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. MACs establish Local Coverage Determinations (LCDs) for certain services when there is no established national policy. When MACS make coverage determinations, they receive input from Contractor Advisory Committees (CACs).

Section §1869(f)(2)(B) of the Social Security Act (SSA), established LCDs.

The 21st Century Cures Act of 2016 added language to section 1862(l)(5)(D) of the SSA directing the Secretary of the Department of Health and Human Services to improve the transparency of the LCD process.¹

CACs supplements a MAC’s internal expertise and ensures unbiased and contemporary consideration of technology and science.¹

MACs must form CACs for each state within its jurisdiction. States with multiple MACs establish joint CACs. CACs are composed of healthcare professionals, beneficiary representatives, and medical organization representatives. MACs ensure that each medical specialty that serves on the CAC has at least one member and a designated alternate.¹ CACs provide a formal mechanism for healthcare professionals in the state to be informed of and participate in the development of an LCD in an advisory capacity. CACs also discuss and improve administrative policies that are within carrier discretion and advise CMDs on certain draft LCDs.²

CAC representatives provide Contractor Medical Directors (CMDs) with specialty-specific input and comments on certain LCDs. While CACs advise MACs on draft LCDs, CMDs make all ultimate decisions. At the beginning of the coverage determination process, CMDs release draft LCDs with a 45-day minimum comment period. During that time, CMDs can receive input from CACs, impacted physicians, specialty societies and other interested stakeholders.² CAC meetings are at the discretion of the MAC and the frequency is based on the appropriateness and on the volume of LCDs that require CAC consultation. The CAC meetings are recorded and maintained on each MACs respective website. CAC meeting can be in-person or online, the meetings are open to the public to attend and observe. The portions of the meeting not discussing evidence for a proposed LCD (e.g. provider practice trend reporting) may be closed to the public.¹

90 percent of Medicare policies are established at the local level, providing contractors with tremendous authority over payment policy in a given state.³

Participation in a CAC is voluntary, MACs do not provide an honorarium or any compensation to members. Expenses are the responsibility of the individuals or the associations they represent.¹

1. United States Department of Health and Human Services. Medicare Program Integrity Manual Chapter 13 – Local Coverage Determinations. Centers for Medicare & Medicaid Services.

2. Contractor Advisory Committee (CAC) 101. American Society of Anesthesiologists; 2014. https://www.asahq.org/-/media/sites/asahq/files/public/resources/practice-management/2014-11-20-cac-101.pdf?la=en&hash=178FEC93EF1A19E87103279621871AAD543555EB. 

3. National and Local Coverage Determinations. Acr.org. https://www.acr.org/Advocacy-and-Economics/Radiology-Economics/Medicare-Medicaid/Coverage.