,,ii  #aai? ,,congress  #b;d ,session   
,s4 #edge  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,septemb] #bc1         
#bjbf,mr4 ,lujn 7= himself & ,mr4       
,cotton7 introduc$ ! foll[+ bill2 :i* 0 
read twice & ref]r$ to ! ,committee on  
,f9ance  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act to   
ensure timely review ( local cov]age    
det]m9ation reque/s "u ! ,m$ic>e        
program4  #a4 ,%ort title ,?is ,act may 
be cit$ z ! ,timely ,access to ,cov]age 
,decisions ,act4  #b4 ,ensur+ timely    
review ( local cov]age det]m9ation      
reque/s "u ! ,m$ic>e program  7a7 ,9    
g5]al ,section #ahfb7l77#e7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#aciey7l77#e77 is am5d$ by add+ at ! end
 ! foll[+ new subp>agraph3  7,e7        
,timeframe = decisions on reque/s =     
local cov]age det]m9ations  7i7 ,9 g5]al
 ,! ,secret>y %all require ea* ,m$ic>e  
adm9i/rative contractor t receives a    
=mal ,,lcd reque/ on or aft] ! date t is
 #ij days aft] ! date ( enactm5t ( ?is  

subp>agraph to det]m9e :e!r su* reque/  
is a complete reque/ or an incomplete   
reque/ n lat] ?an #fj days aft] su*     
contractor receives su* reque/4  7ii7   
,notification ) respect to incomplete   
reque/s ,9 ! case t a ,m$ic>e           
adm9i/rative contractor makes a         
det]m9ation describ$ 9 clause 7i7 )     
respect to a =mal ,,lcd reque/ t su*    
reque/ is incomplete1 su* contractor    
%all1 n lat] ?an #fj days aft] ! date on
 :i* su* contractor receiv$ su* reque/1 
transmit to ! entity t submitt$ su*     
reque/ a writt5 notification ( su*      
det]m9ation t includes a specification (
 ea* item ( additional in=mation ne$$ to
 make su* reque/ complete4  7iii7       
,decision timel9e = complete reque/s ,9 
! case t a ,m$ic>e adm9i/rative         
contractor makes a det]m9ation describ$ 
9 clause 7i7 ) respect to a =mal ,,lcd  
reque/ t su* reque/ is complete1 su*    
contractor %all1 n lat] ?an #a ye> aft] 
! date on :i* su* contractor receiv$ su*
 reque/1 take ! actions describ$ 9      

clauses 7i7 & 7ii7 ( subp>agraph 7,d74  
7iv7 ,=mal ,,lcd reque/ def9$ ,9 ?is    
subp>agraph1 ! t]m =mal ,,lcd reque/    
means a docum5t t id5tifies itself z a  
=mal reque/ = a local cov]age           
det]m9ation4  4  7b7 ,reconsid]ation    
reque/s ,section #ahfb7l77#e7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#aciey7l77#e771 z am5d$ by subsection   
7a71 is fur!r am5d$ by add+ at ! end !  
foll[+ new subp>agraphs3  7,f7          
,timeframe = decisions on reconsid]ation
 reque/s = local cov]age det]m9ations   
7i7 ,9 g5]al ,! ,secret>y %all require  
ea* ,m$ic>e adm9i/rative contractor t   
receives a =mal reconsid]ation reque/ on
 or aft] ! date t is #ij days aft] !    
date ( enactm5t ( ?is subp>agraph to    
det]m9e :e!r su* reque/ is a complete   
reque/ or an incomplete reque/ n lat]   
?an #fj days aft] su* contractor        
receives su* reque/4  7ii7 ,notification
 ) respect to incomplete reque/s ,9 !   
case t a ,m$ic>e adm9i/rative contractor
 makes a det]m9ation describ$ 9 clause  

7i7 ) respect to a =mal reconsid]ation  
reque/ t su* reque/ is incomplete1 su*  
contractor %all1 n lat] ?an #fj days    
aft] ! date on :i* su* contractor       
receiv$ su* reque/1 transmit to ! entity
 t submitt$ su* reque/ a writt5         
notification ( su* det]m9ation t        
includes a specification ( ea* item (   
additional in=mation ne$$ to make su*   
reque/ complete4  7iii7 ,decision       
timel9e = complete reque/s ,9 ! case t a
 ,m$ic>e adm9i/rative contractor makes a
 det]m9ation describ$ 9 clause 7i7 )    
respect to a =mal reconsid]ation reque/ 
t su* reque/ is complete1 su* contractor
 %all1 n lat] ?an #a ye> aft] ! date on 
:i* su* contractor receiv$ su* reque/1  
take ! actions describ$ 9 clauses 7i7 & 
7ii7 ( subp>agraph 7,d74  7iv7          
,def9itions ,9 ?is subp>agraph3 7,i7    
,=mal reconsid]ation reque/ ,! t]m =mal 
reconsid]ation reque/ means1 ) respect  
to a ,m$ic>e adm9i/rative contractor1 a 
docum5t t-- 7aa7 id5tifies itself z a   
=mal reque/ = reconsid]ation ( "p or all

 ( a f9aliz$ local cov]age det]m9ation  
made by su* contractor ) respect to a   
geographic area2 &  7bb7 is submitt$ by 
an int]e/$ p>ty4  7,,ii7 ,int]e/$ p>ty  
,! t]m int]e/$ p>ty means1 ) respect to 
a local cov]age det]m9ation made by a   
,m$ic>e adm9i/rative contractor )       
respect to a geographic area-- 7aa7 an  
individual entitl$ to b5efits "u "p ,a  
or enroll$ "u "p ,b :o resides 91 or    
receives items or s]vices 91 su* area2  
7bb7 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  7cc7 any entity 
t ! ,secret>y det]m9es to be an int]e/$ 
p>ty 9 su* area4  7,g7 ,ag5cy review (  
reconsid]ation decision ,^u ! reque/ (  
an int]e/$ p>ty 7z def9$ 9 subp>agraph  
7,f77iv771 ! ,secret>y %all review !    
f9al det]m9ation 7z def9$ 9 subp>agraph 
7,d77ii77 made by a ,m$ic>e adm9i/rative
 contractor foll[+ a complete =mal      
reconsid]ation reque/ made "u           
subp>agraph 7,f74 ,su* review %all      

include an analysis ( :e!r-- 7i7 !      
det]m9ation did n apply1 or inaccurately
 int]pret$1 qualify+ evid5ce 7z def9$ 9 
subp>agraph 7,d77iv77 relevant to su*   
det]m9ation2  7ii7 ! det]m9ation us$    
language t exce$$ ! scope ( ! int5d$    
purpose ( ! det]m9ation2  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;,a72  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;,a72   
7v7 ! det]m9ation does n apply ) respect
 to items or s]vices to :i* x 0 int5d$  
to apply2 or  7vi7 ! det]m9ation        
conflicts ) any o!r law1 rule1          
regulation1 or national cov]age         
det]m9ation1 z det]m9$ by ! ,secret>y4  
4  7c7 ,developm5t process = specifi$   

,l,c,ds ,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 ,m$ic>e adm9i/rative       
contractor1 su* contractor mu/ take !   
foll[+ actions ) respect to su*         
det]m9ation be=e su* det]m9ation may    
take effect3 7,i7 ,publi% on ! public   
int]net website ( ! ,c5t]s = ,m$ic>e    
,m$icaid ,s]vices commonly ref]r$ to z !
 ,m$ic>e ,cov]age ,database 7or a       
successor website7 & on ! public int]net
 website ( ! ,m$ic>e adm9i/rative       
contractor a propos$ v]sion ( ! specifi$
 local cov]age det]m9ation 79 ?is       
subp>agraph ref]r$ to z a draft         
det]m9ation71 any relat$ cod+ or bill+  
in=mation1 a writt5 rationale = ! draft 
det]m9ation1 & a description ( all      
evid5ce reli$ ^u & consid]$ by !        
contractor 9 ! developm5t ( ! draft     

det]m9ation4  7,,ii7 ,n lat] ?an #fj    
days aft] ! date on :i* ! ,m$ic>e       
adm9i/rative contractor publi%es ! draft
 det]m9ation 9 accordance ) subclause   
7,i7-- 7aa7 conv5e "o or m op51 public  
meet+s to review ! draft det]m9ation1 &1
 ) respect to ea* su* meet+1 make       
available means = ! public to att5d su* 
meet+ remotely1 & make ! plann$ ag5da = 
su* meet+ publicly accessible at lea/   
#ad days 9 advance2  7bb7 receive       
comm5ts ) respect to ! draft            
det]m9ation2 &  7cc7 secure ! advice (  
an exp]t panel1 :i* %all include--      
7,,aa7 #a or m physicians2 7,,bb7 #a or 
m memb]s ( ! ,contractor ,advisory      
,committee 7z describ$ 9 *apt] #ac ( !  
,m$ic>e ,program ,integrity ,manual1 z 9
 effect on ,febru>y #ab1 #bjai72 &      
7,,cc7 #a or m entities advocat+ on     
behalf ( "o or m individuals entitl$ to 
b5efits "u "p ,a or enroll$ "u "p ,b4   
7,,iii7 ,) respect to ea* meet+ conv5$  
pursuant to subclause 7,,ii77aa71 po/ on
 ! public int]net website ( !           

contractor1 n lat] ?an #ad days aft] su*
 meet+ is conv5$1 a record ( su* meet+1 
:i* may include a video or audio record+
 ( ! meet+4  7,,iv7 ,provide a p]iod =  
submission ( writt5 public comm5t on su*
 draft det]m9ation t beg9s on ! date on 
:i* all records requir$ 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  7,i7 ,9 g5]al ,subject to  
subclause 7,,ii71 a ,m$ic>e adm9i/rative
 contractor t has ent]$ into a contract 
) ! ,secret>y "u section #ahgd;,a %all1 
be=e a specifi$ local cov]age           
det]m9ation 79 ?is subp>agraph ref]r$ to
 z ! f9al det]m9ation7 takes effect1 po/
 on ! ,m$ic>e ,cov]age ,database & !    
public int]net website ( ! contractor ! 
foll[+ in=mation3  7aa7 ,a response to  
public comm5ts receiv$ & ! relevant     
issues rais$ at meet+s conv5$ pursuant  
to clause 7i77,,ii77aa7 ) respect to !  
draft det]m9ation4  7bb7 ,! full text ( 

all su* public comm5ts receiv$4  7cc7 ,!
 rationale = ! f9al det]m9ation4  7dd7  
,9 ! case t ! ,m$ic>e adm9i/rative      
contractor consid]$ qualify+ evid5ce 7z 
def9$ 9 clause 7iv77 9 ! developm5t ( ! 
det]m9ation t 0 n describ$ 9 ! writt5   
notice provid$ pursuant to clause       
7i77,i71 a description ( su* qualify+   
evid5ce4  7ee7 ,an effective date = !   
f9al det]m9ation t is n less ?an #de    
days aft] ! date on :i* su* det]m9ation 
is s po/$4  7,,ii7 ,logical outgr[?     
requirem5t ,not)/&+ subclause 7,i71 a   
f9al det]m9ation may n take effect      
unless su* det]m9ation is a logical     
outgr[? ( ! draft det]m9ation publi%$ "u
 clause 7i74  7iii7 ,specifi$ local     
cov]age det]m9ation def9$ ,= purposes ( 
?is subp>agraph1 ! t]m specifi$ local   
cov]age det]m9ation means1 ) respect to 
! relevant geographic area-- 7,i7 a new 
local cov]age det]m9ation2  7,,ii7 a    
revis$ local cov]age det]m9ation t makes
 a sub/antive revision to "o or m exi/+ 
local cov]age det]m9ations 7su* z by    

impos+ new requirem5ts ) respect to     
cov]age ( ! relevant item or s]vice or  
by *ang+ any cod+ or bill+ in=mation    
relat$ to su* det]m9ation72 or  7,,iii7 
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 publicly     
available evid5ce ( g5]al acceptance by 
! m$ical community1 su* z publi%$       
orig9al rese>* 9 pe]-review$ m$ical     
j\rnals1 sy/ematic reviews &            
meta-analyses1 evid5ce-bas$ cons5sus    
/atem5ts1 & cl9ical guidel9es4  4  7d7  
,effective date ,?is section1 & !       
am5dm5ts made by ?is section1 %all apply
 beg9n+ on ! date t is #a ye> aft] !    
date ( ! enactm5t ( ?is section4