By Anna Marie Jilla and Carrie Kovar

This article is a part of the March/April, Volume 35, Number 2, Audiology Today issue

This article provides an overview of the United States Medicare coverage determination structure at both the national and local levels. The national and local coverage determinations may change periodically. Readers are encouraged to reference the Centers for Medicare and Medicaid Services (CMS) website for the most up-to-date coverage policies (Centers for Medicare and Medicaid Services, 2021b).

Background on Medicare and Administrative Structure

The Medicare program is the single largest health insurer of Americans and provides health coverage for individuals 65 years of age and older and those with other qualifying conditions. Medicare is a federally sponsored health plan that coordinates health-care benefits for over 63 million beneficiaries (Tarazi et al, 2022).  

CMS is responsible for coordinating benefits but engages operational assistance through Medicare Administrative Contractors (MACs) (FIGURE 1) to process Medicare Part A and Part B claims for beneficiaries. MACs are granted contracts for processing claims by CMS and are defined through regional jurisdictions that may span multiple states. MACs can be seen as the intermediary between beneficiaries, providers, and CMS (Centers for Medicare and Medicaid Services, 2021a).  

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