National Coverage Determinations (NCDs) are binding on all Medicare contractors, quality improvement organizations, health maintenance organizations, competitive medical plans and health care prepayment plans. The Secretary of the Department of Health and Human Services determines whether a particular item or service is covered nationally by Medicare, which essentially grants, limits or excludes national coverage to all Medicare beneficiaries.
However, 90 percent of Medicare policies are established at the local level, providing carriers with tremendous authority over payment policy in a given state. Representatives of the ACR Radiology, Radiation Oncology, and Nuclear Medicine Carrier Advisory Committee (CAC) Network advocate on behalf of radiology and radiology subspecialties for fair reimbursement policies at the local Medicare level. By reviewing and commenting on Local Coverage Decisions (LCDs) and policy changes before they are implemented, the CAC networks help ensure that members are appropriately reimbursed for medically reasonable and necessary services provided to Medicare patients.
Under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the Secretary of HHS is required to make public the factors considered in making National Coverage Determinations of whether an item or service is reasonable and necessary. The Centers for Medicare and Medicaid Services (CMS) guidance documents contain detailed information on the NCD process and decision-making factors to assist parties or organizations that may request an NCD.
Who can request an NCD?
Anyone can request an NCD from CMS. However, "aggrieved" beneficiaries, defined as "individuals entitled to benefits under Part A, or enrolled under Part B, or both, who are in need of the items or services that are the subject of the coverage determination", are given priority. CMS has outlined a specific process for requesting an NCD, which takes 9 months or more from the date the complete request is received by CMS to the date that coverage changes are implemented.
How can I look up an NCD?
CMS maintains an online database of national and local coverage determinations.
What is MEDCAC?
MEDCAC — the Medicare Evidence Development & Coverage Advisory Committee — advises CMS on whether specific medical items and services are reasonable and necessary under Medicare law related to certain NCD submissions. The MEDCAC performs a detailed analysis and provides comments regarding specific clinical and scientific issues in an open and public forum but CMS makes the final decision on coverage issues.
CMS selects members of the MEDCAC based on their background, education and expertise in a wide variety of scientific, clinical and related fields. CMS looks at ethnicity, gender, geography and other diverse views and screens each member for potential conflicts of interest. See the current MEDCAC roster »
A Local Coverage Determination (LCD), established by Section 522 of the Benefits Improvement and Protection Act, is a decision by a Medicare contractor to cover a particular service on an intermediary-wide or carrier-wide basis (i.e., a determination as to whether the service is reasonable and necessary). The difference between Local Medical Review Policies (LMRPS) and LCDs is that LCDs consist only of "reasonable and necessary" information, while LMRPs may also contain category or statutory provisions. The final rule establishing LCDs was published November 11, 2003. Effective December 7, 2003, CMS's contractors began issuing LCDs instead of LMRPs.
Local Medicare policies under development in your state
When a Medicare contractor develops a new LCD or significantly revises an existing one, a 45-day public comment period is required. During this time, Contractor Medical Directors (CMDs) solicit input from members of the CAC. Comments can be submitted to the CMD or electronically through your Medicare contractor's website. After the CMDs have considered all comments received, there is a 45-day notice period prior to implementation of the final LCD.
Check the CMS interactive map to identify your local Medicare contractor contact information. See the CMS website for further guidance on the LCD process.
For questions about the LCD comment process, please contact Anita McGlothlin at email@example.com.
What is the CAC Network?
The ACR CAC Network was developed to encourage communication and coordination among all radiology CAC representatives. The ACR is committed to providing as much assistance as possible to each CAC representative. Adoption of the ACR CAC Networks and the model by the state chapters created a better organized and more effective mechanism for dealing with local Medicare issues.