Medicare coverage decisions face 60-day deadline

Summary#

The Timely Access to Coverage Decisions Act would amend title XVIII of the Social Security Act, which governs Medicare. Its stated goal is to ensure timely review of requests for local Medicare coverage decisions. It is not law; the bill has been introduced in the Senate.

  • The Secretary of Health and Human Services would have to require Medicare administrative contractors to decide within 60 days whether formal requests for local coverage determinations or reconsiderations are complete.
  • If a request is incomplete, the contractor must send written notice within that same 60-day period and list each item of information needed.
  • For a complete request, the contractor must take specified public-process steps within one year of receiving it. The bill does not guarantee that the request will be approved.
  • Before certain new or substantively revised local coverage determinations take effect, contractors would have to publish a draft, hold public meetings, receive comments, and obtain advice from an expert panel that includes physicians, contractor advisory committee members, and groups advocating for Medicare beneficiaries.
  • The Secretary must review a contractor’s final decision on a completed reconsideration request if an interested party asks. The review must examine six listed issues, including whether the decision used relevant evidence properly and conflicts with other law or national coverage decisions.

What it means for you#

  • Medicare beneficiaries: You may ask the Secretary to review a contractor’s final decision on a local coverage determination if you meet the bill’s definition of an interested party. That includes people entitled to Medicare Part A or enrolled in Part B who live in, or receive items or services in, the affected area. The bill does not change Medicare eligibility or directly guarantee coverage of an item or service.
  • Providers and suppliers: Those furnishing items or services affected by a local coverage determination in the area are included as interested parties for reconsideration requests and Secretary review.
  • Other interested parties: The Secretary may designate other entities as interested parties. The bill does not say how that designation would work.
  • Medicare contractors: They would have new deadlines and public-process duties. For certain drafts, they must publish supporting material, arrange public meetings with remote attendance, provide a written-comment period, and publish information about the final decision.
  • The public: The bill would make specified draft decisions, comments, meeting records, and final-decision information public. It does not require public meetings for every local coverage determination; the process applies to the bill’s defined “specified” determinations.

Money#

No publicly available information on estimated costs.

  • The bill requires the Secretary to impose new duties on Medicare contractors, but gives no staffing or cost estimate.
  • It does not specify an appropriation, fee, fine, or payment to people or providers.

What is unclear#

  • The supplied material does not include the current text of the Social Security Act provisions being amended, so existing requirements and exactly what would change from current law could not be verified.
  • The bill’s general effective date is one year after enactment, but the request deadlines refer to requests received starting 90 days after enactment of the relevant provision. How those dates fit together is unclear.
  • The bill does not set a deadline for the Secretary’s review of a reconsideration decision, say what remedy follows from a review, or explain what happens if a contractor misses a deadline.
  • “Formal LCD request” is defined only as a document identifying itself as a formal request. The bill does not set out required contents or explain how incomplete requests proceed after the contractor asks for more information.
  • The bill does not explain how the new review steps interact with existing processes or how experts on the panel are chosen.

Case for#

  • The bill appears intended to make the handling of local coverage requests more predictable by setting deadlines for completeness decisions and for steps on complete requests.
  • Requiring specific written notice of missing information could help applicants understand what they need to provide.
  • Publishing evidence, rationales, comments, and meeting records could make the basis for coverage decisions easier to examine.
  • Review by the Secretary could provide a check on contractor decisions, including whether evidence was misused or the decision conflicts with other rules.

Case against#

  • The added deadlines, meetings, expert advice, and publication steps could increase contractors’ administrative workload; the bill provides no cost estimate.
  • The required public process could delay some local coverage decisions. The bill does not explain how missed deadlines would be enforced.
  • The Secretary must review several issues but has no stated deadline or specified remedy, so the practical effect of that review is uncertain.
  • The bill does not fully define what makes a request complete or how the Secretary will decide which additional entities count as interested parties.