Medicare Policies 2017-09-19T20:39:48+00:00

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 Cahaba Government Benefit Administrators, 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 Part A Index

Medicare Part B 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

POLYSOMNOGRAPHY and Other Sleep Studies L36839

Effective Date: July 1, 2017

Wisconsin Physicians Service Insurance Corporation

Jurisdiction 5

Surgical Treatment of Obstructive Sleep Apnea (OSA) L34526

Effective Date: January 1, 2017

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: June 5, 2017

Noridian Healthcare Solutions, LLC

Jurisdiction F

POLYSOMNOGRAPHY and Other Sleep Studies L34040

Effective Date: June 5, 2017

Palmetto GBA, LLC

Jurisdiction M

POLYSOMNOGRAPHY L36593

Effective Date: April 27, 2017

First Coast Service Options, Inc.

Jurisdiction N

POLYSOMNOGRAPHY and Sleep Testing L33405

Effective Date: December 21, 2015

Cahaba Government Benefit Administrators

Jurisdiction J

Home Sleep Test (HST) L36745

Effective Date: December 1, 2016

Novitas Solutions, Inc.

Jurisdictions H, L

Outpatient Sleep Studies L35050

Effective Date: October 1, 2016

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.