I 

114TH CONGRESS 

1ST SESSION H. R. 2437 

To amend part B of title XVIII of the Social Security Act regarding high 

cost durable medical equipment, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 19, 2015 

Mrs. BLACKBURN introduced the following bill; which was referred to the 

Committee on Energy and Commerce, and in addition to the Committee 

on Ways and Means, 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 part B of title XVIII of the Social Security 

Act regarding high cost durable medical equipment, and 

for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SEC. ll. PRIOR AUTHORIZATION PROCESS FOR CERTAIN 

4 HIGH COST DURABLE MEDICAL EQUIPMENT, 

5 PROSTHETICS, ORTHOTICS, AND SUPPLIES 

6 UNDER THE MEDICARE PROGRAM. 

7 Section 1834(a)(15) of the Social Security Act (42 

8 U.S.C. 1395m(a)(15)) is amended— 


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1 (1) in the paragraph heading, by striking 

2 ‘‘ITEMS’’and inserting ‘‘ITEMS; PRIOR AUTHORIZA3 TION PROCESS FOR CERTAIN HIGH COST DURABLE

4 MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, 

5 AND SUPPLIES’’; and 

6 (2) by adding at the end the following new sub7 paragraph: 

8 ‘‘(D) PRIOR AUTHORIZATION PROCESS FOR

9 CERTAIN HIGH COST DURABLE MEDICAL EQUIP10 MENT, PROSTHETICS, ORTHOTICS, AND SUP11 PLIES.— 

12 ‘‘(i) IN GENERAL.—Not later than 1 

13 year after the date of the enactment of this 

14 subparagraph, the Secretary shall begin 

15 the process to develop and implement a 

16 prior authorization process for certain du17 rable medical equipment, prosthetics, 

18 orthotics, and supplies. A claim for an item 

19 of durable medical equipment, a prosthetic, 

20 an orthotic, or a supply that has received 

21 prior approval through the prior authoriza22 tion process shall be exempt from subse23 quent pre- and post-payment audits and 

24 only subject to audits for systematic fraud 

25 and abuse. 


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1 ‘‘(ii) CONSIDERATION OF FACTORS.— 

2 The Secretary shall consider the following 

3 factors in developing and implementing the 

4 prior authorization process under this sub5 paragraph: 

6 ‘‘(I) Beneficiary access to timely 

7 care. 

8 ‘‘(II) Alignment with the best 

9 practices of commercial managed care 

10 plans and Medicare Advantage plans 

11 under part C that have expertise in 

12 prior authorization processes. 

13 ‘‘(III) Implementation of stand14 ard medical necessity evaluation prior 

15 authorization requests for physician 

16 and hospital referral agents and non17 physician practitioners. 

18 ‘‘(IV) Accounting for same day 

19 delivery expectations by providing for 

20 expedited emergency review for cer21 tain items, including oxygen. 

22 ‘‘(iii) IMPLEMENTATION.—The Sec23 retary shall promulgate a regulation to 

24 carry out the prior authorization process 


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1 under this subparagraph. The regulation 

2 shall— 

3 ‘‘(I) ensure that stakeholders 

4 participate in the development of the 

5 process; and 

6 ‘‘(II) place priority on prior au7 thorization of items that are subject 

8 to a high number of contractor audits, 

9 including oxygen.’’. 

Æ 


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