,i  #aai? ,,congress  #b;d ,session  ,h4
 ,r4 #ajcid  ,,9 ,,! ,,h\se ,,(         
,,repres5tatives  ,septemb] #ae1        
#bjbf,mr4 ,l&sman 7= himself & ,mr4     
,ond]7 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 to   
e/abli% requirem5ts ) respect to ! use (
 prior au?orization & claims d5ial "u   
,m$ic>e ,advantage plans4  #a4 ,%ort    
title ,?is ,act may be cit$ z !         
,protect+ ,approv$ ,c>e ,act4  #b4      
,e/abli%+ requirem5ts ) respect to ! use
 ( prior au?orization & claims d5ial "u 
,m$ic>e ,advantage plan ,section        
#aheg7;e7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #acie;e-#bg7;e77 is am5d$
 by add+ at ! end ! foll[+ new p>agraph3
  7#g7 ,limitations on claims d5ial =   

cov]$ items & s]vices  7,a7 ,9 g5]al    
,beg9n+ ) plan ye>s beg9n+ on or aft]   
,janu>y #a1 #bjbh1 a contract "u ?is    
section ) an ,,ma organization %all     
require t-- 7i7 9 ! case t ! ,,ma       
organization approves ! furni%+ to an   
individual enroll$ "u an ,,ma plan (f]$ 
by su* ,,ma organization ( an item or   
s]vice ?r\gh a specifi$ au?orization    
made dur+ ! receipt by ! individual (   
su* item or s]vice1 ! ,,ma organization 
may n1 aft] su* approval1 take any ( !  
actions describ$ 9 subp>agraph 7,b7 )   
respect to su* item or s]vice2 &  7ii7 9
 ! case t !re is no requirem5t to obta9 
a specifi$ au?orization ) respect to an 
item or s]vice = :i* b5efits are        
available "u ! plan1 ! ,,ma organization
 may n1 aft] an individual enroll$ "u   
su* plan receives su* item or s]vice1   
take any ( ! actions describ$ 9         
subp>agraph 7,b7 ) respect to su* item  
or s]vice4  7,b7 ,actions describ$ ,=   
purposes ( subp>agraph 7,a71 ! actions  
describ$ 9 ?is subp>agraph are1 )       

respect to an ,,ma organization & an    
item or s]vice1 ! foll[+3  7i7 ,d5y+    
cov]age ( su* item or s]vice on ! basis 
( lack ( m$ical necessity4  7ii7 ,reop5+
 a det]m9ation ( cov]age or paym5t made 
) respect to su* item or s]vice 7includ+
 a specifi$ au?orization7 = any reason  
o!r ?an--  7,i7 good cause 7z describ$ 9
 sections #dje4ihf & #dbb4faf ( title   
#db1 ,code ( ,f$]al ,regulations 7or any
 successor regulation772 or  7,,ii7     
reliable evid5ce ( fraud or simil> fault
 7z su* t]ms are def9$ 9 section        
#dje4ijb ( su* title 7or any successor  
regulation771 z det]m9$ 9 accordance )  
section #dbb4faf ( su* title 7or any    
successor regulation74  7iii7 ,*ang+ !  
code assign$ ) respect to ! claim = su* 
item or s]vice su* t ! am\nt ( paym5t = 
su* claim w\ld be r$uc$1 except = good  
cause 7z describ$ 9 clause 7ii77 or if  
!re is reliable evid5ce ( fraud or      
simil> fault 7z s describ$74  7,c7      
,specifi$ au?orization def9$ ,9 ?is     
p>agraph1 ! t]m specifi$ au?orization-- 

7i7 means1 ) respect to an individual   
enroll$ "u an ,,ma plan (f]$ by a       
,m$ic>e ,advantage organization1 an     
au?orization ( cov]age or paym5t = an   
item or s]vice ?r\gh-- 7,i7 a prior     
au?orization or pres]vice det]m9ation ( 
cov]age or paym5t2 or  7,,ii7 a         
concurr5t det]m9ation made :ile !       
individual is receiv+ ! relevant item or
 s]vice2 &  7ii7 includes an            
au?orization = a transf] ( ! individual 
betwe5 hospitals or betwe5 a hospital & 
po/-acute c>e facility4  4