Medicare LCD and Local Coverage Determinations What is a Medicare LCD? Social Security Act (the Act) Section 1869(f)(2)(B) defines Medicare Local coverage determinations (LCDS). This section provides:
To elaborate, the Social Security Act states, “For purposes of this section, the term ‘local coverage determination’ means a determination by a fiscal intermediary.
(A fiscal intermediary is now called a Medicare Administrative Contractor, or ‘MAC.’ ) or a carrier under [Medicare] part A or part B.
The last part of the Act states, “…as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1862(a)(1)(A).”
What is a Medicare NCD? In short, Medicare National Coverage Determinations, or Medicare NCDs, broadly set national policy. NCDs are supposed to be ‘evidence-based,’ meaning they are based on objective medical data. CMS uses “MEDCAC” to do this. Independent guidance is found in the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). MEDAC provides independent guidance and expert advice to CMS on specific clinical topics.
Medicare LCD Modernization To elaborate, U.S. Office of the Inspector General (OIG) has pointed out that LCDs have been inconsistent and sometimes conflicting .
As a result, the Centers for Medicare and Medicaid Services (CMS) started an LCD modernization process . CMS has revised the Medicare Program Integrity Manual (PIM), Chapter 13 – Local Coverage Determinations (Pub 100-08).
Above all, Medicare Administrative Contractors (or ‘MACs) have the authority and responsibility to develop LCDs for their jurisdictions. To be clear, CMS also intends that LCDs are consistent between all MACs and all jurisdictions and expects that MACs meet and confer regarding these consistencies prior to publication of an LCD.
Active Medicare LCDs, Clinically Appropriate LCD, Medicare Administrative Contractor recommendations to CMS To explain, the new process is intended to provide greater transparency, consistency and patient engagement, as well as support larger CMS innovation initiatives. The revised PIM guides stakeholders by describing the process, what to expect, and how to provide feedback to MACs. It also clarifies CMS’s expectations for MACs.
For example, the new PIM provides the following component of its process before a Medicare LCD is finalized.
First, the new PIM states, “After the proposed LCD is made public, MACs shall hold open meetings to discuss the review of the evidence and the rationale for the proposed LCD(s)…”
Second, the new approach requires review “…with stakeholders in their jurisdiction. The open meeting should endeavor to accommodate some in-person attendance, subject to limitations based on venue.
And thrd, “Interested parties (generally those that would be affected by the LCD, including providers, physicians, vendors, manufacturers, beneficiaries, caregivers, etc.) can make presentations of information related to the proposed LCDs”
How Do you Find a Medicare LCD for Your Jurisdiction? The Medicare Administrative Contractors are listed below as of October 2021 by State, Jurisdiction, and the name of the MAC:
State Jurisdiction (J) Medicare Administrative Contractor (MAC) Medicare LCDs for Alabama DME MAC – JC Alabama DME MAC – JC is CGS Administrators, LLC A/B MAC – JJ Palmetto GBA, LLC HH + H MAC – JM Same as above Medicare LCDs ForAlaska DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JF Same as above HH+ H MAC – J6 Services, Inc. American Samoa DME MAC – JD Same as above A/B MAC – JE Noridian Healthcare Solutions, LLC HH + H MAC – J6 National Government Services, Inc. Arizona DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JF Noridian Healthcare Solutions, LLC HH + H MAC – J6 National Government Services, Inc. Arkansas DME MAC – JC CGS Administrators, LLC A/B MAC – JH Novitas Solutions, Inc. HH + H MAC – JM Palmetto GBA, LLC Medicare LCDs for California DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JE Noridian Healthcare Solutions, LLC HH + H MAC – J6 National Government Services, Inc. Colorado DME MAC – JC CGS Administrators, LLC A/B MAC – JH Novitas Solutions, Inc. HH + H MAC – J15 CGS Administrators, LLC Medicare LCDs for Connecticut DME MAC – JA Noridian Healthcare Solutions, LLC A/B MAC – JK National Government Services, Inc. HH + H MAC – JK National Government Services, Inc. Delaware DME MAC – JA Noridian Healthcare Solutions, LLC A/B MAC – JL Novitas Solutions, Inc. HH + H MAC – J15 CGS Administrators, LLC District of Columbia DME MAC – JA Noridian Healthcare Solutions, LLC A/B MAC – JL Novitas Solutions, Inc. HH + H MAC – J15 CGS Administrators, LLC Florida Medicare Local Coverage Determinations DME MAC – JC CGS Administrators, LLC A/B MAC – JN First Coast Service Options, Inc. HH + H MAC – JM Palmetto GBA, LLC Georgia DME MAC – JC CGS Administrators, LLC A/B MAC – JJ Palmetto GBA, LLC HH + H MAC – JM Palmetto GBA, LLC Guam DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JE Noridian Healthcare Solutions, LLC HH + H MAC – J6 National Government Services, Inc. Medicare LCDs for Hawaii DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JE Noridian Healthcare Solutions, LLC HH + H MAC – J6 National Government Services, Inc. Idaho Medicare LCDs DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JF Noridian Healthcare Solutions, LLC HH + H MAC – J6 National Government Services, Inc. Illinois DME MAC – JB CGS Administrators, LLC A/B MAC – J6 National Government Services, Inc. HH + H MAC – JM Palmetto GBA, LLC Indiana DME MAC – JB CGS Administrators, LLC A/B MAC – J8 Wisconsin Physicians Service Government Health Administrators HH + H MAC – JM Palmetto GBA, LLC Iowa DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – J5 Wisconsin Physicians Service Government Health Administrators HH + H MAC – J15 CGS Administrators, LLC Kansas DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – J5 Wisconsin Physicians Service Government Health Administrators HH + H MAC – J15 CGS Administrators, LLC Kentucky DME MAC – JB CGS Administrators, LLC A/B MAC – J15 CGS Administrators, LLC HH + H MAC – JM Palmetto GBA, LLC Louisiana DME MAC – JC CGS Administrators, LLC A/B MAC – JH Novitas Solutions, Inc. HH + H MAC – JM Palmetto GBA, LLC Maine DME MAC – JA Noridian Healthcare Solutions, LLC A/B MAC – JK National Government Services, Inc. HH + H MAC – JK National Government Services, Inc. Medicare LCDs for Maryland DME MAC – JA Noridian Healthcare Solutions, LLC A/B MAC – JL Novitas Solutions, Inc. HH + H MAC – J15 CGS Administrators, LLC Medicare LCDs for Massachusetts DME MAC – JA Noridian Healthcare Solutions, LLC A/B MAC – JK National Government Services, Inc. HH + H MAC – JK National Government Services, Inc. Michigan DME MAC – JB CGS Administrators, LLC A/B MAC – J8 Wisconsin Physicians Service Government Health Administrators HH + H MAC – J6 National Government Services, Inc. Minnesota DME MAC – JB CGS Administrators, LLC A/B MAC – J6 National Government Services, Inc. HH + H MAC – J6 National Government Services, Inc. Mississippi DME MAC – JC CGS Administrators, LLC A/B MAC – JH Novitas Solutions, Inc. HH + H MAC – JM Palmetto GBA, LLC Missouri DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – J5 Wisconsin Physicians Service Government Health Administrators HH + H MAC – J15 CGS Administrators, LLC Montana DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JF Noridian Healthcare Solutions, LLC HH + H MAC – J15 CGS Administrators, LLC Nebraska DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – J5 Wisconsin Physicians Service Government Health Administrators HH + H MAC – J15 CGS Administrators, LLC Nevada DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JE Noridian Healthcare Solutions, LLC HH + H MAC – J6 National Government Services, Inc. New Hampshire DME MAC – JA Noridian Healthcare Solutions, LLC A/B MAC – JK National Government Services, Inc. HH + H MAC – JK National Government Services, Inc. New Jersey DME MAC – JA Noridian Healthcare Solutions, LLC A/B MAC – JL Novitas Solutions, Inc. HH + H MAC – J6 National Government Services, Inc. New Mexico DME MAC – JC CGS Administrators, LLC A/B MAC – JH Novitas Solutions, Inc. HH + H MAC – JM Palmetto GBA, LLC New York Medicare LCDs DME MAC – JA Noridian Healthcare Solutions, LLC A/B MAC – JK National Government Services, Inc. HH + H MAC – J6 National Government Services, Inc. North Carolina Medicare LCDs DME MAC – JC CGS Administrators, LLC A/B MAC – JM Palmetto GBA, LLC HH + H MAC – JM Palmetto GBA, LLC North Dakota Medicare LCDs DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JF Noridian Healthcare Solutions, LLC HH + H MAC – J15 CGS Administrators, LLC Northern Mariana Islands Medicare LCS DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JE Noridian Healthcare Solutions, LLC HH + H MAC – J6 National Government Services, Inc. Ohio Medicare Local Coverage Determinations DME MAC – JB CGS Administrators, LLC A/B MAC – J15 CGS Administrators, LLC HH + H MAC – JM Palmetto GBA, LLC Oklahoma Medicare LCDs DME MAC – JC CGS Administrators, LLC A/B MAC – JH Novitas Solutions, Inc. HH + H MAC – JM Palmetto GBA, LLC Oregon Medicare Coverage Determinations DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JF Noridian Healthcare Solutions, LLC HH + H MAC – J6 National Government Services, Inc. Medicare LCDs for Pennsylvania DME MAC – JA Noridian Healthcare Solutions, LLC A/B MAC – JL Novitas Solutions, Inc. HH + H MAC – J15 CGS Administrators, LLC Medicare LCDs for Puerto Rico DME MAC – JC CGS Administrators, LLC A/B MAC – JN First Coast Service Options, Inc. HH + H MAC – J6 National Government Services, Inc. Rhode Island DME MAC – JA Noridian Healthcare Solutions, LLC A/B MAC – JK National Government Services, Inc. HH + H MAC – JK National Government Services, Inc. Medicare LCDs for South Carolina DME MAC – JC CGS Administrators, LLC A/B MAC – JM Palmetto GBA, LLC HH + H MAC – J M Palmetto GBA, LLC South Dakota DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JF Noridian Healthcare Solutions, LLC HH + H MAC – J15 CGS Administrators, LLC Tennessee DME MAC – JC CGS Administrators, LLC A/B MAC – JJ Palmetto GBA, LLC HH + H MAC – JM Palmetto GBA, LLC Medicare LCDs for Texas DME MAC – JC CGS Administrators, LLC A/B MAC – JH Novitas Solutions, Inc. HH + H MAC – JM Palmetto GBA, LLC Utah Medicare LCDs DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JF Noridian Healthcare Solutions, LLC HH + H MAC – J15 CGS Administrators, LLC Vermont Medicare LCDs DME MAC – JA Noridian Healthcare Solutions, LLC A/B MAC – JK National Government Services, Inc. HH + H MAC – JK National Government Services, Inc. Medicare LCDs for Virgin Islands DME MAC – JC CGS Administrators, LLC A/B MAC – JN First Coast Service Options, Inc. HH + H MAC – J6 National Government Services, Inc. Virginia DME MAC – JC CGS Administrators, LLC A/B MAC – JL Novitas Solutions, Inc. (includes Part B for counties of Arlington and Fairfax, and the city of Alexandria) A/B MAC – JM Palmetto GBA, LLC (excludes Part B for the counties of Arlington and Fairfax, and the city of Alexandria) CGS Administrators, LLC HH + H MAC – J15 Medicare LCDs for Washington DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JF Noridian Healthcare Solutions, LLC HH + H MAC – J6 National Government Services, Inc. Medicare LCDs for West Virginia DME MAC – JC CGS Administrators, LLC A/B MAC – JM Palmetto GBA, LLC HH + H MAC – J15 CGS Administrators, LLC Wisconsin Medicare Local Coverage Determinations DME MAC – JB CGS Administrators, LLC A/B MAC – J6 National Government Services, Inc. HH + H MAC – J6 National Government Services, Inc. Medicare LCDs for Wyoming DME MAC – JD Noridian Healthcare Solutions, LLC A/B MAC – JF Noridian Healthcare Solutions, LLC HH + H MAC – J15 CGS Administrators, LLC
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