Sec. 203. Exclusions and limitations
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/bill/119/s/1506/is/section-203·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Benefits for items and services are not available under the Medicare for All Program unless the items and services meet the standards developed by the Secretary pursuant to section 201(a). In applying subsection (a), the Secretary shall make national coverage determinations with respect to items and services that are experimental in nature. Such determinations shall be consistent with the national coverage determination process as defined in section 1869(f)(1)(B) of the Social Security Act ( 42 U.S.C. 1395ff(f)(1)(B) ).
The Secretary shall establish a process by which individuals can appeal coverage decisions. The process shall, as much as is feasible, follow the process for appeals under the Medicare program described in section 1869 of the Social Security Act ( 42 U.S.C. 1395ff ). In the case of items and services for which the Department of Health and Human Services has recognized a national practice guideline, such items and services are considered to meet the standards specified in section 201(a) if they have been provided in accordance with such guideline.
For purposes of this subsection, an item or service not provided in accordance with a national practice guideline shall be considered to have been provided in accordance with such guideline if the health care provider providing the item or service— exercised appropriate professional discretion to deviate from the guideline in a manner authorized or anticipated by the guideline; acted in accordance with the laws and requirements in which such item or service is furnished; acted in the best interests of the individual receiving the item or service; and acted in a manner consistent with the individual’s wishes.
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Sec. 203
Exclusions and limitations
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