Engage in Medicare Coverage and Payment Policy Locally

ASA is looking for the Contractor Advisory Committee (CAC) representatives for all states across the country to successfully address Medicare coverage issues at the local level. In order to understand how the CACs are able to influence local coverage and payment policies, you need to know how Medicare policies get implemented at the local level. The Centers for Medicare & Medicaid Services (CMS) contracts with insurance carriers, known as Medicare Administrative Contractors (MACs), to administer the Medicare program in assigned jurisdictions by servicing physicians and suppliers. In addition to processing and paying claims, a MAC’s scope of work includes establishing Local Coverage Determinations (LCDs) for many services where there is no established national policy. §1869(f)(2)(B) of the Social Security Act (asamonitor.pub/49tCdiQ) defines an LCD as a determination by a MAC regarding whether or not a particular item or service is covered in a MAC’s jurisdiction in accordance with Section 1862(a)(1)(A) of the Social Security Act (asamonitor.pub/3PUycge).

When MACs receive a request for coverage of a service, they review the request and publish a draft LCD on their website. The public then has 45 days to provide comment on the draft LCD. MACs also hold open meetings to discuss evidence/literatures of the draft LCD. MACs are expected to respond to the comments they receive. Contractor Medical Directors (CMDs) rely on the input they receive from a variety of sources, including the CACs, to make all final determinations. CAC representatives provide Contractor Medical Directors with specialty-specific input and comments on certain LCDs. Each specialty, such as anesthesiology, has one representative and an alternate representative from each state. CAC members are usually physicians, but they also can include beneficiary representatives or representatives of other medical organizations.

The CAC representatives will monitor policy changes that affect anesthesiology practices through the LCD process and review the quality of the clinical evidence/literature used in the development of the LCD and/or provide additional evidence in order to get coverage for the service included in the LCD. They interact with Contractor Medical Directors by engaging in collaborative discussions and providing advice based on their expertise to facilitate better policies.

The MACs publish the final LCD on their website 45 days before the LCD becomes effective. Similarly, providers and other interested parties can sign up for a listserv in order to receive the announcements of LCDs via email. If the decision is not favorable, a request for reconsideration of the final LCD can be submitted to the MAC in writing, along with the new evidence to support the coverage decision.

Specialty representation in the CAC process is essential in shaping medical policies at state levels. ASA would like to ensure that there is representation for anesthesia and pain services in each state. However, ASA currently doesn’t have CAC representatives from all 50 states. Additionally, in some cases states do not routinely replace positions when their representatives rotate off after serving many years. We are hoping that all state component leaders will appoint two people as their state’s CAC representative and alternate representative. To connect your newly appointed or affirmed representative for your state, please reach out to ASA at PPM@asahq.org.