,i  #aad? ,,congress  #b;d ,session  ,h4
 ,r4 #egba  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,july #aa1 #bjaf,ms4  
,j5k9s ( ,kansas 7= h]self & ,mr4 ,k9d7 
introduc$ ! foll[+ bill2 :i* 0 ref]r$ to
 ! ,committee on ,ways & ,means1 & 9    
addition to ! ,committee on ,en]gy &    
,comm]ce1 = a p]iod to be subsequ5tly   
det]m9$ by ! ,speak]1 9 ea* case =      
consid]ation ( su* provisions z fall )9 
! jurisdiction ( ! committee conc]n$  ,a
 ,,bill  ,to am5d title ,,xviii ( !     
,social ,security ,act 9 ord] to improve
 ! process :]eby m$ic>e adm9i/rative    
contractors issue local cov]age         
det]m9ations "u ! ,m$ic>e program1 & =  
o!r purposes4  #a4 ,%ort title ,?is ,act
 may be cit$ z ! ,local ,cov]age        
,det]m9ation ,cl>ification ,act ( #bjaf4
  #b4 ,improvem5ts 9 ! ,m$ic>e local    
cov]age det]m9ation 7,,lcd7 process =   
specifi$ ,l,c,ds  7a7 ,,lcd developm5t  
process ,section #ahfb7l77#e7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#aciey7l77#e77 is am5d$ by add+ at ! end

 ! foll[+ subp>agraph3  7,d7 ,process = 
issu+ specifi$ local cov]age            
det]m9ations  7i7 ,9 g5]al ,9 ! case ( a
 specifi$ local cov]age det]m9ation 7z  
def9$ 9 clause 7iv77 )9 an area by a    
fiscal int]m$i>y or c>ri] t has ent]$   
into a contract ) ! ,secret>y "u section
 #ahgd;,a1 su* int]m$i>y or c>ri] mu/   
take ! foll[+ actions ) respect to su*  
det]m9ation be=e su* det]m9ation may    
take effect3  7,i7 ,publi% on ! public  
,int]net website ( ! int]m$i>y or c>ri] 
a propos$ v]sion ( ! specifi$ local     
cov]age det]m9ation 79 ?is section      
ref]r$ to z a draft det]m9ation71 a     
writt5 rationale = ! draft det]m9ation1 
& a description ( all evid5ce reli$ ^u &
 consid]$ by ! int]m$i>y or c>ri] 9 !   
developm5t ( ! draft det]m9ation4       
7,,ii7 ,n lat] ?an #fj days aft] ! date 
on :i* ! int]m$i>y or c>ri] publi%es !  
draft det]m9ation 9 accordance )        
subclause 7,i71 conv5e "o or m op51     
public meet+s to review ! draft         
det]m9ation1 receive comm5ts ) respect  

to ! draft det]m9ation1 & secure !      
advice ( an exp]t panel 7su* z a c>ri]  
advisory committee describ$ 9 *apt] #ac 
( ! ,m$ic>e ,program ,integrity ,manual 
9 effect on ,augu/ #ca1 #bjae7 ) respect
 to ! draft det]m9ation4 ,! int]m$i>y or
 c>ri] %all make available means = !    
public to att5d su* meet+s remotely1 su*
 z via teleconf]5ce4  7,,iii7 ,) respect
 to ea* meet+ conv5$ pursuant to        
subclause 7,,ii71 po/ on ! public       
,int]net website ( ! int]m$i>y or c>ri]1
 n lat] ?an #ad days aft] su* meet+ is  
conv5$1 a record ( ! meet+ m9utes = su* 
meet+4  7,,iv7 ,provide a p]iod =       
submission ( writt5 public comm5t on su*
 draft det]m9ation t beg9s on ! date on 
:i* all records requir$ to be po/$ )    
respect to su* draft det]m9ation "u     
subclause 7,,iii7 are s po/$ & t is n   
few] ?an #cj days 9 duration4  7ii7     
,f9aliz+ a specifi$ local cov]age       
det]m9ation ,a fiscal int]m$i>y or c>ri]
 t has ent]$ into a contract ) !        
,secret>y "u section #ahgd;,a %all1 )   

respect to a specifi$ local cov]age     
det]m9ation1 po/ on ! public ,int]net   
website ( ! fiscal int]m$i>y or c>ri] ! 
foll[+ in=mation be=e ! specifi$ local  
cov]age det]m9ation 79 ?is section      
ref]r$ to z ! f9al det]m9ation7 takes   
effect--  7,i7 a response ! issues rais$
 at meet+s conv5$ pursuant to clause    
7i77,,ii7 ) respect to ! draft          
det]m9ation2  7,,ii7 ! rationale = !    
f9al det]m9ation2  7,,iii7 9 ! case t ! 
int]m$i>y or c>ri] consid]$ qualify+    
evid5ce 9 ! developm5t ( ! det]m9ation t
 0 n describ$ 9 ! writt5 notice provid$ 
pursuant to clause 7i77,i71 a           
description ( su* qualify+ evid5ce2 &   
7,,iv7 an effective date = ! f9al       
det]m9ation t is n less ?an #cj days    
aft] ! date on :i* su* det]m9ation is s 
po/$4  7iii7 ,limitation on det]m9ations
 across jurisdictions ,not)/&+ any plan 
"u section #ahfb7l77#e77;,a71 9 ! case (
 a contract ) a fiscal int]m$i>y or     
c>ri] "u section #ahgd;,a1 su* int]m$i>y
 or c>ri] may n f9alize a specifi$ local

 cov]age det]m9ation pursuant to clause 
7ii7 ) respect to a geographic area t   
applies1 or has ! effect ( apply+1      
outside su* area4 ,9 ! case t su* an    
int]m$i>y or c>ri] wi%es to adopt1 )    
respect to a specific geographic area a 
specifi$ local cov]age det]m9ation      
develop$ = a diff]5t geographic area1   
su* int]m$i>y or c>ri] may n s adopt su*
 det]m9ation unless1 prior to s adopt+  
su* det]m9ation1 su* int]m$i>y or c>ri] 
indep5d5tly evaluates & consid]s !      
qualify+ evid5ce support+ ! det]m9ation 
z applicable to su* specific geographic 
area & makes a local cov]age det]m9ation
 = su* area 9 accordance ) ?is          
subp>agraph4  7iv7 ,specifi$ local      
cov]age det]m9ation def9$ ,= purposes ( 
?is subp>agraph1 ! t]m specifi$ local   
cov]age det]m9ation means1 ) respect to 
a geographic area-- 7,i7 a new local    
cov]age det]m9ation 7reg>dless ( :e!r   
su* det]m9ation made by a fiscal        
int]m$i>y or c>ri] t has ent]$ into a   
contract ) ! ,secret>y "u section       

#ahgd;,a & is bas$ ^u a specifi$ local  
cov]age det]m9ation t previ\sly has be5 
made ) respect to ano!r geographic area1
 or by ano!r su* int]m$i>y or c>ri]72   
7,,ii7 a revis$ local cov]age           
det]m9ation = su* geographic area t     
re/ricts "o or m exi/+ cov]age crit]ia =
 su* area 7su* z by add+ noncov]$       
indications to an exi/+ local cov]age   
det]m9ation or by delet+ previ\sly cov]$
 ,,icd-#i or ,,icd-#aj codes72  7,,iii7 
a revis$ local cov]age det]m9ation t    
makes a sub/antive revision to "o or m  
exi/+ local cov]age det]m9ations2 &     
7,,iv7 any o!r local cov]age det]m9ation
 specifi$ by ! ,secret>y pursuant to    
regulations4  7v7 ,qualify+ evid5ce     
def9$ ,= purposes ( ?is subp>agraph1 !  
t]m qualify+ evid5ce means ei!r ( !     
foll[+3  7,i7 ,sci5tific evid5ce publi%$
 9 pe]-review$ m$ical lit]ature1 su* z  
r&omiz$ cl9ical trials or o!r /udies4   
7,,ii7 ,a g5]al cons5sus ( ! applicable 
m$ical community 7su* z a cons5sus ev9c$
 ?r\gh a recogniz$ /&>d ( practice 9 su*

 m$ical community7 t is support$ by     
in=mation provid$ by a recogniz$ m$ical 
au?ority1 su* z a pr(essional m$ical    
society4  4  7b7 ,,lcd reconsid]ation   
process ,section #ahfi7;f7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#acie;ff7f77 is am5d$-- 7#a7 9 p>agraph 
7#b77;,a71 by ins]t+ 7&1 z applicable1 !
 limitations "u p>agraphs 7#h7 & 7#i77  
be=e ! colon2  7#b7 9 p>agraph 7#e71 by 
ins]t+ 7o!r ?an "u p>agraphs 7#h7 &     
7#i77 aft] ?is subsection2  7#c7 by     
r$esignat+ p>agraph 7#h7 z p>agraph     
7#ab72 &  7#d7 by ins]t+ aft] p>agraph  
7#g7 ! foll[+ new p>agraphs3  7#h7      
,c>ri] or fiscal int]m$i>y              
reconsid]ation process = specifi$ local 
cov]age det]m9ations ,= purposes (      
p>agraph 7#b77;,a71 ! limitations       
describ$ 9 ?is p>agraph are t1 ^u ! fil+
 ( a reque/ by an int]e/$ p>ty ) respect
 to a specifi$ local cov]age det]m9ation
 by a fiscal int]m$i>y or c>ri] t has   
ent]$ into a contract ) ! ,secret>y "u  
section #ahgd;,a1 ! int]m$i>y or c>ri]  

%all reconsid] su* det]m9ation 9        
accordance ) ! foll[+ process3  7,a7 ,n 
lat] ?an #cj days aft] su* a reque/ is  
fil$ ) ! fiscal int]m$i>y or c>ri] by ! 
int]e/$ p>ty ) respect to su*           
det]m9ation1 ! int]m$i>y or c>ri] %all--
  7i7 det]m9e :e!r ! reque/ is an       
applicable reque/2 &  7ii7 9 ! case t ! 
reque/ is n an applicable reque/1 in=m !
 int]e/$ p>ty ( ! reasons :y su* reque/ 
is n an applicable reque/4  7,b7 ,9 !   
case t ! int]m$i>y or c>ri] det]m9es "u 
subp>agraph 7,a7 t ! reque/ describ$ 9  
su* subp>agraph is an applicable reque/1
 ! int]m$i>y or c>ri] %all1 n lat] ?an  
#ij days aft] ! date on :i* ! reque/ 0  
fil$ ) ! int]m$i>y or c>ri]1 take !     
actions describ$ 9 subp>agraphs 7,c71   
7,d71 & 7,e7 ) respect to ! det]m9ation4
  7,c7 ,! action describ$ 9 ?is         
subp>agraph is ! action ( specify+ :e!r 
any ( ! foll[+ /atem5ts is applicable to
 ! det]m9ation3  7i7 ,! det]m9ation did 
n apply1 or inaccurately appli$1        
qualify+ evid5ce relevant to su*        

det]m9ation4  7ii7 ,! det]m9ation us$   
language t exce$$ ! scope ( ! int5d$    
purpose ( ! det]m9ation4  7iii7 ,!      
det]m9ation 0 incorrect 9 its           
det]m9ation ( :e!r su* item or s]vice is
 reasonable & necess>y = ! diagnosis or 
treatm5t ( illness or injury "u section 
#ahfb7;a77#a77;,a74  7iv7 ,! det]m9ation
 fail$ to describe1 ) respect to su* an 
item or s]vice1 ! cl9ical conditions to 
be us$ = purposes ( det]m9+ :e!r su*    
item or s]vice is reasonable & necess>y 
= ! diagnosis or treatm5t ( illness or  
injury "u section #ahfb7;a77#a77;,a74   
7v7 ,! det]m9ation does n apply )       
respect to items or s]vices to :i* x 0  
int5d$ to apply4  7vi7 ,! det]m9ation is
 errone\s = ano!r reason t ! int]m$i>y  
or c>ri] id5tifies4  7,d7 ,! action     
describ$ 9 ?is subp>agraph1 ) respect to
 ! det]m9ation1 is ! action ( tak+1 bas$
 on ! specification "u subp>agraph 7,c7 
( :e!r any ( ! /atem5ts 9 su*           
subp>agraph appli$ to su* det]m9ation1  
"o or m ( ! foll[+ actions3  7i7 ,mak+  

no *ange 9 ! det]m9ation4  7ii7 ,resc9d+
 a "p ( ! det]m9ation 7includ+1 z       
applicable1 ! entire det]m9ation74      
7iii7 ,modify+ ! det]m9ation to re/rict 
! cov]age provid$ "u ?is title = an item
 or s]vice t is subject to !            
det]m9ation4  7iv7 ,modify+ !           
det]m9ation to exp& ! cov]age provid$ "u
 ?is title = an item or s]vice t is     
subject to ! det]m9ation4  7,e7 ,!      
action describ$ 9 ?is subp>agraph is !  
action ( mak+ publicly available a      
writt5 description ( ! action tak5 "u   
subp>agraph 7,d7 ) respect to !         
det]m9ation4  7#i7 ,ag5cy evaluation (  
reconsid]ation decision ,= purposes (   
p>agraph 7#b77;,a71 ! limitations       
describ$ 9 ?is p>agraph are t1 9 ! case 
t an int]e/$ p>ty t fil$ an applicable  
reque/ "u p>agraph 7#h7 ) respect to a  
specifi$ local cov]age det]m9ation files
 ) ! ,secret>y1 on a date t is n lat]   
?an #abj days aft] ! date on :i* an     
int]m$i>y or c>ri] takes an action      
describ$ "u p>agraph 7#h77;,d7 ) respect

 to su* det]m9ation1 an appeal ) respect
 to su* decision 9 su* =m & mann] z !   
,secret>y may require1 ! ,secret>y %all1
 n lat] ?an #cj days aft] su* appeal is 
fil$--  7,a7 specify :i*1 if any1 ( !   
/atem5ts 9 subp>agraph 7,c7 ( p>agraph  
7#h7 is applicable to ! det]m9ation2 &  
7,b7 bas$ on su* specification1 take "o 
( ! actions describ$ 9 subp>agraph 7,d7 
( su* p>agraph ) respect to !           
det]m9ation4  ,! ,secret>y %all apply   
subp>agraph 7,a7 z ?\gh ! ref]5ce to !  
int]m$i>y or c>ri] 9 clause 7vi7 (      
p>agraph 7#h77;,d7 7 a ref]5ce to !     
,secret>y4  7#aj7 ,def9itions applicable
 to p>agraphs 7#h7 & 7#i7 ,= purposes ( 
p>agraphs 7#h7 & 7#i73 7,a7 ,! t]m      
applicable reque/ means a reque/ t is   
submitt$ 9 fiscal ye> #bjah or a        
subsequ5t fiscal ye>1 t is solely )     
respect to a specifi$ local cov]age     
det]m9ation1 & t includes a description 
( ! rationale = su* reque/ & any evid5ce
 support+ su* reque/4 ,= purposes ( !   
prec$+ s5t5ce1 ! ,secret>y may n        

require1 z a condition ( treat+ a reque/
 ) respect to su* a det]m9ation z an    
applicable reque/1 t ! reque/ conta9    
qualify+ evid5ce t 0 n consid]$ 9 !     
developm5t ( su* det]m9ation4  7,b7 ,!  
t]m int]e/$ p>ty means1 ) respect to a  
specifi$ local cov]age det]m9ation )9 an
 area by a fiscal int]m$i>y or c>ri] t  
has ent]$ into a contract ) ! ,secret>y 
"u section #ahgd;,a--  7i7 a provid] (  
s]vices or suppli] t1 9 su* area1       
furni%es1 provides1 or supplies items or
 s]vices t are subject to su*           
det]m9ation2 or  7ii7 an organization t 
repres5ts su* a provid] ( s]vices or    
suppli]4  7,c7 ,! t]m qualify+ evid5ce  
has ! mean+ giv5 su* t]m by clause 7v7 (
 section #ahfb7l77#e77;,d74  7,d7 ,! t]m
 specifi$ local cov]age det]m9ation has 
! mean+ giv5 su* t]m by clause 7iv7 (   
su* section4  7#aa7 ,appo9tm5t (        
,ombudsman  7,a7 ,9 g5]al ,! ,secret>y  
%all1 )9 ! ,c5t]s = ,m$ic>e  ,m$icaid   
,s]vices1 appo9t a ,m$ic>e ,reviews &   
,appeals ,ombudsman 7ref]r$ to 9 ?is    

p>agraph z ! ,ombudsman74  7,b7 ,duties 
,! ,ombudsman %all1 ) respect to        
specifi$ local cov]age det]m9ations1    
c>ry out ! foll[+ duties3  7i7 ,provide 
int]e/$ p>ties 7z def9$ 9 p>agraph      
7#aj77;,b77 ) adm9i/rative & te*nical   
assi/ance 9 fil+ reque/s "u p>agraph    
7#h7 & appeals "u p>agraph 7#i74  7ii7  
,make publicly available 9 a uni=m1     
consi/5t1 & easily und]/ood =mat !      
foll[+ in=mation = ea* #ab-mon? p]iod3  
7,i7 ,! numb] ( reque/s fil$ ) fiscal   
int]m$i>ies & c>ri]s "u p>agraph 7#h71 &
 ( appeals fil$ ) ! ,secret>y "u        
p>agraph 7#i71 dur+ su* p]iod4  7,,ii7  
,) respect to su* reque/s dur+ su*      
p]iod1 ! numb] ( times t int]m$i>ies &  
c>ri]s took1 ) respect to ! actions     
describ$ subp>agraph 7,a77iv7 ( su*     
p>agraph1 ea* su* action4  7,,iii7 ,)   
respect to su* appeals dur+ su* p]iod1 !
 numb] ( times t ! ,secret>y took ea*   
su* action4  7,,iv7 ,) respect to !     
numb]s made available "u subclauses     
7,i71 7,,ii71 & 7,,iii71 ! numb] ( ea*  

su* numb] t is attributable to--  7aa7  
ea* fiscal int]m$i>y or c>ri]2 &  7bb7  
ea* int]e/$ p>ty 7z def9$ 9 p>agraph    
7#aj77;,b774  7,v7 ,measures ( !        
responsiv5ess ( fiscal int]m$i>ies &    
c>ri]s ) respect to reque/s fil$ ) su*  
int]m$i>ies & c>ri]s "u p>agraph 7#h74  
7,,vi7 ,recomm5dations to ! ,secret>y ) 
respect to ways to improve-- 7aa7 !     
efficacy & effici5cy ( ! process        
describ$ 9 p>agraph 7#h72 &  7bb7       
communication ) individuals entitl$ to  
b5efits "u "p ,a or enroll$ "u "p ,b1   
provid]s ( s]vices1 & suppli]s reg>d+   
su* process4  4  #c4 ,promulgation (    
regulations2 application date ,!        
,secret>y ( ,heal? & ,human ,s]vices    
%all promulgate regulations to c>ry out 
p>agraph 7#e77;,d7 ( section #ahfb7l7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#aciey7l771 z add$ by subsection 7a71 & 
p>agraphs 7#h7 & 7#i7 ( section         
#ahfi7;f7 ( su* ,act 7#db ,u4,s4,c4     
#acie;ff7f771 z ins]t$ by subsection    
7b71 9 su* a mann] z to ensure t !      

processes describ$ 9 su* p>agraphs are  
fully implem5t$ by ,octob] #a1 #bjag4