Benefit Category Determinations

On December 21, 2021 CMS released an early Christmas present for stakeholders who have clamored for many years for a formalized process for making benefit category determinations (BCD). A BCD is a national decision by CMS whether an item or service meets the statutory definition of a benefit category. Benefit categories include: durable medical equipment, prosthetics, orthotics, supplies and others. When an item meets the definition of a benefit category, it may be covered by Medicare -- as long as the item is not otherwise excluded from coverage by law and is reasonable and necessary for an individual's medical condition.

Since the implementation of Section 531(b) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), CMS has hosted annual public meetings to discuss preliminary coding and payment determinations for new items and services. Since 2005, this process of making preliminary payment determinations has included the determination of whether any new item or service meets the definition of a benefit category as well as how the fee schedule amounts for the items and services are established.

In an effort to increase transparency and structure around the process it uses to make benefit category and payment determinations, CMS elected to establish a regulatory process that mirrors the one that has been used since 2001 for obtaining public consultation on BCDs and payment determinations for new DME and since 2005 for requests for HCPCS codes for items and services other than DME.

This infographic helps show this process.

For more information about this process, and to discuss how it could impact the way that developers commercialize new products, contact us by visiting http://www.policypros.net.

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