House Republicans Call for Greater Transparency of CMS National Coverage Determinations Following GAO Report

WASHINGTON, D.C. - Today, Congressman Brett Guthrie (KY-02), Chairman of the House Committee on Energy and Commerce, and Congressman Jason Smith (MO-08), Chairman of the House Committee on Ways and Means, issued the following joint statement in response to a newly released Government Accountability Office (GAO) report. The report articulates the need for greater transparency and reporting measures in order to improve the Centers for Medicare & Medicaid's (CMS) National Coverage Determination (NCD) process for the approximately 68 million beneficiaries under its purview.

"The GAO report makes clear that CMS must do more to provide transparency and accountability in its coverage decisions. Seniors should never be left waiting without clear answers about whether Medicare will cover the treatments and services their doctors recommend," said Chairmen Guthrie and Smith. "Such clarity would also inspire confidence in American innovators to develop the next treatments and cures for patients. Greater openness in the National Coverage Determination process is essential to ensure trust, timely access to care, and confidence that decisions are being made fairly and consistently. We will continue exercising oversight to make sure CMS meets its responsibility to the more than 68 million Americans who rely on Medicare."

Background:

In its report, GAO found that while CMS generally meets its specified time frames for the coverage determinations it considers, in cases where determinations are not yet considered, there is little to no explanation or specified timeline for when CMS will ultimately make a determination. This means that seniors and their health care providers and innovators are often left in the dark as to whether a particular medication or service is covered by Medicare, which may force patients to delay treatment until a coverage decision is granted by CMS.

In a recent example, the Biden-Harris Administration's CMS used a blanket NCD to restrict Medicare coverage for an entire class of Alzheimer's treatments despite Food and Drug Administration approval for the same class of drug. The opaque nature of CMS's current determination process leaves beneficiaries waiting, in some cases years, for access to a treatment or service their doctor has already deemed medically necessary.

Highlights from the GAO Report:

• CMS has not identified or assessed the causes of delays in coverage determinations.
• Some coverage analyses exceeded timelines by as much as 351 days, including reviews of a cancer cell therapy and medical equipment for pain management.
• CMS officials acknowledged they do not currently document analysis delays.

The GAO report follows a 2023 letter submitted by the Energy and Commerce and Ways and Means Committees to the Biden-Harris Administration's Health and Human Services Secretary and CMS Administrator, highlighting grave concerns with CMS's coverage process and the need for timelier updates.

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