Local Coverage Determination Clarification Act of 2018

Mr. Speaker, I move to suspend the rules and pass the bill (H.R. 3635) to amend title XVIII of the Social Security Act in order to improve the process whereby medicare administrative contractors issue local coverage determinations under the Medicare program, and for other purposes, as amended.

Mr. Speaker, I ask unanimous consent that all Members may have 5 legislative days in which to revise and extend their remarks and include extraneous material on H.R. 3635, currently under consideration.

Mr. Speaker, I yield myself such time as I may consume.

Mr. Speaker, today, I rise in support of H.R. 3635, the Local Coverage Determination Clarification Act. I introduced this legislation along with Congressman Kind, which will help ensure the Medicare coverage decisions are made by qualified health experts through a transparent process that is based on sound medical evidence.

Medicare administrative contractors, or MACs, play a critical role in ensuring that Medicare beneficiaries have access to needed care. However, the less-than-transparent process used by MACs to make coverage decisions can limit or deny patients' access to necessary care.

Specifically, the science that guides some of these decisions can be flawed, mischaracterized, or misapplied. The deliberations and decisions of the MACs, which should be based on medical science, are often conducted behind closed doors, with little opportunity for interested stakeholders to raise issues or offer alternatives. These decisions affect millions of Medicare beneficiaries and impact crucial access to innovative technologies and services.

The establishment of a clear process informed by health experts will make the local coverage determination, or LCD, process and the decisions developed by that process more sound, more transparent, and ensure accountability among MACs. These requirements are necessary to ensure that our Nation's seniors receive quality healthcare treatment.

Specifically, H.R. 3635 would improve the LCD process by requiring that carrier advisory committee meetings of the MAC are open, public, and on the record, with minutes taken and posted to the MAC's website for public inspection. The gravity of limiting or precluding coverage for both beneficiaries and practitioners heightens the need for transparency, especially when such meetings are currently closed off.

MACs would be required to include, at the outset of the coverage determination process, a description of the evidence a MAC considered when drafting a local coverage determination as well as the rationale it relies on to deny coverage.

Additionally, under current rules, local coverage determinations are essentially unreviewable once they become final. This legislation would create a process for stakeholders to request additional review of a MAC's local coverage decision from the Centers for Medicare and Medicaid Services.

It would also require the Secretary to submit a report to Congress regarding the number of requests filed with fiscal intermediaries and carriers and the number of appeals filed with the Secretary, as well as the actions in response. Additionally, the report would recommend ways to improve the usefulness and efficiency of the process as well as the communication with Medicare beneficiaries and providers.

While I am pleased that the legislation we have here today takes steps to improve the process and bring transparency to protect access for Medicare patients, we must continue to work to ensure that MACs independently evaluate the evidence of other MACs' coverage decisions. Local coverage determinations should be thoroughly evaluated by experts in each local jurisdiction.

Currently, loopholes in the process allow contractors to adopt another MAC's coverage determination without the necessary scientific rigor and meaningful engagement with stakeholders that is vital in forming the most appropriate policy. Due to regional, geographic, and population-based deficiencies, these carbon-copied LCDs may not reflect the specific geographic region they are intended to serve. Local coverage determinations should be just that--local.

Put simply, what works best for one location does not always work best for another location. Applying local coverage determinations across jurisdictions has the practical effect of establishing national coverage policies without having followed the more rigorous national coverage determination process. As such, I look forward to working with my colleagues on this issue, moving forward.

Medicare beneficiaries deserve transparency and accountability for these decisions that directly impact their access to care. These reforms are necessary to ensure that local coverage determinations do not impede a physician's medical judgment and deny patients access to medically necessary care. By changing the LCD process, Congress can ensure that medical and scientific evidence is not used selectively to deny appropriate coverage to seniors.

I want to thank Mr. Kind, who joined me in introducing this legislation.

I want to ask my colleagues for their bipartisan support of this bill as we work to improve access and care for every American.

Mr. Speaker, I reserve the balance of my time.

Mr. Speaker, I yield myself the balance of my time.

Mr. Speaker, in closing, I am proud to stand here today in support of this commonsense legislation that creates transparency and accountability to the local coverage determinations process and will help ensure that Medicare patients receive the medical care they need.

Mr. Speaker, I hope everyone will join me in voting for this legislation on the House floor today as we work to improve access and care for every American, and I yield back the balance of my time.

Mr. Speaker, I move to suspend the rules and pass the bill (H.R. 6690) to establish a smart card pilot program to combat fraud, waste, and abuse and to protect beneficiary identity under the Medicare program, as amended.

Mr. Speaker, I ask unanimous consent that all Members may have 5 legislative days in which to revise and extend their remarks and include extraneous material on H.R. 6690, currently under consideration.

Mr. Speaker, I yield myself such time as I may consume.

Mr. Speaker, we have an opportunity to do something together on a bipartisan basis that can bring a level of confidence to a program that all of us cherish and all of us want to defend, and that is Medicare. Medicare is an incredibly popular program. It is a necessary program, and it is a program that needs all of us to defend it, particularly on the integrity side.

If Medicare were to ask CMS today what their fraudulent or erroneous payment rate is, those two numbers together, they would come back and they would tell them it is about 10 percent. So, in other words, about $40 billion a year, Mr. Speaker, is going out the door not to benefit seniors, but it is going out the door either fraudulently or erroneously.

I thank Mr. Blumenauer from Oregon because, together, we have been working on this concept which would apply the same type of technology that we see in so many other parts of the economy right now, and that is smart card technology, and use it in a Medicare setting. The proposal is this: Let's try it. Let's see how it works. Let's have a pilot program.

Toward that end, what we are hoping and the expectation is that the same types of savings that we have seen in the private sector we will see in this sector to make sure that seniors are protected, not only the funds that seniors have come to rely on, but their identities and so forth.

This is a concept, again, that Mr. Blumenauer and I have worked on.

I thank Chairman Brady for his work on this bill and the attention that this has gotten on a bipartisan basis.

I think it is particularly interesting to note that AARP has weighed in very strongly in favor of it. Let me just read one quick snapshot from a letter that they sent to Mr. Blumenauer and me at the end of August, and I will just give you a couple of sentences.

``While the new cards are more secure than before, `smart cards' could provide even greater security, and have the potential to contain useful health information and facilitate care. If enacted, this pilot program would also help Medicare learn more about the beneficiary engagement and education. This technology deserves to be tested and evaluated.''

Mr. Speaker, in a nutshell, this is a proposal to create a pilot program. I urge its passage, and I reserve the balance of my time.

Committee on Ways and Means,

House of Representatives,

Washington, DC, September 7, 2018.

Hon. Greg Walden,

Chairman, Committee on Energy and Commerce,

Washington, DC.

Dear Chairman Walden: I write to you regarding several

health bills the Committee on Ways and Means ordered

favorably reported to the House. The following bills were

also referred to the Committee on Energy and Commerce.

I ask that the Committee on Energy and Commerce waive

formal consideration of the following bills so that they may

proceed expeditiously to the House Floor:

H.R. 6662, Empowering Seniors' Enrollment Decision Act of

2018;

H.R. 6690, Fighting Fraud to Protect Care for Seniors Act

of 2018;

H.R. 6561, Comprehensive Care for Seniors Act of 2018; and

H.R. 3635, Local Coverage Determination Clarification Act

of 2018.

I acknowledge that by waiving formal consideration of the

bills, the Committee on Energy and Commerce is in no way

waiving its jurisdiction over the subject matter contained in

those provisions of the bills that fall within your Rule X

jurisdiction. I would support your effort to seek appointment

of

an appropriate number of conferees on any House-Senate

conference involving this legislation.

I will include a copy of our letters in the Congressional

Record during consideration of this legislation on the House

floor.

Sincerely,

Kevin Brady,

Chairman.

Mr. Speaker, I want to thank Mr. Levin for his observations about this bill, that it is created in a spirit of bipartisanship, and I appreciate his support for it.

I think it is interesting, just a little bit of a point of clarification, because we were able to discuss in the committee the GAO report. There are two facets of it. There are two numbers, and those people who are tracking this closely will care about it. There is one 2 percent representation and then a 22 percent representation.

Here is the story. The GAO said only 2 percent of cases that they evaluated would have been completely changed by this. I think if we were talking about any other thing in Medicare as it relates to 2 percent, we would be chasing it. Be that as it may, 2 percent would be completely changed. Twenty-two percent of the cases they evaluated, however, would be impacted in some way.

So the bottom line here is that we have an opportunity to adopt technology at a cost of about $40 million, we are told, to pursue $40 billion in fraud and error. That is good math any day of the week. Both sides of the aisle recognize it.

Mr. Speaker, I urge its passage, and I yield back the balance of my time.

Mr. Speaker, I yield myself such time as I may consume.

Mr. Speaker, this is the first of four bills that came out of the Ways and Means Committee. They came out without much controversy. The only one that really had any is this first bill. I am not sure we will have any speakers on our side. I will say a few words about this bill in a few minutes.

I first want to talk a bit about bipartisanship. These four bills do have some bipartisanship. Unfortunately, what isn't bipartisan is the basic dispute about healthcare and about the continuation of the reform that we on the Democratic side started some years ago with our President.

It has turned out to be an important piece of legislation--I think historic--and the more people look at it and the more they are covered by it, the greater the support for it.

Unfortunately, unlike the bipartisanship in these four bills, ACA continues to be hit by the worst kind of partisanship and continued efforts to undermine and destroy it.

In October 2017, the administration ended cost-sharing reduction subsidies. That has led to premium increases of 20 to 25 percent across the Nation. In June of this year, the Trump administration expanded the reach of junk insurance policies that have weakened the risk pool, and these policies are not subject to consumer protections.

In July, we saw the impact of this firsthand in Michigan. The administration announced another cut in so-called navigator organizations. They slashed the funding from $63 million just 2 years ago to $10 million. It had an impact throughout this country, and I saw firsthand what it meant in the State of Michigan.

Essentially, the administration said we are going to cut and essentially eliminate help for outreach to people in terms of their knowing about the ACA and how, as millions of others have, they can obtain coverage.

I think maybe most disturbing, last week, the Federal court heard arguments in Texas v. the United States. It is a lawsuit launched by Republicans that could jeopardize healthcare for 130 million patients living with preexisting conditions. The Republicans like to point to language that says that won't happen. But essentially, I think they have their heads in the sand on this if the court were to rule in favor of the suit. I think, to the disgrace of the administration, they decided not to defend the government's position.

So we are here today with bipartisan bills, and it is really sad-- indeed, worse than that. We haven't had a single hearing on any of the issues I mentioned. And the Republicans, while they come here and talk about bipartisanship, which has been so essential until recent years when it comes to healthcare, they now essentially are engaging in very partisan efforts to undermine healthcare for millions and millions of people.

So let me just say, Mr. Speaker, a brief word about this. Mr. Roskam has been working on this for a long time, working with Mr. Blumenauer, and I think the gentleman's efforts to strive for some bipartisanship have been a positive.

As I said at the beginning, of all four bills, this one had the most discussion in our committee and had some disagreement. The smart card idea has been examined by a number of entities, including the Government Accountability Office. According to their 2016 report--and I have copies of their report of 2016, and there is also another report that relates to this--according to that, their estimate was that smart cards would help in only a minority of cases. In fact, of the 739 healthcare fraud cases that the GAO examined, only 18 would have been fully addressed had Medicare used these cards. That is only about 2 percent of the cases.

Also, transition to smart cards is going to be significant, and the estimate is that it is going to cost about $40 million. As we discussed in the committee, some thought there might be a better use of this money.

Be that as it may, this has been worked on, and Mr. Roskam and Mr. Blumenauer have combined forces to undertake this 3-year pilot program.

So under those circumstances, wishing we had more bipartisanship on healthcare issues that run more deeply and affect the needs of people even more broadly, with that caveat, I do not suggest anything but support for this bill.

Mr. Speaker, I have no further conversation, and I yield back the balance of my time.

Mr. Speaker, I yield myself such time as I may consume.

Mr. Speaker, my colleague has well described the purpose of this legislation. As she indicated, the bill establishes a timeline through which MACs must publish proposed LCDs online. She described what they are so the public can be sure what MACs and LCDs are.

It would further require public meetings to review draft determinations and ensure expert input is being sought on all proposals.

The bill also provides that stakeholders and beneficiaries, as she mentioned, may request reconsideration of LCDs and that MACs must respond to these requests.

These are small but useful improvements to the local coverage determination process. It will help improve transparency and ensure that appropriate coverage determinations are made for Medicare beneficiaries.

Mr. Speaker, I am pleased to indicate support for this bill, and I yield back the balance of my time.