Medicare Advantage

Commercial and Medicare Policy Directory

Medicare Advantage Management (132)

Medicare Advantage Policies

As a third party that administers Medicare Advantage products, Blue Cross Blue Shield of Massachusetts uses guidance from the Centers for Medicare and Medicaid Services (CMS) for coverage determinations. Coverage determinations are based on National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). In addition, available CMS Medicare-related manuals are used to guide medical policy for Medicare Advantage members.

National Coverage Determinations (NCD)

Blue Cross Blue Shield is required to make coverage determinations for services through the CMS National Coverage Determination policies and benefit manuals. When there is no National Coverage Determination, Blue Cross Blue Shield of Massachusetts Commercial medical policies are followed for Medicare Advantage members.

Local Coverage Determinations (LCD) Massachusetts Jurisdiction

Blue Cross Blue Shield of Massachusetts is required to make coverage determinations for services that each Medicare Administrative Contractor publishes as the Local Coverage Determination. The Local Coverage Determinations used for coverage determinations are based on the jurisdiction of the member’s residency (unless otherwise specified by CMS). When there is no Local Coverage Determination or benefit statement that addresses the service/procedure, Blue Cross Blue Shield of Massachusetts Commercial medical policies are followed for Medicare Advantage members.

Local Coverage Determinations Molecular Diagnostic Tests (MolDX) Program by Palmetto GBA
Blue Cross Blue Shield of Massachusetts is required to make coverage determinations for services that each Medicare Administrative Contractor publishes as the Local Coverage Determination. When there is no Molecular Diagnostic Test Program Local Coverage Determination (MolDX LCD) on the jurisdiction of the member’s residency, Palmetto GBA MolDX Local Coverage Determinations are followed for Medicare Advantage members.