I 118th CONGRESS 1st Session H. R. 5395 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.

1. Short title This Act may be cited as the Coverage Parity for Medicare Patients Act of 2023 . 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. .