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, responded to a new Government Accountability Office (GAO) report regarding the Centers for Medicare & Medicaid Services’ (CMS) National Coverage Determination (NCD) process. The NCD process impacts approximately 68 million beneficiaries.
Chairmen Guthrie and Smith issued a joint statement: “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. 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.”
The GAO report found that while CMS generally meets specified time frames for some coverage determinations, there is often little explanation or set timeline when determinations have not yet been considered. This situation leaves both seniors and health care providers uncertain about whether certain medications or services will be covered by Medicare, which can result in delayed treatment until CMS issues a decision.
One recent example cited was CMS’s use of a blanket NCD under the Biden-Harris Administration to restrict Medicare coverage for an entire class of Alzheimer’s treatments despite approval from the Food and Drug Administration. The current determination process has been described as opaque, with some beneficiaries waiting years for access to treatments deemed medically necessary by their physicians.
Key findings from the GAO report include that CMS has not identified or assessed causes behind delays in coverage determinations; some analyses exceeded timelines by up to 351 days—including reviews involving cancer cell therapy and pain management equipment—and that CMS officials acknowledged they do not document analysis delays.
This GAO review follows a 2023 letter from both committees addressed to Health and Human Services Secretary Xavier Becerra and CMS Administrator Chiquita Brooks-LaSure, expressing concerns about CMS’s coverage process and calling for timelier updates.
