[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 8129 Introduced in House (IH)]
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119th CONGRESS
2d Session
H. R. 8129
To amend title XVIII of the Social Security Act to establish a full
risk ACO program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
March 26, 2026
Ms. Tenney (for herself and Mr. Schneider) introduced the following
bill; which was referred to the Committee on Ways and Means, and in
addition to the Committee on Energy and Commerce, for a period to be
subsequently determined by the Speaker, in each case for consideration
of such provisions as fall within the jurisdiction of the committee
concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to establish a full
risk ACO program.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. FULL RISK ACO PROGRAM.
Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is
amended by adding at the end the following new section:
``full risk accountable care organization program
``Sec. 1899B.
``(a) Findings.--Congress finds as follows:
``(1) Successful pilots over the last decade have
demonstrated that full risk accountable care organizations
(ACOs), including full risk ACOs that focus on a complex care
population are successful at improving health outcomes while
lowering costs in traditional Medicare.
``(2) Traditional Medicare lacks a permanent program that
allows providers flexibility to engage in full risk models
outside of time-limited pilot projects.
``(3) A wide range of organizations serving a range of
traditional Medicare beneficiaries, including rural and
underserved areas, would benefit from permanent options for
full risk accountable care.
``(4) Full risk models can transform care by allowing more
flexible and diverse payment options beyond fee-for-service
reimbursement, impact cash flow, and tailor experiences for
clinicians and beneficiaries.
``(5) ACO options must encourage better care coordination
for complex care beneficiaries, those with six or more chronic
conditions.
``(b) Establishment.--By June 30, 2026, the Secretary shall
establish a full risk ACO program (in this section referred to as the
`program') that adopts proven provider incentives to deliver high-
quality care to better meet the needs of Traditional Medicare
beneficiaries (as defined in subsection (l)). Under such program--
``(1) groups of health care professionals shall work
together to manage and coordinate care for Medicare fee-for-
service beneficiaries through a `standard' or `complex care'
full risk ACO.
``(2) providers and suppliers participating in this program
shall be paid in a manner that incentivizes furnishing items
and services in such practice to provide high-quality care
tailored to meet the needs of Medicare fee-for-service
beneficiaries while reducing the cost of care.
``(c) Full Risk ACO Program With Standard and Complex Care Track
Options.--
``(1) In general.--An ACO participating in this program is
a group of providers and suppliers focused on individualizing
care to meet the specific needs of Traditional Medicare
beneficiaries by emphasizing advanced primary care, care
coordination, and the delivery of care in alternate settings
for beneficiaries needing medical and nonmedical assistance in
managing their health.
``(2) Requirements.--In order to participate in the program
under this program, an ACO:
``(A) Must be formed by the following ACO
participants or combinations of ACO participants,
consistent with the Medicare Shared Savings Program:
``(i) ACO professionals in group practice
arrangements.
``(ii) Networks of individual practices of
ACO professionals.
``(iii) Partnerships or joint venture
arrangements between hospitals and ACO
professionals.
``(iv) Hospitals employing ACO
professionals.
``(v) CAHs that bill under Method II (as
described in section 413.70(b)(3) of this
chapter).
``(vi) RHCs.
``(vii) FQHCs.
``(viii) Teaching hospitals that have
elected under section 415.160 of this
subchapter to receive payment on a reasonable
cost basis for the direct medical and surgical
services of their physicians.
``(B) Shall be structured to allow the organization
to receive and distribute payments for services and
performance incentives to participant and preferred
providers and suppliers.
``(C) Shall include a sufficient number and type of
providers for the Medicare fee-for-service
beneficiaries aligned or assigned to the ACO, as
determined by the Secretary.
``(D) Shall serve a required minimum number of
aligned and/or attributed beneficiaries.
``(i) A Standard Full Risk ACO shall have
at least 2,500 aligned and/or assigned
beneficiaries.
``(ii) A complex care full risk ACO shall
have at least 250 aligned and/or assigned
beneficiaries in the first year; at least 500
aligned or assigned beneficiaries in the second
year; and at least 1,000 aligned and/or
assigned beneficiaries in the third year and in
every participation year after that.
``(E) May establish `preferred provider'
relationships, and may pay such providers a portion or
all of the provider's fee-for-service claims in lieu of
fee-for-service reimbursement from CMS.
``(F) Shall have a financial guarantee mechanism in
place commensurate with the financial arrangement
selected in this program.
``(G) Shall enter into an agreement with the
Secretary to participate in the program for a five-year
period. The agreement may be renewed for additional
performance periods.
``(H) Shall permit participation in the program at
the TIN-NPI level.
``(3) Clinical services.--An ACO participating in this
program shall provide individualized care to meet the specific
needs of Medicare fee-for-service beneficiaries attributed or
aligned to the ACO. This may include the following:
``(A) Coordinated care across the care continuum,
including transitions.
``(B) Social support services.
``(C) Behavioral health services.
``(D) Nonvisit-based care (including email, text,
phone, video, or other technology).
``(E) Extended care access options and technology
platforms enabling patient stratification, outcomes
tracking, and practice-based population management.
``(F) In-home care.
``(G) Palliative care.
``(H) Other items and services as determined
appropriate by the Secretary.
``(4) Quality and reporting requirements.--The Secretary
shall develop quality performance standards for full risk ACOs.
``(A) Standard full risk acos.--The Secretary shall
deploy a limited set of quality measures that
prioritize patient experience and health outcomes while
reducing clinician burden.
``(B) Additional requirement for quality
performance for complex care full risk acos.--The
Secretary shall deploy the quality measures in
(c)(4)(A) and include a Days at Home measure.
``(C) Overlap with medicare access and chip
reauthorization act.--All full risk ACO program
participants shall be exempt from the Merit-Based
Incentive Payment System (MIPS).
``(5) Beneficiary communications.--The Secretary shall
promulgate requirements for ACO marketing to Medicare fee-for-
service beneficiaries that educates and informs beneficiaries
about their care options.
``(d) Payment Arrangements for ACOs, Participant and Preferred
Providers.--
``(1) In general.--A full risk ACO is eligible to receive
the following payments under the program under this section:
``(A) Primary care capitation.--A per-beneficiary,
per-month capitated payment for primary care services
provided by Participant Providers and preferred
providers who have opted into the capitated arrangement
with the full risk ACO reflective of the predicted
Medicare Part B costs representing professional
services for which the ACO is directly responsible. In
a given year, such payment may be up to 7 percent of
the total health care spending for the beneficiary
under this title for the year. The program shall
include a repayment mechanism for the primary care
capitation to ensure that this does not result in
additional Medicare spending.
``(B) Total care capitation.--A per-beneficiary,
per-month capitated payment for all Medicare Part A and
Part B services provided to aligned beneficiaries by
all Participant Providers and by preferred providers
who have opted into the capitated arrangement. The TCC
payment amount will reflect the estimated total cost of
care for the full risk ACO's aligned population for
services provided by the providers participating in the
capitation mechanism. Providers that elect to
participate in Total Care Capitation will agree to a
100 percent reduction of their fee-for-service claims.
``(C) Option for claims reduction and population-
based payment.--Full Risk ACOs can enter into
arrangements whereby CMS would reduce claims payments
for aligned beneficiaries for Participant and Preferred
Providers and CMS would make a monthly payment to the
ACO equivalent to the estimated value of the FFS claims
reductions for those services.
``(2) Financial arrangements.--
``(A) In general.--This program shall offer full
financial risk for participant ACOs.
``(B) Financial arrangements.--The Secretary shall
make multiple financial arrangements available to ACOs,
reflecting varying experience with and ability to
assume risk for Medicare fee-for-service beneficiaries.
The Secretary shall make one or more financial
arrangements available to ACOs under both of the
following solutions:
``(i) Full risk arrangement.--ACOs
participating in full risk arrangements shall
share in 100 percent of savings and losses,
subject to a discount and risk corridors.
``(ii) Discount.--The Secretary shall
determine and apply a discount to the full risk
ACO's benchmark.
``(C) Benchmark for standard full risk acos.--The
benchmark for Standard Full Risk ACOs shall be
developed by--
``(i) calculating the ACOs historical
baseline spending for its aligned beneficiary
population;
``(ii) trending the historical baseline
expenditures forward based on an adjusted
version of the U.S. Per Capita Cost growth
trend;
``(iii) blending the historical baseline
expenditures with regional expenditures using
an adjusted Medicare Advantage rate book;
``(iv) risk adjust the blended
expenditures; and
``(v) apply the discount.
``(D) Benchmark for complex care full risk acos.--
The benchmarking methodology for Complex Care Full Risk
ACOs shall be developed separately, taking into account
the appropriate weighting of the regional component (at
least half) and remove the ceiling on the regional
blend.
``(E) Risk corridors.--The Secretary shall develop
risk corridors appropriate to this program.
``(e) Risk Adjustment.--
``(1) Prospective risk adjustment.--Subject to paragraph
(2), the Secretary shall use prospective risk adjustment for a
standard full risk ACO. Risk adjustment methodologies should be
identical to Medicare Advantage to the extent practical.
``(2) Concurrent risk adjustment for complex care full risk
aco.--The Secretary shall use concurrent risk adjustment to
adjust the benchmark for a complex care full risk ACO.
``(f) Beneficiary Assignment.--
``(1) In general.--Full Risk ACO program participants shall
use the Medicare Shared Savings Program alignment and
assignment methodologies, including a choice of prospective
assignment or prospective assignment with retrospective
reconciliation.
``(2) Signed voluntary alignment.--In addition to the
methodology in subsection (f)(1), Standard and Complex Care
Full Risk ACOs shall be permitted to use signed voluntary
alignment. Such alignment shall take effect on a monthly basis.
``(3) Opt-out.--Medicare beneficiaries shall have the
ability to opt out of participating in the full risk ACO
program.
``(g) Waivers.--The Secretary may waive such provisions of this
title and title XI as the Secretary determines necessary in order to
implement the demonstration program.
``(h) Data.--The Secretary shall provide to program participants
under this section regular reports with up-to-date provider claims data
and payment information with respect to Medicare fee-for-service
beneficiaries attributed or aligned in the ACO and shall provide other
data to ACOs as necessary.
``(i) Treatment Under the Medicare Access and CHIP Reauthorization
Act.--An ACO participating in this program shall be considered an
`advanced alternative payment model'.
``(j) Definitions.--In this section:
``(1) Concurrent risk adjustment.--The term `concurrent
risk adjustment' means a risk adjustment model that uses
current year diagnoses, demographics, and other factors to
predict cost in that same year.
``(2) Medicare fee-for-service beneficiary.--The term
`Medicare fee-for-service beneficiary' means an individual who
is enrolled in the original Medicare fee-for-service program
under parts A and B and is not enrolled in a Medicare Advantage
plan under part C, an eligible organization under section 1876,
or a PACE program under section 1894.
``(3) Physician.--The term `physician' means a physician as
defined in section 1861(r)(1).
``(4) Standard full risk aco.--The term `standard full risk
ACO' means an ACO composed of Medicare fee-for-service
beneficiaries, less than two-thirds of which have six or more
chronic co-morbidities.
``(5) Complex care full risk aco.--The term `complex care
full risk ACO' means an ACO composed of Medicare fee-for-
services beneficiaries, at least two-thirds of which have six
or more chronic co-morbidities.''.
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