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The Contractors Who Determine Medicare Access

Which prescription medications can Medicare beneficiaries access? The answer often lies with little-known entities called Medicare administrative contractors.  

Understanding Medicare Administrative Contractors  

Medicare administrative contractors are private health insurers who process medical claims for Medicare beneficiaries. Each geographic region has its own Medicare administrative contractor, responsible for managing Medicare Part A and B claims

These contractors can play a central role in determining whether Medicare beneficiaries can access their medication. That’s why it’s important that, as medication approvals change, these contractors remain flexible in their coverage approach.  

Medicare administrative contractors’ decisions are implemented through what are known as local coverage determinations. These are policy determinations, where Medicare administrative contractors decide whether a particular medication or service is “reasonable or necessary” and will be covered by Medicare in a given jurisdiction. Where a person lives, therefore, can sometimes determine whether he or she can access the full range of treatments.  

How Medicare Administrative Contractors Limit Patient Care 

To appreciate the impact of Medicare administrative contractors, consider how a medication for gout remains out of reach for many seniors.   

Gout, the most common form of inflammatory arthritis, results in flares – episodes marked by intense joint pain and limited mobility. People living with gout are sometimes prescribed a combination of medications, some to manage the ongoing disease and others to address painful flares. 

One medication, known as corticotropin gel, is on a list of self-administered drugs. Now, the FDA has approved a new, smaller vial to help patients receive timely flare treatment at their point-of-care sites. For these painful and acute episodes, getting treated quickly matters, so the injected medication is probably best administered immediately in a medical provider’s office.

If the physician administers the drug, the service would then be covered under Medicare Part B. But because the drug is only included on the self-administered drug list, the treatment falls under Medicare Part D, meaning providers cannot administer the treatment in their office.  

In short, even though the new dosage to treat gout flares is best administered by a health care provider, if Medicare administrative contractors insist on keeping the medication on the list of self-administered drugs, it will effectively remain out of reach for patients.  

As the gout example illustrates, decisions that belong between a patient and health care provider are too often subject to outside restrictions. Medicare administrative contractors must be more flexible, stay current with new FDA-approved treatments options, and adjust coverage polices so that patients get the tailored care that meets their needs. 

Understanding how third parties like Medicare administrative contractors influence health care decisions is important if patients and providers are to advocate for better access within the Medicare system.

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