; or (II) improve the quality of patient care without increasing spending. (ii) The Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such waiver would reduce (or would not result in any increase in) net program spending under this title. (iii) The Secretary determines that such waiver would not deny or limit the coverage or provision of benefits under this title for individuals. (D) Public comment The Secretary shall establish a process by which stakeholders may (on at least an annual basis) submit requests for a waiver under this paragraph. .