Friday, September 6, 2019

New LCD Rules 2019: A Flow Chart View

For 2019, CMS posted new rules for the Local Coverage Determination process, the first substantial update since the 1990s.

The CMS rulebook for MACs is online (called Program Integrity Manual, Chapter 13, LCDs).  Find it at CMS, here.

However, it can be confusing to understand what is the same and what is dropped or wholly new.   I've tried to show major features of the old and new process in two slides. 

The PPT slides are open-access in the cloud here.

Old Process 1990s-2018

New Process 2019 Forward

New features include:
  • Special rules for asking for an "Informal Meeting," which MAC can grant at its discretion
  • Special rules for applying for an LCD ("New LCD Request" rules) such as "stating the benefit category"
  • MAC must acknowledge it has received, validated, and queued the LCD request, but there is no timeline for further action.  MAC should NOT say if it views coverage request favorably or unfavorably.
  • CAC meeting is OPTIONAL
  • CAC meeting may be PRIOR to any LCD, as "information gathering" for the MAC
    • MAC controls agenda, speakers, etc
    • CAC must be an open audioconference with later transcript
    • CAC meeting may be multi-MAC
  • New LCDs, LCD restriction, LCD expansion must *all* go through public process
    • This is a big change in regard to LCD expansions, which were formally quick online edits.
  • Draft LCD must be killed if not finalized in 1 year

Expect the process to take a full year. 

Example:  MAC request from stakeholder in January, with publications.  MAC holds informal meeting in February.  MAC holds CAC meeting in May.  MAC writes draft LCD in June.  Draft LCD circulated to CMS in July (in case CMS has any questions).  LCD draft posted in August.  Public meeting in September.  45 day comment period to November 1.  MAC reviews comments in November, December, January.  MAC posts revised LCD in February, effective April. 


All draft and active LCDs are in an online CMS database, here.


There was a CMS press release on the changes in October 2018, but frankly, I found it more confusing than helpful and it discussed a "faster" process which I can't see in the real world.  Here.