US · guidance
CMS Pub. 100-16, ch. 4, § 90.3.1
When the Significant Cost Criterion is Not Met
When CMS determines that a NCD or legislative change in benefits does not meet a
criterion for significant cost, the MA plan is required to provide coverage for the NCD or
legislative change in benefits and assume risk for the costs of that service or benefit as of
the effective date of the NCD or as of the date specified in the legislation/regulation.
NCDs are effective on the date that CMS releases the Final Decision Memorandum for
the NCD. The NCD effective date is the date when the new or changed benefit/service
must be made available to enrollees by the plan. The implementation date in the
corresponding Medicare Change Request (CR) /Transmittal guidance (TR) is the latest
date by which MA plans must have payment system edits in place and coverage/non-coverage fully implemented for providers/suppliers. Plans must ensure that the
items/services are covered, and provider claims paid, retroactive to the NCD effective
date. More information related to Medicare CR/TRs and manual guidance may be found
in references provided in section 90.6 below.
History
(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
5e2bebd0d7712f882f0c842fa6689da6f200db5726f468f6408af6e568a63d0e
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