Local Coverage Determination Clarification Act of 2016

Local Coverage Determination Clarification Act of 2016

This bill amends title XVIII (Medicare) of the Social Security Act to revise the process by which Medicare administrative contractors (MACs) issue and reconsider local coverage determinations (LCDs) that: (1) are new, (2) restrict or substantively revise existing LCDs, or (3) are otherwise specified in regulation. (MACs are private insurers that process Medicare claims within specified geographic areas.)

Before such an LCD may take effect, the MAC issuing the determination must, with respect to each geographic area to which the determination applies:

• publish online a proposed version of the determination and other specified, related information;
• convene one or more public meetings to review the draft determination, receive comments, and secure the advice of an expert panel;
• post online a record of the minutes from each such meeting;
• provide a period for submission of written public comments; and
• post online specified information related to the rationale for the final determination.

Upon the filing of an applicable request by an interested party with regard to the reconsideration of a specified LCD, the MAC that issued the determination shall:

• provide specified information related to whether the determination failed to correctly apply qualifying relevant evidence, exceeds the scope of its intended purpose, fails to apply as intended, or is otherwise erroneous;
• preserve the determination, modify the determination, or rescind the determination in part; and
• make publicly available a written description of such action.

An interested party may appeal a reconsideration decision to the Centers for Medicare & Medicaid Services (CMS).

CMS shall appoint a Medicare Reviews and Appeals Ombudsman to carry out specified duties with regard to LCDs.