Local coverage determination (LCD) policies issued by Medicare administrative contractors (MACs) serve as the workhorse of Medicare coverage policy. About 90 percent of coverage determinations are made through LCDs. Coverage policies include a defined list of services the insurer will cover and specific exclusions. Medicare provides coverage of services that are determined to be “reasonable and necessary” for Medicare beneficiaries. If a specific item or service is not covered under an LCD, this does not mean it isn’t covered. Claims may be adjudicated on a case-by-case basis. The Centers for Medicare and Medicaid Services (CMS) also issues national coverage determination (NCD) policies that provide nationwide uniform coverage of medical items and services.
Effective January 8, 2019, CMS implemented multiple changes to the LCD process to address reconsideration of existing LCDs and consideration of requests for new local coverage policies. Some of these changes were required by statute, while others reflect input received through formal rulemaking. The changes are meant to increase transparency in the LCD process, address process reforms, and provide opportunities for stakeholder involvement in the process.
Each Medicare administrative contractor established procedures to implement the new CMS LCD process. We encourage you to view your MAC’s website for guidance on the new CMS LCD process. Some highlights of the new process include the following:
- The MAC must post the coverage determination in its entirety including where and when the proposed determination was first made public.
- MACs must provide a summary of evidence considered by the contractor during the development of the LCD and a response to individual comments submitted on the LCD.
- MACs must include the rationale that supports the LCD.
- Proposed LCDs must be posted for public comment for at least 45 days.
- MACs must post the final LCD at least 45 days before the effective date.
- Contractor Advisory Committees (CACs) (sometimes known as Carrier Advisory Committees) must include external representation from the stakeholder community.
- CMS determined that MACs may convene multijurisdictional Contractor Advisory Committees.
A detailed description of these CMS updates to the LCD process may be found in the CMS Medicare Program Integrity Manual. Additional information is also available through a MedLearn Matters article at www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmatt....
The Academy works hard to track LCD policy changes or other carrier actions that might affect the provision of hearing health services to Medicare beneficiaries. However, local level member involvement is the key to ensuring that audiology is adequately represented before local Medicare administrative contractors.
We encourage you to get to know the relevant medical directors of your MAC. Build a relationship and offer yourself as a resource. Check out your MAC website for opportunities to join the MAC’s Contractor Advisory Committee. If you are appointed, you will have the opportunity to provide important input on the development and review of requests for new Medicare LCDs. Payer advocacy is both a right and a responsibility. No one is a more effective advocate for audiology than you can be!