Dear Senator:
As leading organizations representing the interests of patients, providers and manufacturers, we
write to ask that you cosponsor S.794, the Local Coverage Determination Clarification Act of 2017.
Medicare coverage policy decisions are made nationally and locally. National coverage
decisions (NCDs) are made by CMS to describe the circumstances under which Medicare will
cover an item or service on a nationwide basis. Local Coverage Determinations (LCDs) are
developed by Medicare Administrative Contractors (MACs) on whether, and under what
circumstances, to cover a particular item or service on a contractor-wide basis.
Most coverage policy is determined on a local level by MACs. MACs may make coverage
decisions where the Centers for Medicare and Medicaid has not made a national coverage
determination or where the rules are too vague regarding a specific procedure. LCD policy may
not, however, conflict with a NCD. Although CMS’ Program Integrity Manual instructs MACs
on how to develop LCDs, the current process lacks transparency and sufficient stakeholder
involvement to ensure decisions are in the best interests of patients.
As a result of contractor reforms that have taken place over the past several years, local MACs
are now responsible for much larger jurisdictions, and there are fewer opportunities for
stakeholders to interact with the contractor medical directors who make local medical policies.
As an example, a decision by one MAC could impact beneficiaries in ten states.
Moreover, contractors are allowed to adopt another MAC’s draft LCDs. This ability to
coordinate decisions effectively transforms a local coverage determination into a national one
without having followed the more rigorous national coverage determination requirements. Basic
procedural fairness for patients, providers, manufacturers and other stakeholders is often lacking
in local coverage decisions.
…
Read full letter here
