[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2356 Introduced in House (IH)]







106th CONGRESS
  1st Session
                                H. R. 2356

   To amend title XVIII of the Social Security Act to improve review 
 procedures under the Medicare Program by making those procedures more 
equitable and efficient for beneficiaries and other claimants, and for 
                            other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             June 24, 1999

 Mr. Thomas (for himself, Mr. Stark, Mrs. Johnson of Connecticut, Mr. 
McCrery, Mr. Sam Johnson of Texas, Mr. Camp, Mr. Ramstad, Mr. English, 
 Mr. McIntosh, and Mr. LoBiondo) introduced the following bill; which 
was referred to the Committee on Ways and Means, and in addition to the 
 Committee on 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 improve review 
 procedures under the Medicare Program by making those procedures more 
equitable and efficient for beneficiaries and other claimants, 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 ``Medicare Patient Appeals Act of 
1999''.

SEC. 2. REVISION OF APPEALS PROCESS.

    (a) Deadlines for Consideration of Appeals.--Section 1869 of the 
Social Security Act (42 U.S.C. 1395ff) is amended--
            (1) in subsection (a), by inserting ``consistent with 
        subsections (c) and (d)'' before the period; and
            (2) by adding at the end the following new subsections:
    ``(c) Deadlines for Reconsiderations and Appeals Under Part A.--
Reconsideration and appeals under subsections (a) and (b) with respect 
to matters under part A shall be conducted consistent with the 
following:
            ``(1) Deadlines for administrative action.--
                    ``(A) Reconsidered determination.--The Secretary 
                shall conduct and conclude a reconsideration of an 
                initial determination, and mail the notice of 
                reconsidered determination, by not later than the end 
                of the 60-day period beginning on the date a request 
                for reconsideration has been timely filed.
                    ``(B) Hearing by administrative law judge.--
                            ``(i) In general.--Except as provided in 
                        clause (ii), an administrative law judge shall 
                        conduct and conclude a hearing and render a 
                        decision on such hearing by not later than the 
                        end of the 90-day period beginning on the date 
                        a request for hearing has been timely filed.
                            ``(ii) Waiver of deadline by party seeking 
                        hearing.--The 90-day period under clause (i) 
                        shall not apply in the case of a motion or 
                        stipulation by the party requesting the hearing 
                        to waive such period.
                    ``(C) Departmental appeals board review.--The 
                Departmental Appeals Board of the Department of Health 
                and Human Services shall conduct and conclude a review 
                of the decision on a hearing described in subparagraph 
                (B) and make a decision or remand the case to the 
                administrative law judge for reconsideration by not 
                later than the end of the 90-day period beginning on 
                the date a request for review has been timely filed.
            ``(2) Consequences of failure to meet deadlines.--
                    ``(A) In general.--(i) In the case of a failure by 
                the Secretary to mail the notice of reconsidered 
                determination by the end of the period described in 
                paragraph (1)(A), the party requesting the 
                reconsideration may request a hearing before an 
                administrative law judge, notwithstanding any 
                requirements for a reconsidered determination for 
                purposes of the party's right to such hearing.
                    ``(ii) In the case of a failure by an 
                administrative law judge to render a decision by the 
                end of the period described in paragraph (1)(B), the 
                party requesting the hearing may request a review by 
                the Departmental Appeals Board of the Department of 
                Health and Human Services, notwithstanding any 
                requirements for a hearing for purposes of the party's 
                right to such a review.
                    ``(B) DAB hearing procedure.--In the case of a 
                request described in subparagraph (A)(ii), the 
                Departmental Appeals Board shall review the case de 
                novo.
    ``(d) Deadlines for Reviews and Appeals Under Part B.--Reviews and 
appeals under subsections (a) and (b) with respect to matters under 
part B shall be conducted consistent with the following:
            ``(1) Deadlines.--
                    ``(A) Review of initial determination.--A carrier 
                shall conduct and conclude a review of an initial 
                determination, and mail the notice of review 
                determination, by not later than the end of the 60-day 
                period beginning on the date a request for review has 
                been timely filed.
                    ``(B) Carrier hearing.--
                            ``(i) Deadline for decision.--A carrier 
                        shall conduct and conclude a hearing, and mail 
                        the notice of the decision, by not later than 
                        the end of the 60-day period beginning on the 
                        date a request for a carrier hearing has been 
                        timely filed.
                            ``(ii) Option to proceed to hearing by 
                        administrative law judge.--No carrier hearing 
                        shall be held, and no requirement for a carrier 
                        hearing shall apply with respect to rights to a 
                        hearing before an administrative law judge, if 
                        the party to the carrier review elects a 
hearing before an administrative law judge in lieu of a carrier 
hearing.
                    ``(C) Hearing by administrative law judge.--
                            ``(i) In general.--Except as provided in 
                        clause (ii), an administrative law judge shall 
                        conduct and conclude a hearing and render a 
                        decision on such hearing by not later than the 
                        end of the 90-day period beginning on the date 
                        a request for hearing has been timely filed.
                            ``(ii) Waiver of deadline by party seeking 
                        hearing.--The 90-day period under clause (i) 
                        shall not apply in the case of a motion or 
                        stipulation by the party requesting the hearing 
                        to waive such period.
                    ``(D) Departmental appeals board review.--The 
                Departmental Appeals Board of the Department of Health 
                and Human Services shall conduct and conclude a review 
                of the decision on a hearing described in subparagraph 
                (C) and make a decision or remand the case to the 
                administrative law judge for reconsideration by not 
                later than the end of the 90-day period beginning on 
                the date a request for review has been timely filed.
            ``(2) Consequences of failure to meet deadlines.--
                    ``(A) In general.--(i) In the case of a failure by 
                a carrier to mail notice within the time period 
                described in subparagraphs (A) and (B) of paragraph 
                (1), the party requesting the review or carrier hearing 
                (as the case may be) may request a hearing before an 
                administrative law judge, notwithstanding any 
                requirements for a carrier review or a carrier hearing 
                for purposes of the party's right to a hearing before 
                such judge.
                    ``(ii) In the case of a failure by an 
                administrative law judge to render a decision by the 
                end of the period described in paragraph (1)(C), the 
                party requesting the hearing may request a review by 
                the Departmental Appeals Board, notwithstanding any 
                requirements for a hearing for purposes of the party's 
                right to such a review.
                    ``(B) DAB hearing procedure.--In the case of a 
                request described in subparagraph (A)(ii), the 
                Departmental Appeals Board shall review the case de 
                novo.''.
    (b) Review of National and Local Coverage Decisions.--
            (1) In general.--Section 1869(b)(3) of the Social Security 
        Act (42 U.S.C. 1395ff(b)(3)) is amended to read as follows:
    ``(3) Review of any coverage determination respecting whether or 
not a particular type or class of items or services is covered under 
this title shall be subject to the following limitations:
            ``(A) In the case of any national coverage determination 
        under section 1862(a)(1), the following limitations apply:
                    ``(i) Such a determination shall not be reviewed by 
                any administrative law judge.
                    ``(ii) Such a determination shall not be held 
                unlawful or set aside on the ground that a requirement 
                of section 553 of title 5, United States Code, or 
                section 1871(b), relating to publication in the Federal 
                Register or opportunity for public comment, was not 
                satisfied.
                    ``(iii) Upon the filing of a complaint by an 
                aggrieved party, such a determination shall be reviewed 
                by the Departmental Appeals Board of the Department of 
                Health and Human Services. In conducting such a review, 
                the Departmental Appeals Board shall review the record 
                and shall permit discovery and the taking of evidence 
                to evaluate the reasonableness of the determination. In 
                reviewing such a determination, the Departmental 
                Appeals Board shall defer only to the reasonable 
                findings of fact, reasonable interpretations of law, 
                and reasonable applications of fact to law by the 
                Secretary.
                    ``(iv) A decision of the Departmental Appeals Board 
                constitutes a final agency action and is subject to 
                judicial review.
            ``(B) In the case of a local coverage determination made by 
        a fiscal intermediary or a carrier under this title, the 
        following limitations apply:
                    ``(i) Upon the filing of a complaint by an 
                aggrieved party, such a determination shall be reviewed 
                by an administrative law judge of the Department of 
                Health and Human Services. The administrative law judge 
                shall review the record and shall permit discovery and 
                the taking of evidence to evaluate the reasonableness 
                of the determination. In reviewing such a 
                determination, the judge shall defer only to the 
                reasonable findings of fact, reasonable interpretations 
                of law, and reasonable applications of fact to law by 
                the Secretary.
                    ``(ii) Such a determination may be reviewed by the 
                Departmental Appeals Board of the Department of Health 
                and Human Services.
                    ``(iii) A decision of the Departmental Appeals 
                Board constitutes a final agency action and is subject 
                to judicial review.
            ``(C) In the case of review of a determination under 
        subparagraph (A)(iii) or (B)(i) where the moving party alleges 
        that there are no material issues of fact in dispute, and 
        alleges that the only issue is the constitutionality of a 
        provision of this title, or that a regulation, determination, 
        or ruling by the Secretary is invalid, the moving party may 
        seek review by a court of competent jurisdiction.''.
            (2) Pending national coverage determinations.--Section 
        1869(b) of such Act (42 U.S.C. 1395ff(b)) is amended by adding 
        at the end the following new paragraph:
    ``(6)(A) In the event the Secretary has not issued a national 
coverage or noncoverage determination with respect to a particular type 
or class of items or services, an affected party may submit to the 
Secretary a request to make such a determination with respect to such 
items or services. By not later than the end of the 90-day period 
beginning on the date the Secretary receives such a request, the 
Secretary shall take one of the following actions:
            ``(i) Issue a national coverage determination, with or 
        without limitations.
            ``(ii) Issue a national noncoverage determination.
            ``(iii) Issue a determination that no national coverage or 
        noncoverage determination is appropriate as of the end of such 
        90-day period with respect to national coverage of such items 
        or services.
    ``(B) When issuing a determination under subparagraph (A), the 
Secretary shall include a explanation of the basis for the 
determination. An action taken under subparagraph (A) is deemed to be a 
national coverage determination for purposes of review under paragraph 
(3)(A).''.
    (c) Standing.--Section 1869 of such Act (42 U.S.C. 1395ff), as 
amended in subsection (a), is further amended by adding at the end the 
following new subsection:
    ``(e) An action under this section may only be initiated by an 
aggrieved person, or class of persons, with respect to claims for 
rights to, or payments for, items and services under this title, or 
coverage of items and services under this title. Such a person, or 
class of persons, includes the following:
            ``(1) Individuals entitled to benefits under part A, or 
        enrolled under part B, or both.
            ``(2) Providers of services.
            ``(3) Physicians.
            ``(4) Other health care professionals entitled to payment 
        for services furnished under this title.
            ``(5) Suppliers and manufacturers of items and services 
        covered, or seeking to be covered, under this title.''.
    (d) Elimination of Sua Sponte Motions by the Secretary on Decisions 
of the Provider Reimbursement Review Board.--Section 1878(f)(1) of such 
Act (42 U.S.C. 1395oo(f)(1)) is amended--
            (1) in the first sentence, by striking ``unless the 
        Secretary, on his own motion, and within 60 days after the 
        provider of services is notified of the Board's decision, 
        reverses, affirms, or modifies the Board's decision'';
            (2) in the second sentence, by striking ``, or of any 
        reversal, affirmance, or modification by the Secretary,'' and 
        ``or of any reversal, affirmance, or modification by the 
        Secretary is received''; and
            (3) in the fifth sentence, by striking `` and not subject 
        to review by the Secretary''.
    (e) Conforming Regulations.--
            (1) In general.--The Secretary of Health and Human Services 
        shall promptly publish notice of revisions in the process under 
        section 1869 of the Social Security Act (42 U.S.C. 1395ff), in 
        order to reflect the modifications to such process made by this 
        section.
            (2) References.--For purposes of this section and the 
        notice published under paragraph (1), reference to--
                    (A) a reconsideration of an initial determination 
                in subsection (c)(1)(A) of section 1869 of the Social 
                Security Act (42 U.S.C. 1395ff), as added under 
                subsection (a)(2), is a reference to a reconsideration 
                of an initial determination under section 405.715 of 
                title 42 of the Code of Federal Regulations;
                    (B) the requirement to mail the notice of 
                reconsidered determination in such subsection, as so 
                added, is a reference to such requirement under section 
                405.716 of such title;
                    (C) a hearing conducted by an administrative law 
                judge in subsection (c)(1)(B)(i) of such section, as so 
                added, is a reference to such a hearing under section 
                405.720 of such title;
                    (D) review conducted by the Departmental Appeals 
                Board of the Department of Health and Human Services in 
                paragraphs (1)(C) and (2)(A)(ii) of subsection (c) of 
                such section 1869, as so added, is a reference to such 
                review conducted under section 405.724 of such title;
                    (E) a review of an initial determination in 
                subsection (d)(1)(A) of such section, as so added, is a 
                reference to such review conducted under section 
                405.807 of such title;
                    (F) the requirement to mail the notice of review 
                determination in such subsection, as so added, is a 
                reference to such requirement under section 405.811 of 
                such title;
                    (G) a hearing in subsection (d)(1)(B)(i) of such 
                section, as so added, is a reference to such a hearing 
                under section 405.830 of such title;
                    (H) a hearing before an administrative law judge in 
                subparagraphs (B)(ii) and (C)(i) of subsection (d)(1) 
                of such section, as so added, is a reference to such a 
                hearing under section 405.855 of such title; and
                    (I) review conducted by the Departmental Appeals 
                Board of the Department of Health and Human Services in 
                paragraphs (1)(D) and (2)(A)(ii) of subsection (d) of 
                such section, as so added, is a reference to such 
                review conducted under section 405.856 of such title.
    (f) Effective Date.--This section, and the amendments made by this 
section, apply as of the date that is 90 days after the date of the 
enactment of this Act, and apply to reconsiderations, reviews, motions, 
and determinations pending before, on, or after such date.
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