I 
118TH CONGRESS 
1ST SESSION H. R. 5396 
To amend title XVIII of the Social Security Act to prohibit Medicare local 
coverage determinations from restricting access to care, and for other 
purposes. 
IN THE HOUSE OF REPRESENTATIVES 
SEPTEMBER 12, 2023 
Mr. BUCSHON introduced the following bill; which was referred to the Com-
mittee on Ways and Means, and in addition to the Committee on Energy 
and Commerce, for a period to be subsequently determined by the Speak-
er, in each case for consideration of such provisions as fall within the ju-
risdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to prohibit 
Medicare local coverage determinations from restricting 
access to care, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Coverage Determina-
tion Clarity Act of 2023’’. 
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SEC. 2. IMPROVING ACCESS TO ITEMS AND SERVICES 
UNDER MEDICARE LOCAL COVERAGE DETER-
MINATIONS. 
(a) IN GENERAL.—Section 1862(l)(5) of the Social 
Security Act (42 U.S.C. 1395y(l)(5)) is amended— 
(1) in subparagraph (A), by striking ‘‘The Sec-
retary’’ and inserting ‘‘Subject to subparagraph (E), 
the Secretary’’; and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(E) PROHIBITION
ON
LIMITING
ACCESS 
ITEMS AND SERVICES.— 
‘‘(i) REVIEW
OF
LOCAL
COVERAGE 
DETERMINATIONS.—Beginning in 2024, 
and annually thereafter, the Secretary 
shall review each local coverage determina-
tion in effect as of the date of such review 
to determine whether such local coverage 
determination denies, limits, or conditions 
the coverage or provision of items or serv-
ices beyond that provided by a national 
coverage determination that has deter-
mined that such items or services be cov-
ered nationally under this title. 
‘‘(ii) CONFLICT
BETWEEN
A
NA-
TIONAL COVERAGE DETERMINATION AND A 
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LOCAL
COVERAGE
DETERMINATION.—A 
local coverage determination denies, limits, 
or conditions the coverage or provision of 
items or services for purposes of clause (i) 
to the extent that such local coverage de-
termination limits access to such items or 
services by imposing restrictions that do 
not directly interpret provisions of a na-
tional coverage determination that has de-
termined that such items or services be 
covered nationally under this title. 
‘‘(iii) REVISION OF LOCAL COVERAGE 
DETERMINATIONS.— 
‘‘(I) IN GENERAL.—If the review 
conducted by the Secretary under 
clause (i) determines that a local cov-
erage determination denies, limits, or 
conditions the coverage or provision of 
items or services that are approved, 
cleared, authorized, or licensed under 
section 505, 510(k), 513, or 515 of 
the Federal Food, Drug, and Cos-
metic Act or section 351 of the Public 
Health Service Act, the Secretary 
shall direct the appropriate Medicare 
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‘‘(v) ERROR VERIFICATION AND COR-
RECTIVE
ACTIONS.—In verifying any po-
tential errors and taking corrective actions, 
Medicare administrative contractors, com-
prehensive error rate testing recovery audi-
tors, and unified program integrity con-
tractors and independent review agencies— 
‘‘(I) shall not deviate from local 
coverage determination provisions ap-
plicable in the region in which such 
verification or corrective action occurs; 
and 
‘‘(II) shall provide transparent 
review by publishing the names of the 
reviewers and their qualifications in a 
place and format available to pro-
viders. 
‘‘(vi) REPORTS
TO
CONGRESS.—Be-
ginning in 2025 and each year thereafter, 
the Secretary shall submit a report to the 
appropriate committees of Congress on the 
findings of the review conducted under 
clause (i) and any local coverage deter-
minations revised pursuant to clause (iii) 
during the preceding year.’’. 
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(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall apply with respect to proposed and 
final local coverage determinations posted on Medicare ad-
ministrative contractor websites on and after January 1, 
2023. 
Æ 
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