,,ib  ,union ,cal5d> ,no4 #gbd  #aae?   
,,congress  #b;d ,session  ,h4 ,r4 #cfce
  ,report ,no4 #aae-icc1 ,"p ,i  ,,9 ,,!
 ,,h\se ,,( ,,repres5tatives  ,augu/ #a1
 #bjag ,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$  ,septemb] #aj1                 
#bjah;,additional sponsors3 ,mr4        
,meehan1 ,mr4 ,sessions1 ,mr4 ,cr[ley1  
,mr4 ,mull91 ,mr4 ,pet]son1 ,mr4        
,m>*ant1 ,mr4 ,engel1 ,mr4 ,upton1 ,ms4 
,sewell ( ,alabama1 ,mr4 ,m\lton1 ,mr4  
,tonko1 ,mr4 ,loebsack1 ,mr4 ,ru%1 ,ms4 
,s*ak[sky1 ,mr4 ,roe ( ,t5nessee1 ,mr4  
,/iv]s1 ,mr4 ,blum5au]1 ,ms4 ,de,gette1 
,mr4 ,br5dan ,f4 ,boyle ( ,p5nsylvania1 
,mr4 ,bilirakis1 ,mr4 ,co/ello (        
,p5nsylvania1 ,mr4 ,au/9 ,scott (       
,georgia1 ,mr4 ,c>t] ( ,georgia1 ,mr4   

,s*weik]t1 ,mr4 ,mi*ael ,f4 ,doyle (    
,p5nsylvania1 ,ms4 ,ku/] ( ,new         
,hamp%ire1 ,mr4 ,des,jarlais1 ,mr4      
,h>ris1 ,mr4 ,bi%op ( ,mi*igan1 ,ms4    
,matsui1 ,mr4 ,?ompson ( ,cali=nia1 ,mr4
 ,h>p]1 ,mr4 ,crd5as1 ,mr4 ,curbelo (   
,florida1 ,mr4 ,"y ( ,i[a1 ,mr4 ,m>%all1
 ,mr4 ,lance1 ,mr4 ,flores1 ,mrs4       
,blackburn1 ,mr4 ,mc,nerney1 ,mr4       
,f]guson1 ,mr4 ,ruiz1 ,mr4 ,pauls51 ,mr4
 ,sean ,patrick ,maloney ( ,new ,york1  
,mr4 ,ku/(f ( ,t5nessee1 ,mr4 ,pet]s1   
,mr4 ,khanna1 ,mr4 ,kelly (             
,p5nsylvania1 ,mr4 ,butt]field1 ,mrs4   
,black1 ,ms4 ,cl>ke ( ,new ,york1 ,ms4  
,norton1 ,mr4 ,walb]g1 ,mr4 ,cook1 ,mr4 
,?ompson ( ,p5nsylvania1 ,mr4           
,rupp]sb]g]1 ,mr4 ,tipton1 ,mr4         
,de,fazio1 ,miss ,rice ( ,new ,york1    
,mr4 ,cram]1 ,mr4 ,k5n$y1 ,mr4 ,w5/rup1 
,ms4 ,h]r]a ,beutl]1 ,mr4 ,biggs1 ,mr4  
,huiz5ga1 ,mr4 ,hurd1 ,mr4 ,craw=d1 ,mr4
 ,smi? ( ,nebraska1 ,mr4 ,?ompson (     
,mississippi1 ,mr4 ,we/]man1 ,mrs4      
,lesko1 ,mr4 ,byrne1 ,ms4 ,eddie ,b]nice

 ,johnson ( ,texas1 ,mr4 ,duncan (      
,t5nessee1 ,mr4 ,brat1 ,mr4 ,cleav]1    
,mr4 ,poliqu91 ,mr4 ,dunn1 ,mr4 ,r5acci1
 & ,mr4 ,c(fman  ,septemb] #aj1 #bjah   
,report$ f ! ,committee on ,ways &      
,means ) an am5dm5t ,/rike out all aft] 
! enact+ clause & ins]t ! "p pr9t$ 9    
italic  ,septemb] #aj1 #bjah;,committee 
on ,en]gy & ,comm]ce dis*>g$2 committ$  
to ! ,committee ( ! ,:ole ,h\se on !    
,/ate ( ! ,union & ord]$ to be          
printed,for text ( introduc$ bill1 see  
copy ( bill z introduc$ on ,augu/ #a1   
#bjag  ,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
 ( #bjah4  #b4 ,improvem5ts 9 ! ,m$ic>e 
local cov]age det]m9ation 7,,lcd7       
process = specifi$ ,l,c,ds  7a7 ,,lcd   
developm5t process ,section             

#ahfb7l77#e77;,d7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #aciey7l77#e77;,d77 
is am5d$ to read z foll[s3  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 7iii77 )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 subp>agraph  
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 subp>agraph  
ref]r$ to z ! f9al det]m9ation7 takes   
effect--  7,i7 a response to ! 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/$4  7iii7 ,specifi$ 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+ non-cov]$      
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 or    
7,,iv7 any o!r local cov]age det]m9ation
 specifi$ by ! ,secret>y pursuant to    
regulations4  7iv7 ,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$-- 7#a7 9 p>agraph 
7#b77;,a71 by ins]t+ 7o!r ?an !         
reconsid]ation process describ$ 9       
p>agraphs 7#h7 & 7#i77 aft] local       
cov]age det]m9ation2  7#b7 9 p>agraph   
7#e71 by ins]t+ 7o!r ?an "u !           
reconsid]ation process describ$ 9       
p>agraphs 7#h7 & 7#i77 aft] local       
cov]age det]m9ation2  7#c7 by r$esignat+
 p>agraph 7#h7 z p>agraph 7#ac72 &  7#d7
 by ins]t+ aft] p>agraph 7#g7 ! foll[+  
new p>agraphs3  7#h7 ,c>ri] or fiscal   
int]m$i>y reconsid]ation process =      
specifi$ local cov]age det]m9ations ,^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 ,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$i>y or c>ri] 9 clause 7vi7 (      
p>agraph 7#h77;,c7 7 a ref]5ce to !     
,secret>y4  7#aj7 ,rule ( con/ruction   
,no?+ 9 p>agraph 7#h7 or 7#i7 may be    
con/ru$ z affect+ ! "r ( an aggriev$    
p>ty to file a compla9t "u p>agraph     
7#b77;,a7 & receive a det]m9ation 9     
accordance ) ! provisions ( su*         
p>agraph4  7#aa7 ,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> #bjai 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 7iv7 
( section #ahfb7l77#e77;,d74  7,d7 ,!   
t]m specifi$ local cov]age det]m9ation  
has ! mean+ giv5 su* t]m by clause 7iii7
 ( su* section4  7#ab7 ,report ,n lat]  
?an ,decemb] #ca ( ea* ye> 7beg9n+ )    
#bjai71 ! ,secret>y %all submit to      
,congress a report conta9+ ! foll[+3    
7,a7 ,! numb] ( reque/s fil$ ) fiscal   
int]m$i>ies & c>ri]s "u p>agraph 7#h71 &
 ! numb] ( appeals fil$ ) ! ,secret>y "u
 p>agraph 7#i71 dur+ ! #a-ye> p]iod end+
 on su* date4  7,b7 ,) respect to su*   
reque/s fil$ ) su* int]m$i>ies & c>ri]s 
"u p>agraph 7#h7 dur+ su* p]iod1 ! numb]
 ( times t int]m$i>ies & c>ri]s took1 ) 
respect to ! actions describ$ 9         
subp>agraphs 7,c7 ?r\gh 7,e7 ( su*      
p>agraph1 ea* su* action4  7,c7 ,)      
respect to su* appeals fil$ ) !         
,secret>y "u p>agraph 7#i7 dur+ su*     
p]iod1 ! numb] ( times t ! ,secret>y    
took1 ) respect to ! actions describ$ 9 
subp>agraph 7,d7 ( p>agraph 7#h71 ea*   
su* action4  7,d7 ,recomm5dations on    

ways to improve-- 7i7 ! efficacy & !    
effici5cy ( ! process describ$ 9        
p>agraph 7#h72 &  7ii7 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 am5d$ 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 ,july  
#a1 #bjai4  ,septemb] #aj1 #bjah        
,report$ f ! ,committee on ,ways &      
,means ) an amendment,september #aj1    
#bjah;,committee on ,en]gy & ,comm]ce   
dis*>g$2 committ$ to ! ,committee ( !   
,:ole ,h\se on ! ,/ate ( ! ,union &     
ord]$ to be pr9t$