Medicare Hopes New Program Manual Will Boost Beneficiary Visibility

November 2018

The Centers for Medicare & Medicaid Services (CMS) is hoping that some changes to Medicare’s Program Integrity Manual will improve patient access to care and health care devices.

The changes are designed to make it easier for Medicare Administrative Contractors (MACs) to administer control over local coverage determinations (LCDs).

Doctor reviews information with patient

What is a MAC?

A MAC is a private insurer that has been granted jurisdiction to approve and process Medicare claims. When an item or service is not covered nationally or is not covered fully enough by Medicare, the MAC will typically determine the coverage on a local level, known as an LCD.

The changes made are designed to make the process of determining the LCD simpler and clearer, will in turn hopefully lead to easier access to medical services and devices for Medicare beneficiaries, especially beneficiaries in a Medicare Private-Fee-For-Service plan.

The changes include:

  • Requiring a consistent, standardized summary of the clinical evidence supporting LCD decisions.

  • Including a beneficiary representative and other health care professionals – in addition to physicians – on Contractor Advisory Committees that inform LCDs.

  • Ensuring that Contractor Advisory Committee meetings are open to the public.

  • Redesigning the manual so it reads more like a “roadmap” to help stakeholders further engage in the LCD process and outline expectations for MACs.

The changes came in response to the 21st Century Cures Act, which stated that the CMS must create more transparency about the LCD process.

How do these changes help Medicare beneficiaries?

The changes also pave the way for better patient involvement in the LCD process. Instead of having to attend an in-person meeting to request an LCD, patients may now tune in to a webinar to submit an LCD request.

The CMS also hopes that the changes will help the organization better understand what patients need to improve their health and wellness and lower the cost of care by removing some administrative hurdles.

The moves are the latest in the CMS Patients Over Paperwork initiative, which aims to reduce some of the bureaucratic obstacles to patient care and service.