[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 8500 Introduced in House (IH)]
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119th CONGRESS
2d Session
H. R. 8500
To amend title XVIII of the Social Security Act to ensure timely review
of local coverage determination requests under the Medicare program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
April 27, 2026
Mr. Dunn of Florida (for himself, Ms. Barragan, and Ms. Tenney)
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 ensure timely review
of local coverage determination requests under the Medicare program.
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 ``Timely Access to Coverage Decisions
Act of 2026''.
SEC. 2. ENSURING TIMELY REVIEW OF LOCAL COVERAGE DETERMINATION REQUESTS
UNDER THE MEDICARE PROGRAM.
(a) In General.--Section 1862(l)(5) of the Social Security Act (42
U.S.C. 1395y(l)(5)) is amended by adding at the end the following new
subparagraph:
``(E) Timeframe for decisions on requests for local
coverage determinations.--
``(i) In general.--The Secretary shall
require each Medicare administrative contractor
that receives a formal LCD request on or after
the date that is 90 days after the date of
enactment of this subparagraph to determine
whether such request is a complete request or
an incomplete request not later than 60 days
after such contractor receives such request.
``(ii) Notification with respect to
incomplete requests.--In the case that a
Medicare administrative contractor makes a
determination described in clause (i) with
respect to a formal LCD request that such
request is incomplete, such contractor shall,
not later than 60 days after the date on which
such contractor received such request, transmit
to the entity that submitted such request a
written notification of such determination that
includes a specification of each item of
additional information needed to make such
request complete.
``(iii) Decision timeline for complete
requests.--In the case that a Medicare
administrative contractor makes a determination
described in clause (i) with respect to a
formal LCD request that such request is
complete, such contractor shall, not later than
1 year after the date on which such contractor
received such request, take the actions
described in clauses (i) and (ii) of
subparagraph (D).
``(iv) Formal lcd request defined.--In this
subparagraph, the term `formal LCD request'
means a document that identifies itself as a
formal request for a local coverage
determination.''.
(b) Reconsideration Requests.--Section 1862(l)(5) of the Social
Security Act (42 U.S.C. 1395y(l)(5)), as amended by subsection (a), is
further amended by adding at the end the following new subparagraphs:
``(F) Timeframe for decisions on reconsideration
requests for local coverage determinations.--
``(i) In general.--The Secretary shall
require each Medicare administrative contractor
that receives a formal reconsideration request
on or after the date that is 90 days after the
date of enactment of this subparagraph to
determine whether such request is a complete
request or an incomplete request not later than
60 days after such contractor receives such
request.
``(ii) Notification with respect to
incomplete requests.--In the case that a
Medicare administrative contractor makes a
determination described in clause (i) with
respect to a formal reconsideration request
that such request is incomplete, such
contractor shall, not later than 60 days after
the date on which such contractor received such
request, transmit to the entity that submitted
such request a written notification of such
determination that includes a specification of
each item of additional information needed to
make such request complete.
``(iii) Decision timeline for complete
requests.--In the case that a Medicare
administrative contractor makes a determination
described in clause (i) with respect to a
formal reconsideration request that such
request is complete, such contractor shall, not
later than 1 year after the date on which such
contractor received such request, take the
actions described in clauses (i) and (ii) of
subparagraph (D).
``(iv) Definitions.--In this subparagraph:
``(I) Formal reconsideration
request.--The term `formal
reconsideration request' means, with
respect to a Medicare administrative
contractor, a document that--
``(aa) identifies itself as
a formal request for
reconsideration of part or all
of a finalized local coverage
determination made by such
contractor with respect to a
geographic area; and
``(bb) is submitted by an
interested party.
``(II) Interested party.--The term
`interested party' means, with respect
to a local coverage determination made
by a Medicare administrative contractor
with respect to a geographic area--
``(aa) an individual
entitled to benefits under part
A or enrolled under part B who
resides in, or receives items
or services in, such area;
``(bb) a provider of
services or supplier that, in
such area, furnishes, provides,
or supplies items or services
that are subject to such
determination; or
``(cc) any entity that the
Secretary determines to be an
interested party in such area.
``(G) Agency review of reconsideration decision.--
Upon the request of an interested party (as defined in
subparagraph (F)(iv)), the Secretary shall review the
final determination (as defined in subparagraph
(D)(ii)) made by a Medicare administrative contractor
following a complete formal reconsideration request
made under subparagraph (F). Such review shall include
an analysis of whether--
``(i) the determination did not apply, or
inaccurately interpreted, qualifying evidence
(as defined in subparagraph (D)(iv)) relevant
to such determination;
``(ii) the determination used language that
exceeded the scope of the intended purpose of
the determination;
``(iii) the determination was incorrect in
its determination of whether such item or
service is reasonable and necessary for the
diagnosis or treatment of illness or injury
under section 1862(a)(1)(A);
``(iv) the determination failed to
describe, with respect to such an item or
service, the clinical conditions to be used for
purposes of determining whether such item or
service is reasonable and necessary for the
diagnosis or treatment of illness or injury
under section 1862(a)(1)(A);
``(v) the determination does not apply with
respect to items or services to which it was
intended to apply; or
``(vi) the determination conflicts with any
other law, rule, regulation, or national
coverage determination, as determined by the
Secretary.''.
(c) Development Process for Specified LCDs.--Section 1862(l)(5)(D)
of the Social Security Act (42 U.S.C. 1395y(l)(5)(D)) is amended to
read as follows:
``(D) Process for issuing specified local coverage
determinations.--
``(i) In general.--In the case of a
specified local coverage determination (as
defined in clause (iii)) within an area by a
Medicare administrative contractor, such
contractor must take the following actions with
respect to such determination before such
determination may take effect:
``(I) Publish on the public
internet website of the Centers for
Medicare & Medicaid Services commonly
referred to as the `Medicare Coverage
Database' (or a successor website) and
on the public internet website of the
Medicare administrative contractor a
proposed version of the specified local
coverage determination (in this
subparagraph referred to as a `draft
determination'), any related coding or
billing information, a written
rationale for the draft determination,
and a description of all evidence
relied upon and considered by the
contractor in the development of the
draft determination.
``(II) Not later than 60 days after
the date on which the Medicare
administrative contractor publishes the
draft determination in accordance with
subclause (I)--
``(aa) convene one or more
open, public meetings to review
the draft determination, and,
with respect to each such
meeting, make available means
for the public to attend such
meeting remotely, and make the
planned agenda for such meeting
publicly accessible at least 14
days in advance;
``(bb) receive comments
with respect to the draft
determination; and
``(cc) secure the advice of
an expert panel, which shall
include--
``(AA) 1 or more
physicians;
``(BB) 1 or more
members of the
Contractor Advisory
Committee (as described
in chapter 13 of the
Medicare Program
Integrity Manual, as in
effect on February 12,
2019); and
``(CC) 1 or more
entities advocating on
behalf of one or more
individuals entitled to
benefits under part A
or enrolled under part
B.
``(III) With respect to each
meeting convened pursuant to subclause
(II)(aa), post on the public internet
website of the contractor, not later
than 14 days after such meeting is
convened, a record of such meeting,
which may include a video or audio
recording of the meeting.
``(IV) Provide a period for
submission of written public comment on
such draft determination that begins on
the date on which all records required
to be posted with respect to such draft
determination under subclause (III) are
so posted and that is not fewer than 30
days in duration.
``(ii) Finalizing a specified local
coverage determination.--
``(I) In general.--Subject to
subclause (II), a Medicare
administrative contractor that has
entered into a contract with the
Secretary under section 1874A shall,
before a specified local coverage
determination (in this subparagraph
referred to as the `final
determination') takes effect, post on
the Medicare Coverage Database and the
public internet website of the
contractor the following information:
``(aa) A response to public
comments received and the
relevant issues raised at
meetings convened pursuant to
clause (i)(II)(aa) with respect
to the draft determination.
``(bb) The full text of all
such public comments received.
``(cc) The rationale for
the final determination.
``(dd) In the case that the
Medicare administrative
contractor considered
qualifying evidence (as defined
in clause (v)) in the
development of the
determination that was not
described in the written notice
provided pursuant to clause
(i)(I), a description of such
qualifying evidence.
``(ee) An effective date
for the final determination
that is not less than 45 days
after the date on which such
determination is so posted.
``(II) Logical outgrowth
requirement.--Notwithstanding subclause
(I), a final determination may not take
effect unless such determination is a
logical outgrowth of the draft
determination published under clause
(i).
``(iii) Specified local coverage
determination defined.--For purposes of this
subparagraph, the term `specified local
coverage determination' means, with respect to
the relevant geographic area--
``(I) a new local coverage
determination;
``(II) a revised local coverage
determination that makes a substantive
revision to one or more existing local
coverage determinations (such as by
imposing new requirements with respect
to coverage of the relevant item or
service or by changing any coding or
billing information related to such
determination); or
``(III) any other local coverage
determination specified by the
Secretary pursuant to regulations.
``(iv) Qualifying evidence defined.--For
purposes of this subparagraph, the term
`qualifying evidence' means publicly available
evidence of general acceptance by the medical
community, such as published original research
in peer-reviewed medical journals, systematic
reviews and meta-analyses, evidence-based
consensus statements, and clinical
guidelines.''.
(d) Effective Date.--This section, and the amendments made by this
section, shall apply beginning on the date that is 1 year after the
date of the enactment of this section.
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