The proposed program would be implemented across at least five states or Medicare administrative jurisdictions. The Secretary has the discretion to expand the program to more areas post-implementation. The basis for deeming services as medically necessary will depend on whether they are commonly covered by a significant number of health plans or insurance policies in the selected jurisdictions. This could lead to a more standardized approach to how Medicare recognizes the necessity of specific medical services, potentially impacting the coverage decisions for many patients.
Summary
House Bill 5395, titled the 'Coverage Parity for Medicare Patients Act of 2023', seeks to amend Title XVIII of the Social Security Act by establishing a demonstration program aimed at medical necessity determinations under the Medicare program. This initiative intends to ensure that certain medical items or services provided to Medicare beneficiaries are recognized as reasonable and necessary based on established criteria. The bill necessitates that the Secretary of Health and Human Services set up this program by January 1, 2026, with the aim of enhancing patient access to required Medicare services.
Contention
While the bill focuses on improving access to necessary healthcare for Medicare beneficiaries, it may also provoke discussions regarding the administrative responsibilities and authority of the Secretary of Health and Human Services. Some stakeholders might raise concerns about the criteria that will be developed for determining spending on medical items or services. This could lead to debates around regional disparities in healthcare access and whether certain demographics might be disproportionately affected by the program's implementation or expansion.