FAQ

Frequently Asked Questions

Medicare is a promise to our nation’s seniors. It should safeguard them from unnecessary hardship later in life, not create more uncertainty and concern about the availability of the best treatment options available.

Early intervention in cancer diagnoses lead to better outcomes – meaning our senior citizens can enjoy a longer life. As part of 60 Plus’s commitment to advancing access to quality healthcare for senior citizens, we are fighting to ensure those on Medicare have access to the treatment that best suits their health needs.

Critical decisions about selecting the best treatment pathway for an individual senior should be in the hands of their medical professionals, not middlemen who have a financial incentive to deny access to innovative testing.

A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a contract by the Centers for Medicare and Medicaid Services (CMS) to process Medicare Part A and Part B (A/B) medical claims for Medicare Fee-For-Service (FFS) beneficiaries within a specific geographic jurisdiction. There are 7 MACs that operate across the county.

CMS relies on a network of MACs to serve as the primary operational contact between Medicare FFS programs and health care providers. MACs provide many services, including:

  • Make and account for Medicare FFS payments
  • Enroll providers in the Medicare FFS program
  • Handle provider reimbursement services and audit institutional provider cost reports
  • Handle redetermination requests (1st stage appeals process)
  • Respond to provider inquiries
  • Educate providers about Medicare FFS billing requirements
  • Review medical records for selected claims
  • Coordinate with CMS and other FFS contractors
  • Establish local coverage determinations (LCD’s)

MACs are charged with determining whether tests meet the Centers for Medicare and Medicaid Services’ statutorily defined definitions of medical necessity and reasonableness and should be covered by Medicare. MACs perform this determination by conducting a review of the medical evidence supporting the use of a specific test which evaluates the medical evidence through the lens of CMS’ definitions of medical necessity and reasonableness. These evidence reviews are formalized in the Local Coverage Determination process.

A Local Coverage Determination (LCD) is a formalized process whereby a Medicare Administrative Contractor (MAC) reviews and determines whether or not an item or service is covered within the jurisdiction of the MAC.

LCDs can be requested by beneficiaries, healthcare professionals, or any interested party within the MAC’s jurisdiction. When making an LCD request, askers must present peer-reviewed evidence for review, justification of medical use, and include information addressing the relevance, usefulness, clinical health outcomes, or medical benefits of the item or service.

Once received, the MAC of jurisdiction will review the request in 60 calendar days. If the request is complete and valid, the MAC will begin the LCD development process. Unfortunately, once the LCD process begins, it may take up to four years for a MAC to publish a coverage decision.

Unfortunately, many Americans know someone who has been diagnosed with cancer, especially as they grow older. While cancer can be diagnosed at any age, for Americans 60 years and older, one in one thousand people are diagnosed with cancer. Moreover, 68 million Americans are beneficiaries of Medicare.

The decision process can run awry due to little supervision from CMS, and MACs are left to make decisions with broad, sweeping impact unchecked. This costs America’s senior citizens and Medicare beneficiaries time as they are left to wait, while the middlemen make unilateral, flawed decisions that deny seniors the best treatment plan approaches as determined by their doctors—including access to both older and newer, advanced diagnostic tests.

Recently, innovative diagnostic tests have been developed that enable clinicians and their patients to select the best treatment plan approaches for their patient specific cancer as opposed to a population based one size fits all approach. However, we are seeing the decision process for covering such diagnostics fail by MACs implementing coverage decisions at odds with the CMS established definition for medical reasonableness and necessity and reversing coverage for tests with long-standing clinical use.

MACs have introduced LCDs which have removed coverage or are threatening coverage for various cancer diagnostic tests. If Medicare does not cover these tests, clinicians and patients won’t use them, and they will instead default to one size fits all treatment plans that can include unnecessary radiation therapy and unnecessary surgery. While this alone is an upsetting reality, the impact of MACs is felt by not only the patients, but also their families and loved ones.

Secure Our Care is a project of 60 Plus, a non-partisan, non-profit organization that advocates for seniors and advances causes that matter most to seniors and their families. Founded in 1992, 60 Plus Association, the American Association of Senior Citizens is a 501c4 non-partisan, non-profit organization that advocates for seniors who believe in market-based solutions and are dedicated to protecting your right to freedom of speech and limited but effective government. We are committed to educating and advancing issues that matter most to seniors and their families such as protecting Social Security and Medicare, ensuring access to quality medical care, expanded educational options, lower taxes, retirement security, energy independence and permanently repealing the death tax.