The Centers for Medicare & Medicaid Services (CMS) issued a final rule Tuesday that will speed Medicare beneficiaries’ access to the latest advanced devices.
The Medicare Coverage of Innovative Technology (MCIT) (CMS-3372-F) final rule will ensure that Medicare beneficiaries get access to the latest medical technology faster than ever.
Under current rules, Food and Drug Administration (FDA) approval of a device is followed by a long and costly process for Medicare coverage. The lag time between the two results in innovators first spending time and resources on FDA approval and then subsequently on the Medicare coverage process. This causes undue burden for innovators and could delay access to these potentially lifesaving technologies during the existing Medicare coverage determination process, CMS said in an announcement.
“Government processes have slowed beneficiaries’ access to innovative treatments. Despite being deemed safe and effective by the FDA, Medicare beneficiaries have not had predictable, immediate access to innovative breakthrough devices,” said CMS Administrator Seema Verma, noting that the MCIT rule will eliminate this delay for both seniors and innovators.
The final rule creates a new, accelerated Medicare coverage pathway for innovative products that the FDA deems “breakthrough,” which are approved on an expedited basis and could include devices that harness new technologies like implants or gene-based tests to diagnose or treat life-threatening or irreversibly debilitating diseases or conditions like cancer and heart disease.
Under the MCIT rule, Medicare can provide national coverage simultaneously with FDA approval, up to a period of four years. After the coverage period is over, CMS will reevaluate the device based on clinical and real-world evidence of improvement in health outcomes among Medicare beneficiaries to determine more permanent coverage. This four-year timeline may offer incentives to manufacturers of these breakthrough devices to develop additional evidence regarding the applicability of their products to the Medicare population, so they might continue Medicare coverage beyond the initial four years.
CMS said that because the MCIT rule will provide national Medicare coverage for four years, it will correspond with the local coverage determination (LCD) process, thus promoting equal access for seniors regardless of where they live. Currently, under the local coverage process, 16 Medicare Administrative Contractors (MACs) make Medicare coverage decisions on the local level–12 for Medicare Parts A and B, and four for durable medical equipment. MACs can cover items or services on a claim-by-claim basis or through a Local Coverage Determination (LCD), which applies only to that MAC’s jurisdiction. In the absence of national Medicare coverage decision for an innovative technology, the technology could be covered in one area of the country but not in another.
In addition, to secure an LCD, innovators must seek separate decisions from each of the MACs. MCIT makes this step unnecessary. Under MCIT, breakthrough devices receive national coverage for four years, as early as the date of FDA approval, meaning innovators no longer must seek LCDs from each MAC. Innovators will have the option to choose when they would like coverage to begin. This will give innovators flexibility to align the coverage process with their manufacturing and distribution cycles.
After the final rule takes effect, upon manufacturer request, Medicare may cover through MCIT eligible breakthrough devices the FDA has approved, including breakthrough devices that received FDA marketing authorization approval within two calendar years prior to the final rule’s effective date, giving Medicare beneficiaries access to these innovative and potentially life-saving devices.
In addition, the MCIT final rule will clarify the standard CMS uses to determine whether Medicare should cover items and services, like devices and surgical procedures. Under the Medicare law, with relatively few exceptions, the program can only cover items or services that are “reasonable and necessary” for the diagnosis or treatment of illness or injury or improve the functioning of a malformed body member. This final rule will codify CMS’s definition of reasonable and necessary in regulation to give innovators a clearer understanding of CMS standards.