When the Significant Cost Criterion is Not Met

90.3.1 – When the Significant Cost Criterion is Not Met (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) 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.