment of degenerative MR through coverage with evidence development (CED) and with mandatory registry participation.

This summarizes CMS Transmittal R10985NCD. (NCD 20.33)

Ventricular Assist Devices (VADs)

Effective with dates of service on or after 12/01/2020

 

Medicare covers left ventricular assist devices (LVADs) if they are FDA approved for short-term (e.g., bridge-to-recovery and bridge-to-heart transplant) or long-term (e.g., destination therapy) mechanical circulatory support for heart failure patients who meet the following criteria:

• have New York Heart Association (NYHA) Class IV heart failure; and
• have a left ventricular ejection fraction (LVEF) ≤ 25%; and
• are inotrope dependent

     OR have a Cardiac Index (CI) < 2.2 L/min/m2, while not on inotropes and meet one of the following:

• Are on optimal medical management (OMM), based on current heart failure practice guidelines for at least 45 out of the last 60 days and are failing to respond; or
• have advanced heart failure for at least 14 days and are dependent on an intra-aortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days.

 

This summarizes CMS Transmittal R10837 (NCD 20.9.1)

Removal of Six National Coverage Determinations

Revised 8/2/2021

 

This affects services given on or after January 1, 2021

 

These sections will be removed from Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual. The Centers for Medicare & Medicaid Services determined that no national coverage determination is appropriate at this time. In the absence of an NCD, coverage determinations will be made by the Medicare Administrative Contractors under 1862(a)(1)(A) of the Social Security Act.

 

This doesn’t mean the services aren't covered. We’ll still review services that are reasonable and necessary for your diagnosis or condition.

Sections affected:

• NCD 20.5 Extracorporeal Immunoadsorption (ECI) Using Protein A Columns
• NCD 30.4 Electrosleep Therapy
• NCD 100.9 Implantation of Gastrointestinal Reflux Devices
• NCD 110.19 Abarelix for the Treatment of Prostate Cancer
• NCD 220.2.1 Magnetic Resonance Spectroscopy
• NCD 220.6.16 FDG PET for Inflammation and Infection

Coverage determinations will fall under NCD 220.6 Positron Emission Tomography (PET) Scans

This summarizes CMS Transmittal 10927

Colorectal Cancer Screening Blood Based Biomarker Tests

Effective with dates of service on or after January 19, 2021

CMS covers a blood-based biomarker test as part of a colorectal cancer screening test once every 3 years for when performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory, and ordered by a treating physician and when all of the following requirements are met:

The patient is:

• age 50-85 years,
• asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test),
• at average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).

The blood-based biomarker screening test must have all of the following:

• Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening;
• Proven test performance characteristics for a blood-based screening test with both sensitivity greater than or equal to 74% and specificity greater than or equal to 90% in the detection of colorectal cancer compared to the recognized standard (accepted as colonoscopy at this time), as minimal threshold levels, based on the pivotal studies included in the FDA labeling.

This summarizes CMS Transmittal 10818 (NCD 210.3)

Chimeric Antigen Receptor T-cell Therapy

This affects services given on or after August 7, 2019

Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment. The recent NCD changes are as follows:

Effective for claims with dates of service on and after August 7, 2019.

CMS will cover autologous treatment for cancer with T-cells expressing at least one CAR when administered at healthcare facilities enrolled in the FDA Risk Evaluation and Mitigation Strategies (REMS) and meets specified FDA conditions.

If you think you qualify, speak with your physician.

This summarizes CMS transmittal R10454NCD

 

Effective for dates of service on or after August 7, 2019, Medicare covers autologous treatment for cancer with T-cells expressing at least one chimeric antigen receptor (CAR) when:

• administered at specific healthcare facilities
• enrolled in the FDA Risk Evaluation and Mitigation Strategies (REMS)
• used for a medically accepted or an FDA-approved indication
• and the use is supported in one or more CMS-approved compendia

(CAR) T-cell therapy is not covered when the use is for a non-FDA-approved autologous T-cells expressing at least one CAR and the requirements listed above are not met.

This summarizes CMS Transmittal 10796 (NCD 110.24)

Acupuncture for Chronic Low Back Pain

This affects services given on or after January 21, 2020

Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment. The recent NCD changes are as follows:

• CMS will cover acupuncture for chronic low back pain (cLBP) effective for claims with dates of service on and after January 21, 2020.

This NCD expands coverage for acupuncture services specifically targeted for chronic low back pain. Medicare determined it will cover acupuncture for cLBP up to 12 visits in 90 days. These services will only be covered by Medicare if cLBP:

• lasts 12 weeks or longer
• nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc.
• disease);
• not associated with surgery; and
• not associated with pregnancy

If you think you qualify, speak with your physician.

 

This summarizes CMS transmittal R10128NCD 

Next Generation Sequencing (NGS)

This affects services given on or after March 16, 2018

The Centers for Medicare & Medicaid Services (CMS) reviewed the evidence for laboratory diagnostic tests using NGS in patients with cancer. They determined that some tests could improve health outcomes for Medicare beneficiaries with advanced cancer. Testing will be covered for beneficiaries with:

• recurrent, relapsed, refractory or metastatic cancer
• advanced stages III or IV cancer if the beneficiary either:
  • has not been previously tested using the same NGS test for the same primary diagnosis of cancer or
  • will get repeat testing using the same NGS test only when the treating physician gives a new primary cancer diagnosis and there will be further cancer treatment (e.g., therapeutic chemotherapy) 

The test must be ordered by the treating physician, performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, and have all of the following requirements met:

• Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic; and,
• an FDA-approved or -cleared indication for use in that patient’s cancer; and,
• results provided to the treating physician for management of the patient using a report template to specify treatment options

This summarizes CMS transmittal R210NCD

Magnetic Resonance Imaging (MRI)

This affects services given on or after April 10, 2018

Medicare will allow for coverage of MRI for beneficiaries under certain conditions with any of the following: implanted pacemaker, implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), or cardiac resynchronization therapy defibrillator (CRT-D).

If you think you qualify, speak with your physician.

This summarizes CMS transmittal R208NCD

Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)

This affects services given on or after December 7, 2017.

Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies).  These changes only apply to members involved in the special studies.  The recent NCD changes are as follows:

• You are having surgery on your lower spine where the surgeon uses a very small incision and surgery is guided with imaging (x-ray) assistance (often referred to as “Percutaneous Image-guided Lumbar Decompression”/PILD)
• You have a condition where the open spaces of your spine are narrowed and this puts pressure on your spinal cord or nerves (“Lumbar Spinal Stenosis”) and you have not had relief with non-surgical treatments.

• You meet all the other specified conditions of the Medicare approved study.

These services will only be covered by Medicare if they are provided in a Medicare-approved clinical study under Coverage with Evidence Development (CED.)

If you think you qualify, speak with your physician.

This summarizes CMS transmittal R196NCD.

Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)

This affects services given on or after April 3, 2017.

Local Medicare administrators will decide if they'll cover topical oxygen for the treatment of chronic non-healing wounds.

This summarizes CMS transmittal R203NCD.

Leadless Pacemakers

This affects services given on or after January 18, 2017

Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies). These changes only apply to members involved in the special studies. The recent NCD changes are as follows:

Medicare will cover placement of a “leadless pacemaker” if you are enrolled in a special approved clinical study. A leadless pacemaker is placed without the need for a device pocket and insertion of a pacing lead which are parts of traditional pacing systems. You should speak with your doctor if you think you qualify to be a participant in an approved clinical study to receive this device.”

This summarizes CMS transmittal R201NCD

Gender Dysphoria and Gender Reassignment Surgery

This affects services given on or after August 30, 2016

Centers for Medicare and Medicaid Services (CMS) recently released a notice in response to public questions around gender reassignment surgeries. This notice restates that there are no national CMS coverage guidelines for this service. Coverage decisions for this type of surgery are made by your local Plan, according to your benefits and your Plan’s medical necessity guidelines. If you have any questions about your coverage for this type of surgery, please contact Member Services at number on your Member ID.

This summarizes CMS transmittal R194NCD

Percutaneous Left Atrial Appendage Closure (LAAC)

This affects services given on or after February 8, 2016

Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies).  These changes only apply to members involved in the special studies.  The recent NCD changes are as follows:

• Coverage will be approved for a special heart procedure (Left Atrial Appendage Closure, LAAC, if the device planned for use has FDA approval; and
• You have a specific type of irregular heart beat (Non-Valvular Atrial Fibrillation, NVAF; and

You meet all the other specified conditions of the Medicare approved study. These services will only be covered by Medicare if they are provided in a Medicare-approved clinical study under Coverage with Evidence Development (CED.)

If you think you qualify, speak with your physician.

This summarizes CMS transmittal R192NCD

Stem Cell Transplantation for Multiple Myeloma, Myelofibrosis, Sickle Cell Disease, and Myelodysplastic Syndromes

This affects services given on or after January 27, 2016

Centers for Medicare and Medicaid Services (CMS) has issued National Coverage Determinations (NCD’s) that affect coverage for treatment done as part of special studies (Coverage with Evidence Development/CED, Medicare approved studies).  These changes only apply to members involved in the special studies.  The recent NCD changes are as follows:

• Expanded coverage for donor stem cell transplant (allogenic hematopoietic stem cell transplant) for sickle cell disease, certain diseases of the blood cells (myelofibrosis, multiple myeloma), other rare diseases. In a donor stem cell transplant, a doctor takes part of a healthy donor’s stem cell or bone marrow. This is then specially prepared and given to a patient through a tube in a vein (intravenous infusion). The patient also receives high dose chemotherapy (such as certain cancer drugs) and/or radiation treatments before getting this transplant through the vein.

This NCD expands coverage for donor HSCT items and services. These services will only be covered by Medicare if they are provided in a Medicare-approved clinical study under Coverage with Evidence Development (CED.). When bone marrow or peripheral blood stem cell transplantation is covered, all required steps are included in coverage.  If you think you qualify, speak with your physician.

This summarizes CMS transmittal R191NCD

Test for Colorectal Cancer Using Cologuard

This affects services given on or after October 9, 2014

Cologuard is a test that is performed on a stool sample to check for colon cancer. You no longer need authorization from your health plan before you have this test done.

This summarizes CMS transmittal R183NCD

Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)

This is effective for services on or after May 25, 2017.

The Centers for Medicare and Medicaid Services (CMS) issued an NCD to cover SET for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic PAD.

SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest. SET has been recommended as the initial treatment for patients suffering from IC, the most common symptom experienced by people with PAD.

The SET program must:

• Consist of sessions lasting 30-60 minutes, comprising a therapeutic exercise-training program for PAD in patients with claudication
• Be conducted in a hospital outpatient setting, or a physician’s office
• Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD
• Be under the direct supervision of a physician (as defined in Section 1861(r)(1)) of the Social Security Act (the Act), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in Section 1861(aa)(5) of the Act)) who must be trained in both basic and advanced life support techniques.

This summarizes CMS transmittal R206NCD.