Skin Substitute Access and Payment Reform Act

Predictable Payment Adjustments: For 2027 and each year after, the payment amount for skin substitute products will be adjusted annually based on the percentage increase in the Consumer Price Index for All Urban Consumers (Section 2(b)(1)(A)(ii)).

Standardized Coverage: During 2026, a skin substitute product cannot be deemed not covered by Medicare based solely on an analysis of clinical evidence, unless the Secretary determines it is unsafe due to contamination, serious infectious disease, or serious adverse reactions (Section 3(5)).

Prevention of Abuse: The bill implements measures to identify and monitor the top 3 percent of providers receiving the highest payments to assess potential fraud, waste, or abuse (Section 3(1)).

Increased Oversight for Certain Providers: Providers identified as "outlier providers" may be subjected to prepayment claim reviews (Section 3(2)) and prior authorization requirements (Section 3(3)).

Risk of Program Exclusion: If an outlier provider's request for prior authorization is denied at a rate exceeding 75 percent over six consecutive months, it may be determined that an abuse of billing privileges exists, which could lead to the provider being excluded from Federal health care programs (Section 3(4)).

Financial Costs for Program Management: The Secretary will transfer $5,000,000 for each of fiscal years 2027 through 2030 from the Federal Supplementary Medical Insurance Trust Fund to the CMS Program Management Account to fund prior authorization processes (Section 3(3)(C)).