H.R. 8500

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 8500 Introduced in House (IH)]

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119th CONGRESS
2d Session
H. R. 8500

To amend title XVIII of the Social Security Act to ensure timely review 
of local coverage determination requests under the Medicare program.

_______________________________________________________________________

IN THE HOUSE OF REPRESENTATIVES

April 27, 2026

Mr. Dunn of Florida (for himself, Ms. Barragan, and Ms. Tenney) 
introduced the following bill; which was referred to the Committee on 
Ways and Means, and in addition to the Committee on Energy and 
Commerce, for a period to be subsequently determined by the Speaker, in 
each case for consideration of such provisions as fall within the 
jurisdiction of the committee concerned

_______________________________________________________________________

A BILL

To amend title XVIII of the Social Security Act to ensure timely review 
of local coverage determination requests under the Medicare program.

Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the ``Timely Access to Coverage Decisions 
Act of 2026''.

SEC. 2. ENSURING TIMELY REVIEW OF LOCAL COVERAGE DETERMINATION REQUESTS 
UNDER THE MEDICARE PROGRAM.

(a) In General.--Section 1862(l)(5) of the Social Security Act (42 
U.S.C. 1395y(l)(5)) is amended by adding at the end the following new 
subparagraph:
``(E) Timeframe for decisions on requests for local 
coverage determinations.--
``(i) In general.--The Secretary shall 
require each Medicare administrative contractor 
that receives a formal LCD request on or after 
the date that is 90 days after the date of 
enactment of this subparagraph to determine 
whether such request is a complete request or 
an incomplete request not later than 60 days 
after such contractor receives such request.
``(ii) Notification with respect to 
incomplete requests.--In the case that a 
Medicare administrative contractor makes a 
determination described in clause (i) with 
respect to a formal LCD request that such 
request is incomplete, such contractor shall, 
not later than 60 days after the date on which 
such contractor received such request, transmit 
to the entity that submitted such request a 
written notification of such determination that 
includes a specification of each item of 
additional information needed to make such 
request complete.
``(iii) Decision timeline for complete 
requests.--In the case that a Medicare 
administrative contractor makes a determination 
described in clause (i) with respect to a 
formal LCD request that such request is 
complete, such contractor shall, not later than 
1 year after the date on which such contractor 
received such request, take the actions 
described in clauses (i) and (ii) of 
subparagraph (D).
``(iv) Formal lcd request defined.--In this 
subparagraph, the term `formal LCD request' 
means a document that identifies itself as a 
formal request for a local coverage 
determination.''.
(b) Reconsideration Requests.--Section 1862(l)(5) of the Social 
Security Act (42 U.S.C. 1395y(l)(5)), as amended by subsection (a), is 
further amended by adding at the end the following new subparagraphs:
``(F) Timeframe for decisions on reconsideration 
requests for local coverage determinations.--
``(i) In general.--The Secretary shall 
require each Medicare administrative contractor 
that receives a formal reconsideration request 
on or after the date that is 90 days after the 
date of enactment of this subparagraph to 
determine whether such request is a complete 
request or an incomplete request not later than 
60 days after such contractor receives such 
request.
``(ii) Notification with respect to 
incomplete requests.--In the case that a 
Medicare administrative contractor makes a 
determination described in clause (i) with 
respect to a formal reconsideration request 
that such request is incomplete, such 
contractor shall, not later than 60 days after 
the date on which such contractor received such 
request, transmit to the entity that submitted 
such request a written notification of such 
determination that includes a specification of 
each item of additional information needed to 
make such request complete.
``(iii) Decision timeline for complete 
requests.--In the case that a Medicare 
administrative contractor makes a determination 
described in clause (i) with respect to a 
formal reconsideration request that such 
request is complete, such contractor shall, not 
later than 1 year after the date on which such 
contractor received such request, take the 
actions described in clauses (i) and (ii) of 
subparagraph (D).
``(iv) Definitions.--In this subparagraph:
``(I) Formal reconsideration 
request.--The term `formal 
reconsideration request' means, with 
respect to a Medicare administrative 
contractor, a document that--
``(aa) identifies itself as 
a formal request for 
reconsideration of part or all 
of a finalized local coverage 
determination made by such 
contractor with respect to a 
geographic area; and
``(bb) is submitted by an 
interested party.
``(II) Interested party.--The term 
`interested party' means, with respect 
to a local coverage determination made 
by a Medicare administrative contractor 
with respect to a geographic area--
``(aa) an individual 
entitled to benefits under part 
A or enrolled under part B who 
resides in, or receives items 
or services in, such area;
``(bb) a provider of 
services or supplier that, in 
such area, furnishes, provides, 
or supplies items or services 
that are subject to such 
determination; or
``(cc) any entity that the 
Secretary determines to be an 
interested party in such area.
``(G) Agency review of reconsideration decision.--
Upon the request of an interested party (as defined in 
subparagraph (F)(iv)), the Secretary shall review the 
final determination (as defined in subparagraph 
(D)(ii)) made by a Medicare administrative contractor 
following a complete formal reconsideration request 
made under subparagraph (F). Such review shall include 
an analysis of whether--
``(i) the determination did not apply, or 
inaccurately interpreted, qualifying evidence 
(as defined in subparagraph (D)(iv)) relevant 
to such determination;
``(ii) the determination used language that 
exceeded the scope of the intended purpose of 
the determination;
``(iii) the determination was incorrect in 
its determination of whether such item or 
service is reasonable and necessary for the 
diagnosis or treatment of illness or injury 
under section 1862(a)(1)(A);
``(iv) the determination failed to 
describe, with respect to such an item or 
service, the clinical conditions to be used for 
purposes of determining whether such item or 
service is reasonable and necessary for the 
diagnosis or treatment of illness or injury 
under section 1862(a)(1)(A);
``(v) the determination does not apply with 
respect to items or services to which it was 
intended to apply; or
``(vi) the determination conflicts with any 
other law, rule, regulation, or national 
coverage determination, as determined by the 
Secretary.''.
(c) Development Process for Specified LCDs.--Section 1862(l)(5)(D) 
of the Social Security Act (42 U.S.C. 1395y(l)(5)(D)) is amended to 
read as follows:
``(D) Process for issuing specified local coverage 
determinations.--
``(i) In general.--In the case of a 
specified local coverage determination (as 
defined in clause (iii)) within an area by a 
Medicare administrative contractor, such 
contractor must take the following actions with 
respect to such determination before such 
determination may take effect:
``(I) Publish on the public 
internet website of the Centers for 
Medicare & Medicaid Services commonly 
referred to as the `Medicare Coverage 
Database' (or a successor website) and 
on the public internet website of the 
Medicare administrative contractor a 
proposed version of the specified local 
coverage determination (in this 
subparagraph referred to as a `draft 
determination'), any related coding or 
billing information, a written 
rationale for the draft determination, 
and a description of all evidence 
relied upon and considered by the 
contractor in the development of the 
draft determination.
``(II) Not later than 60 days after 
the date on which the Medicare 
administrative contractor publishes the 
draft determination in accordance with 
subclause (I)--
``(aa) convene one or more 
open, public meetings to review 
the draft determination, and, 
with respect to each such 
meeting, make available means 
for the public to attend such 
meeting remotely, and make the 
planned agenda for such meeting 
publicly accessible at least 14 
days in advance;
``(bb) receive comments 
with respect to the draft 
determination; and
``(cc) secure the advice of 
an expert panel, which shall 
include--

``(AA) 1 or more 
physicians;

``(BB) 1 or more 
members of the 
Contractor Advisory 
Committee (as described 
in chapter 13 of the 
Medicare Program 
Integrity Manual, as in 
effect on February 12, 
2019); and

``(CC) 1 or more 
entities advocating on 
behalf of one or more 
individuals entitled to 
benefits under part A 
or enrolled under part 
B.

``(III) With respect to each 
meeting convened pursuant to subclause 
(II)(aa), post on the public internet 
website of the contractor, not later 
than 14 days after such meeting is 
convened, a record of such meeting, 
which may include a video or audio 
recording of the meeting.
``(IV) Provide a period for 
submission of written public comment on 
such draft determination that begins on 
the date on which all records required 
to be posted with respect to such draft 
determination under subclause (III) are 
so posted and that is not fewer than 30 
days in duration.
``(ii) Finalizing a specified local 
coverage determination.--
``(I) In general.--Subject to 
subclause (II), a Medicare 
administrative contractor that has 
entered into a contract with the 
Secretary under section 1874A shall, 
before a specified local coverage 
determination (in this subparagraph 
referred to as the `final 
determination') takes effect, post on 
the Medicare Coverage Database and the 
public internet website of the 
contractor the following information:
``(aa) A response to public 
comments received and the 
relevant issues raised at 
meetings convened pursuant to 
clause (i)(II)(aa) with respect 
to the draft determination.
``(bb) The full text of all 
such public comments received.
``(cc) The rationale for 
the final determination.
``(dd) In the case that the 
Medicare administrative 
contractor considered 
qualifying evidence (as defined 
in clause (v)) in the 
development of the 
determination that was not 
described in the written notice 
provided pursuant to clause 
(i)(I), a description of such 
qualifying evidence.
``(ee) An effective date 
for the final determination 
that is not less than 45 days 
after the date on which such 
determination is so posted.
``(II) Logical outgrowth 
requirement.--Notwithstanding subclause 
(I), a final determination may not take 
effect unless such determination is a 
logical outgrowth of the draft 
determination published under clause 
(i).
``(iii) Specified local coverage 
determination defined.--For purposes of this 
subparagraph, the term `specified local 
coverage determination' means, with respect to 
the relevant geographic area--
``(I) a new local coverage 
determination;
``(II) a revised local coverage 
determination that makes a substantive 
revision to one or more existing local 
coverage determinations (such as by 
imposing new requirements with respect 
to coverage of the relevant item or 
service or by changing any coding or 
billing information related to such 
determination); or
``(III) any other local coverage 
determination specified by the 
Secretary pursuant to regulations.
``(iv) Qualifying evidence defined.--For 
purposes of this subparagraph, the term 
`qualifying evidence' means publicly available 
evidence of general acceptance by the medical 
community, such as published original research 
in peer-reviewed medical journals, systematic 
reviews and meta-analyses, evidence-based 
consensus statements, and clinical 
guidelines.''.
(d) Effective Date.--This section, and the amendments made by this 
section, shall apply beginning on the date that is 1 year after the 
date of the enactment of this section.
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