The Lymphedema Treatment Act is a federal law passed on December 23, 2022, that will go into effect on January 1, 2024, to improve Medicare insurance coverage for the medically necessary, doctor-prescribed compression supplies that are the cornerstone of lymphedema treatment.
Currently, Medicare and other similar policies do not cover doctor-prescribed compression supplies used daily, which are critical components, of lymphedema treatment. An estimated 3-5 million Americans suffer from lymphedema, a buildup of lymphatic fluid that can be painful and debilitating. Compression supplies can be costly without insurance assistance, and therefore, many patients suffer from worsening progression of their condition without the supplies needed to maintain it. The Center for Medicare Services (CMS) does not have the authority to add or redefine benefit categories, only Congress does, which explains the need for legislation.
What’s happening now with the LTA?
As of March 2023, CMS has been hearing from various stakeholders including the Lymphedema Advocacy Group (LAG), medical societies including the Lymphology Association of North America (LANA) and the National Lymphedema Network (NLN) as well as from a compression-industry coalition, among others.
While the overall process is not concrete, it appears that CMS will draft a guidance document that will be available towards the end of the second quarter. The guidance document will specify who is covered and under what circumstances, as well as what is specifically covered, i.e., supply type, quantity, and frequency.
After the document is published, there will be a period in which feedback is given which typically includes a meeting where presenters have approximately 5 minutes to present optional language and modifications to the proposed guidance document. After the hearing, CMS will publish the final version of the document. At this point, the local administrative entities will enact local coverage determinations based on the guidance document provided.
Local administrative entities will publish more descriptive, intensive articles outlining prerequisites for coverage, qualifications for coverage, limitations, etc. These publications also specify what is needed in documentation, clinical diagnosis, and medical records for coverage.
Following local coverage determination, coding specific to coverage, often HCPC (Healthcare Common Procedure Coding System) codes for supplies and CPT (Current Procedural Terminology) codes for clinical services are structured and the appropriate fee schedules (i.e., what Medicare is going to pay,) will be published towards the end of 2023 for a January 2024 implementation.
medi – An early advocate for change
medi has been a proud sponsor and supporter of the Lymphedema Treatment Act since its inception. Michael Cannon, Director of Training and Education for medi, has been an original board member of the Lymphedema Advocacy Group since 2010, advocating in Washington D.C. with Congressional members to effect change in coverage for the lymphedema community.
What does the Lymphedema Treatment Act do?
The Lymphedema Treatment Act (LTA) will provide Medicare coverage for the diagnosis of Lymphedema by amending the Medicare statute to allow for coverage of compression supplies. Although this legislation relates specifically to a change in Medicare law, it would set a precedent for Medicaid and private insurers to follow.
The Lymphedema Treatment Act will amend Sec. 1861 [42 U.S.C. 1395x] of the Social Security Act to enable coverage of these items under Durable Medical Equipment.
The main highlights of the passing of this bill will be to:
- Improve insurance coverage for prescribed medical compression supplies
- Reduce total healthcare costs with lymphedema
It is important to keep in mind that the above timeline is a rough estimate and may vary based on CMS policy and resources. We do know that this will be a years-long process and we will keep this blog up to date as new information is available.