Sponsors (3)
The bill speeds and expands transparency and review of Medicare coverage decisions—improving timeliness, clarity, and public participation—but raises risks to patient care quality, access to novel therapies, administrative costs, and privacy if deadlines and evidence rules are applied too narrowly or hastily.
Medicare beneficiaries will receive timelier local coverage determinations (LCDs) and reconsideration decisions because Medicare Administrative Contractors (MACs) must decide completeness within 60 days and issue final actions within one year.
Hospitals and clinicians will get clearer, public rationales and evidence for coverage rules because MACs must publish draft determinations, supporting evidence, and written rationales before finalizing.
Medicare beneficiaries and providers gain an administrative review pathway because the Secretary must review MAC final determinations on request for misapplication or scope errors.
Patients (especially those with chronic conditions) and Medicare beneficiaries face increased risk that faster timelines will produce rushed or lower-quality coverage determinations, leading to inappropriate denials or approvals that could harm care.
Patients and Medicare beneficiaries may experience delays in access to novel therapies because a narrowly defined 'qualifying evidence' could exclude real‑world or emerging evidence from coverage decisions.
State governments, MACs, and hospitals could face increased administrative burden and costs as tighter deadlines and new publication/review requirements shift resources within MACs and CMS.
Based on analysis of 2 sections of legislative text.
Requires MACs to screen requests within 60 days, notify requesters of missing information, and issue substantive LCD/reconsideration decisions within one year after a complete submission.
Official title: To amend title XVIII of the Social Security Act to ensure timely review of local coverage determination requests under the Medicare program.
Introduced April 27, 2026 by Neal Patrick Dunn · Last progress April 27, 2026
Requires Medicare administrative contractors (MACs) to screen, notify, and decide formal local coverage determination (LCD) and reconsideration requests within set deadlines. For requests submitted on or after 90 days after enactment, MACs must determine within 60 days whether a request is complete (and if incomplete, notify the requester and list missing items), and must issue a substantive decision within one year after receiving a complete request. The Secretary must review, at the request of an interested party, final MAC determinations after reconsideration for errors in applying evidence, scope, or reasonable-and-necessary standards.