Medicare Policies
General Information
Medicare is a single-payer, national insurance program administered by the U.S. federal government for people age 65 or older, people under age 65 with certain disabilities, and people of all ages with end-stage renal disease.
Medicare has four parts: Part A is hospital/hospice insurance, Part B is medical insurance, Part C includes health plans branded as Medicare Advantage and Part D covers many prescription drugs. Providers working in hospital settings, including critical access hospitals and skilled nursing facilities, are considered Medicare Part A providers. Providers working in outpatient clinics and settings are considered Medicare Part B providers. The Medicare Provider-Supplier Enrollment webpage provides additional details on how to enroll as a Medicare provider or supplier.
The Centers for Medicare and Medicaid Services (CMS) establishes national coverage determinations (NCDs) for items and services furnished through Medicare.
CMS also awards geographic jurisdictions to private health care insurers called Medicare Administrative Contractors (MACs) to develop policies and process claims. The policies that MACs develop are called Local Coverage Determinations (LCDs) and these may vary from region to region. An LCD can never contradict an NCD, but it can expand on coverage policies for a particular region.
A/B MACs process Medicare Part A and Medicare Part B claims for a defined geographic area or “jurisdiction.” Part A and B providers are required to adhere to the LCD(s) that is in place for their particular jurisdiction.
| MAC Jurisdiction | States in which Part A & Part B Claims are Processed | MAC |
|---|---|---|
| 5 | Iowa, Kansas, Missouri, Nebraska | Wisconsin Physicians Service Insurance Corporation |
| 6 | Illinois, Minnesota, Wisconsin | National Government Services, Inc. |
| 8 | Indiana, Michigan | Wisconsin Physicians Service Insurance Corporation |
| 15 | Kentucky, Ohio | CGS Administrators, LLC |
| E | California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands | Noridian Healthcare Solutions, LLC |
| F | Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming | Noridian Healthcare Solutions, LLC |
| H | Arkansas, Colorado, New Mexico, Oklahoma, Texas, Louisiana, Mississippi | Novitas Solutions, Inc. |
| J | Alabama, Georgia, Tennessee | Palmetto GBA, LLC |
| K | Connecticut, New York, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont | National Government Services, Inc. |
| L | Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania (includes Part B for counties of Arlington and Fairfax in Virginia and the city of Alexandria, VA) | Novitas Solutions, Inc. |
| M | North Carolina, South Carolina, Virginia, West Virginia (excludes Part B for the counties of Arlington and Fairfax in Virginia and the city of Alexandria, VA) | Palmetto GBA, LLC |
| N | Florida, Puerto Rico, U.S. Virgin Islands | First Coast Service Options, Inc. |
Contractor and Medical Director Index
Medicare also awards MACs the ability to process Medicare Durable Medical Equipment, Orthotics, and Prosthetics (DMEPOS) claims for a defined jurisdiction. These contractors are called DME MACs.
| DME MAC Jurisdiction | States in which Part A & Part B Claims are Processed | MAC |
|---|---|---|
| DME A | Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont | Noridian Healthcare Solutions, LLC |
| DME B | Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, Wisconsin | CGS Administrators, LLC |
| DME C | Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, Puerto Rico, U.S. Virgin Islands | CGS Administrators, LLC |
| DME D | Alaska, Arizona, California, Hawaii, Idaho, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming, American Samoa, Guam, Northern Mariana Islands | Noridian Healthcare Solutions, LLC |
National Coverage Determinations
Sleep Testing for Obstructive Sleep Apnea (OSA) (240.4.1)
Effective Date: March 3, 2009
Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (240.4)
Effective Date: March 13, 2008
Medicare Part A/B – Local Coverage Determinations
The following chart lists all sleep policy LCDs organized by MAC.
| MAC | LCD |
|---|---|
| Wisconsin Physicians Service Insurance Corporation
Jurisdiction 5, 8 |
POLYSOMNOGRAPHY and Other Sleep Studies L36839
Effective Date: January 1, 2018 |
| Wisconsin Physicians Service Insurance Corporation
Jurisdiction 5, 8 |
Surgical Treatment of Obstructive Sleep Apnea (OSA) L34526
Effective Date: January 1, 2018 |
| CGS Administrators, LLC
Jurisdiction 15 |
POLYSOMNOGRAPHY and Other Sleep Studies L36902
Effective Date: March 6, 2017 |
| Noridian Healthcare Solutions, LLC
Jurisdiction E |
POLYSOMNOGRAPHY and Other Sleep Studies L36861
Effective Date: October 1, 2017 |
| Noridian Healthcare Solutions, LLC
Jurisdiction F |
POLYSOMNOGRAPHY and Other Sleep Studies L34040
Effective Date: October 1, 2017 |
| Palmetto GBA, LLC
Jurisdiction J, M |
POLYSOMNOGRAPHY L36593
Effective Date: March 8, 2018 |
| First Coast Service Options, Inc.
Jurisdiction N |
POLYSOMNOGRAPHY and Sleep Testing L33405
Effective Date: March 15, 2018 |
| Novitas Solutions, Inc.
Jurisdictions H, L |
Outpatient Sleep Studies L35050
Effective Date: March 8, 2018 |
DME – Local Coverage Determinations
The following chart lists all of the LCDs and Local Coverage Articles for Positive Airway Pressure (PAP) devices and Oral Appliances for the treatment of OSA.
| DME MAC | LCD | Local Coverage Article |
|---|---|---|
| CGS Administrators, LLC
Jurisdictions B, C
Noridian Healthcare Solutions, LLC Jurisdictions A, D |
Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718)
Effective Date: January 1, 2017 |
Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea – Policy Article (A52467) |
| Oral Appliances for Obstructive Sleep Apnea (L33611)
Effective Date: January 1, 2017 |
Oral Appliances for Obstructive Sleep Apnea – Policy Article (A52512) |