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[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5395 Introduced in House (IH)]

<DOC>

118th CONGRESS
  1st Session
                                H. R. 5395

    To amend title XVIII of the Social Security Act to establish a 
  demonstration program relating to medical necessity determinations 
                      under the Medicare program.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                           September 12, 2023

 Mrs. Harshbarger 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 establish a 
  demonstration program relating to medical necessity determinations 
                      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 ``Coverage Parity for Medicare 
Patients Act of 2023''.

SEC. 2. ESTABLISHING A DEMONSTRATION PROGRAM RELATING TO MEDICAL 
              NECESSITY DETERMINATIONS UNDER THE MEDICARE PROGRAM.

    Section 1862 of the Social Security Act (42 U.S.C. 1395y) is 
amended by adding at the end the following new subsection:
    ``(p) Demonstration Program Relating to Medical Necessity 
Determinations.--
            ``(1) In general.--Not later than January 1, 2026, the 
        Secretary shall establish a demonstration program (in this 
        subsection referred to as the `program') under which an item or 
        service furnished to an individual entitled to benefits under 
        part A or enrolled under part B is deemed to be reasonable and 
        necessary for purposes of subsection (a)(1) if such item or 
        service meets the criteria specified in paragraph (3).
            ``(2) Selection of participating areas.--The Secretary 
        shall select no fewer than 5 States (or, at the option of the 
        Secretary, no fewer than 3 Medicare administrative contractor 
        jurisdictions relating to the administration of parts A and B 
        (as specified by the Secretary)) in which to carry out the 
        program.
            ``(3) Specified criteria.--
                    ``(A) In general.--For purposes of paragraph (1), 
                the criteria specified in this paragraph are, with 
                respect to an item or service furnished to an 
                individual in a State or jurisdiction (as applicable) 
                selected by the Secretary under paragraph (2), the 
                following:
                            ``(i) Such item or service so furnished 
                        would be covered under a significant number of 
                        group health plans and group or individual 
                        health insurance coverage offered in such State 
                        or jurisdiction if so furnished to a similarly 
                        situated individual enrolled under such plan or 
                        coverage (as applicable).
                            ``(ii) The item or service is safe and 
                        effective.
                            ``(iii) The item or service--
                                    ``(I) is not experimental or 
                                investigational; or
                                    ``(II) is experimental or 
                                investigational, but is furnished as 
                                part of a clinical trial that meets the 
                                standards of coverage applicable under 
                                any national coverage determination 
                                relating to clinical trials.
                    ``(B) Significant coverage.--The Secretary shall 
                through notice-and-comment rulemaking establish 
                requirements for what constitutes coverage of an item 
                or service under a significant number of group health 
                plans and group or individual health insurance coverage 
                in a State or jurisdiction. Such requirements may 
                provide that such significant number is demonstrated 
                through a showing that a majority of similarly situated 
                individuals covered under such a plan or group or 
                individual health insurance coverage in such State or 
                jurisdiction would have benefits available under such 
                plan or coverage for such item or service or through 
                such other similar metrics determined appropriate by 
                the Secretary.
            ``(4) Duration.--
                    ``(A) In general.--The program shall be in effect 
                for a period of not less than 4 years.
                    ``(B) Expansion.--The Secretary may, during the 
                period in which the program is in effect and as 
                determined appropriate by the Secretary, expand the 
                program to additional States or jurisdictions not 
                originally selected under paragraph (2).
                    ``(C) Termination.--The Secretary may terminate the 
                program--
                            ``(i) only on or after the date that is 4 
                        years after the effective date of the program; 
                        and
                            ``(ii) only once the Secretary has 
                        concluded a 60-day public comment period with 
                        respect to such termination.''.
                                 <all>
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