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determination

What is determination?

What is determination?

Determination in Original Medicare is a reference to either the National Coverage Determination (NCD)1 process or a Local Coverage Determination (LCD) process,2 under which rules are established for what services Medicare will cover.

Medicare Advantage plans are required to cover all services that are covered by Original Medicare, and they can also cover various additional services.3

But Medicare Advantage plans and Medicare Part D plans also have their own coverage determination protocols to ensure, for example, that prior authorization is obtained when necessary, or that an enrollee is using an in-network medical provider if that’s a plan requirement.

Enrollees can request a coverage determination from their Medicare Advantage or Part D insurer, to find out whether a particular service will be covered.4

Footnotes
  1. ”Medicare Coverage Determination Process” Centers for Medicare & Medicaid Services. Accessed June 27, 2025 ⤶
  2. ”Local Coverage Determinations” Centers for Medicare & Medicaid Services. Accessed June 27, 2025 ⤶
  3. ”Understanding Medicare Advantage plans” Medicare.gov. Accessed June 27, 2205 ⤶
  4. ”Coverage Determinations” Centers for Medicare & Medicaid Services. Accessed June 27, 2025 ⤶

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