Coverage Determination Clarity Act of 2023

[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5396 Introduced in House (IH)]

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118th CONGRESS
  1st Session
                                H. R. 5396

 To amend title XVIII of the Social Security Act to prohibit Medicare 
local coverage determinations from restricting access to care, and for 
                            other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 12, 2023

 Mr. Bucshon introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on Energy 
    and Commerce, for a period to be subsequently determined by the 
  Speaker, in each case for consideration of such provisions as fall 
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
 To amend title XVIII of the Social Security Act to prohibit Medicare 
local coverage determinations from restricting access to care, and for 
                            other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Coverage Determination Clarity Act 
of 2023''.

SEC. 2. IMPROVING ACCESS TO ITEMS AND SERVICES UNDER MEDICARE LOCAL 
              COVERAGE DETERMINATIONS.

    (a) In General.--Section 1862(l)(5) of the Social Security Act (42 
U.S.C. 1395y(l)(5)) is amended--
            (1) in subparagraph (A), by striking ``The Secretary'' and 
        inserting ``Subject to subparagraph (E), the Secretary''; and
            (2) by adding at the end the following new subparagraph:
                    ``(E) Prohibition on limiting access items and 
                services.--
                            ``(i) Review of local coverage 
                        determinations.--Beginning in 2024, and 
                        annually thereafter, the Secretary shall review 
                        each local coverage determination in effect as 
                        of the date of such review to determine whether 
                        such local coverage determination denies, 
                        limits, or conditions the coverage or provision 
                        of items or services beyond that provided by a 
                        national coverage determination that has 
                        determined that such items or services be 
                        covered nationally under this title.
                            ``(ii) Conflict between a national coverage 
                        determination and a local coverage 
                        determination.--A local coverage determination 
                        denies, limits, or conditions the coverage or 
                        provision of items or services for purposes of 
                        clause (i) to the extent that such local 
                        coverage determination limits access to such 
                        items or services by imposing restrictions that 
                        do not directly interpret provisions of a 
                        national coverage determination that has 
                        determined that such items or services be 
                        covered nationally under this title.
                            ``(iii) Revision of local coverage 
                        determinations.--
                                    ``(I) In general.--If the review 
                                conducted by the Secretary under clause 
                                (i) determines that a local coverage 
                                determination denies, limits, or 
                                conditions the coverage or provision of 
                                items or services that are approved, 
                                cleared, authorized, or licensed under 
                                section 505, 510(k), 513, or 515 of the 
                                Federal Food, Drug, and Cosmetic Act or 
                                section 351 of the Public Health 
                                Service Act, the Secretary shall direct 
                                the appropriate Medicare administrative 
                                contractor to expeditiously revise such 
                                local coverage determination to 
                                eliminate the limitation.
                                    ``(II) Timing.--A Medicare 
                                administrative contractor shall publish 
                                a revised local determination no later 
                                than the date that is 180 days after 
                                the date on which the Secretary directs 
                                such contractor to revise a local 
                                coverage determination under subclause 
                                (I).
                            ``(iv) New local coverage determinations.--
                        The Secretary shall require each Medicare 
                        administrative contractor that develops a local 
                        coverage determination to ensure that any such 
                        local coverage determination does not deny, 
                        limit, or condition the coverage or provision 
                        of items or services pursuant to clause (ii) 
                        beyond that provided by a national coverage 
                        determination that has determined that such 
                        items or services be covered nationally under 
                        this title.
                            ``(v) Error verification and corrective 
                        actions.--In verifying any potential errors and 
                        taking corrective actions, Medicare 
                        administrative contractors, comprehensive error 
                        rate testing recovery auditors, and unified 
                        program integrity contractors and independent 
                        review agencies--
                                    ``(I) shall not deviate from local 
                                coverage determination provisions 
                                applicable in the region in which such 
                                verification or corrective action 
                                occurs; and
                                    ``(II) shall provide transparent 
                                review by publishing the names of the 
                                reviewers and their qualifications in a 
                                place and format available to 
                                providers.
                            ``(vi) Reports to congress.--Beginning in 
                        2025 and each year thereafter, the Secretary 
                        shall submit a report to the appropriate 
                        committees of Congress on the findings of the 
                        review conducted under clause (i) and any local 
                        coverage determinations revised pursuant to 
                        clause (iii) during the preceding year.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply with respect to proposed and final local coverage determinations 
posted on Medicare administrative contractor websites on and after 
January 1, 2023.
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