[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9544 Introduced in House (IH)]
<DOC>
119th CONGRESS
2d Session
H. R. 9544
To amend title XVIII of the Social Security Act to ensure appropriate
payments under Medicare Advantage, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 30, 2026
Mr. Doggett (for himself, Ms. Ansari, Ms. Balint, Mr. Casar, Ms. Chu,
Ms. Clarke of New York, Mr. Cleaver, Mr. Cohen, Mr. Davis of Illinois,
Ms. DeLauro, Mr. Deluzio, Mrs. Dingell, Mr. Garamendi, Mr. Garcia of
Illinois, Mr. Garcia of California, Mrs. Grijalva, Mr. Huffman, Mr.
Jackson of Illinois, Ms. Jayapal, Mr. Johnson of Georgia, Mr. Khanna,
Mr. Mfume, Mr. Nadler, Ms. Norton, Ms. Ocasio-Cortez, Ms. Omar, Ms.
Pingree, Mr. Pocan, Ms. Randall, Ms. Schakowsky, Mr. Scott of Virginia,
Mr. Smith of Washington, Mr. Takano, Mr. Thanedar, Mr. Thompson of
Mississippi, Ms. Tlaib, Ms. Velazquez, Ms. Waters, Mrs. Watson Coleman,
Mr. Green of Texas, Mr. Carson, Mr. McGovern, Ms. Tokuda, and Mr.
DeSaulnier) introduced the following bill; which was referred to the
Committee on Ways and Means, and in addition to the Committees on
Energy and Commerce, and Veterans' Affairs, 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 ensure appropriate
payments under Medicare Advantage, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Saving Medicare Enrollees from
Deceptive Insurers and Creating Ample Resources for Everyone Act of
2026'' or the ``Save MEDICARE Act of 2026''.
SEC. 2. RISK ADJUSTMENT.
(a) Rulemaking.--As part of the annual rulemaking cycle for
Medicare Advantage for payments applicable to 2028 and subsequent
years, the Secretary of Health and Human Services, in consultation with
the Inspector General of the Department of Health and Human Services--
(1) shall include an analysis identifying diagnosis codes
with a high rate of differential coding between equivalent
enrollees in Medicare Advantage and Medicare beneficiaries not
enrolled under a Medicare Advantage plan, a high rate of
discretionary coding, or limited treatment implications; and
(2) shall exclude or adjust diagnosis codes that the
Secretary determines are most likely to be subject to coding
variation by Medicare Advantage plans from diagnosis data
submitted to the Secretary for purposes of determining
appropriate payment adjustments for health status.
(b) Exclusion of Diagnoses Collected From Chart Reviews and Health
Risk Assessments.--
(1) Medicare advantage plans.--Section 1853(a)(1)(C) of
such Act (42 U.S.C. 1395w-23(a)(1)(C)) is amended by adding at
the end the following new clause:
``(iv) Exclusion of diagnoses collected
from chart reviews and health risk
assessments.--
``(I) In general.--For 2028 and
each subsequent year, for purposes of
establishing the payment adjustment
factors and adjusting payment based on
health status under clause (i), the
Secretary shall not take into account a
diagnosis collected from a chart review
or a health risk assessment.
``(II) Identification of diagnoses
collected from chart reviews and health
risk assessments.--The Secretary shall
establish procedures to provide for the
identification and verification of
diagnoses collected from chart reviews
and health risk assessments.''.
(2) Prescription drug plans.--Section 1860D-15(c)(1) of the
Social Security Act (42 U.S.C. 1395w-115(c)(1)) is amended by
adding at the end the following new subparagraph:
``(E) Exclusion of diagnoses collected from chart
reviews and health risk assessments.--
``(i) In general.--For 2028 and each
subsequent year, for purposes of establishing
the methodology and adjusting the standardized
bid amount based on health status under
subparagraph (A), the Secretary shall not take
into account a diagnosis collected from a chart
review or a health risk assessment.
``(ii) Identification of diagnoses
collected from chart reviews and health risk
assessments.--The Secretary shall establish
procedures to provide for the identification
and verification of diagnoses collected from
chart reviews and health risk assessments.''.
(c) Medpac Study and Report.--
(1) Study.--The Medicare Payment Advisory Commission shall
conduct a study to determine how results from a Consumer
Assessment of Healthcare Providers and Systems (CAPHS)-sized
survey could be extrapolated across all enrollees under a
Medicare Advantage contract for the purposes of calculating
risk adjusted payments. Such study shall include
recommendations on methodology, modifications to the CAPHS
survey questions, and CAHPS survey sample size.
(2) Report.--Not later than 3 years after the date of
enactment of this Act, the Medicare Payment Advisory Commission
shall submit to Congress a report on the study conducted under
paragraph (1), together with recommendations for such
legislation and administrative action as the Commission
determines appropriate.
SEC. 3. QUALITY BONUS PROGRAM.
Section 1853(o)(1) of the Social Security Act (42 U.S.C. 1395w-
23(o)(1)) is amended, in the matter preceding subparagraph (A), by
inserting ``and ending with 2028,'' after ``2012''.
SEC. 4. BENCHMARK PAYMENTS.
(a) Eliminating the County Quartile System.--Section 1853(n)(2)(A)
of the Social Security Act (42 U.S.C. 1395w-23(n)(2)(A)) is amended--
(1) by redesignating clauses (i) and (ii) as subclauses (I)
and (II), respectively, and indenting appropriately;
(2) by striking ``is the product of'' and inserting ``is--
``(i) for each of 2012 through 2027, the
product of''; and
(3) by adding at the end the following new clause:
``(ii) for 2028 and each subsequent year,
is the base payment amount specified in
subparagraph (E) for the area and year adjusted
to take into account the phase-out in the
indirect costs of medical education from
capitation rates described in subsection (k)(4)
and, for 2021 and subsequent years, the
exclusion of payments for organ acquisitions
for kidney transplants from the capitation rate
as described in subsection (k)(5).''.
(b) Modifications to Base Payment Amount.--Section 1853(n)(2) of
the Social Security Act (42 U.S.C. 1395w-23(n)(2)) is amended--
(1) in subparagraph (E), by striking ``subparagraphs (F)
and (G)'' and inserting ``subparagraphs (F), (G), and (H)'';
and
(2) by adding at the end the following new subparagraph:
``(H) Adjustment for favorable selection.--For 2028
and each subsequent year:
``(i) In general.--The base payment amount
specified in subparagraph (E) for a year shall
be adjusted to account for favorable selection
between Medicare Advantage and the original
Medicare fee-for-service program under parts A
and B in accordance with this subparagraph.
``(ii) Analysis.--
``(I) In general.--In order to
ensure the accuracy of the adjustment
under clause (i), the Secretary shall
annually conduct an analysis of any
differences in selection between
Medicare Advantage and the original
Medicare fee-for-service program under
parts A and B described in such
subclause and publish the results of
such analysis on the internet website
of the Centers for Medicare & Medicaid
Services in plain language and in
research-downloadable files. The
Secretary shall conduct such analysis
among subgroups of the Medicare
population, including by at a minimum
race, gender, zip code, income level,
and health condition.
``(II) Timing.--The Secretary shall
complete such analysis by the date
necessary to ensure that the results of
such analysis are incorporated on a
timely basis into the base payment
amount for 2029 and subsequent years.
``(III) Data.--In conducting such
analysis, the Secretary shall use data
submitted with respect to 2025 and
subsequent years, as available and
updated as appropriate.
``(iii) Methodology.--In calculating the
adjustment under clause (i) for each year, the
Secretary shall apply the Medicare Payment
Advisory Commission's method for estimating
favorable selection into Medicare Advantage as
described in its March 2026 report to Congress.
Applying such method, the Secretary shall
calculate a `selection percentage' to adjust
for favorable selection between Medicare
Advantage and the original Medicare fee-for-
service program under parts A and B. The
selection percentage shall be calculated before
the intervention of Medicare Advantage plans as
the ratio of expected spending for the national
average Medicare Advantage beneficiary relative
to expected spending for the national average
fee-for-service beneficiary, after
standardizing for measured risk A value of 1
indicates no difference in expected spending
while values below 1 indicate lower expected
spending in Medicare Advantage than in fee-for-
service Medicare for beneficiaries with the
same risk scores. The base payment amount
specified in subparagraph (E) shall be
multiplied by the selection percentage to yield
a selection-adjusted base payment amount. The
selection-adjusted base payment amount shall
replace the prior base payment amount in all
calculations of payment benchmarks for Medicare
Advantage.
``(iv) Medpac review.--The Medicare Payment
Advisory Commission shall conduct and publish a
review of the analysis conducted under clause
(ii) and any adjustments made under clause (i)
based on such analysis not later than 2 years
after implementation of this subparagraph and
biennially thereafter.''.
SEC. 5. RISK ADJUSTMENT DATA VALIDATION.
(a) Risk Adjustment Data Validation Reforms.--Section 1853(a)(1)(C)
of the Social Security Act is amended by adding at the end the
following new paragraph:
``(7) Improving timeliness of radv audits and appeals.--For
plan years beginning on or after January 1, 2028, the following
requirements shall apply with respect to the Medicare Advantage
Risk Adjustment Data Validation Program:
``(A) Contract-level audits.--The Secretary shall
complete contract-level audits within one year.
``(B) Medical record reviews.--The Secretary shall
complete RADV medical record reviews within 60 days.
``(C) Deadline for completion of stages 1 and 2 of
appeals.--
``(i) Stage 1.--The reconsideration stage
described in section 422.311(c)(6) of title 42,
Code of Federal Regulations (or a successor
regulation), shall be completed within 90 days.
``(ii) Stage 2.--The hearing stage
described in section 422.311(c)(7) of title 42,
Code of Federal Regulations (or a successor
regulation), shall be completed within 90 days.
``(D) User fee.--The Secretary shall reduce the
payments to Medicare Advantage organizations under
section 1853 by 0.02 percent for the purpose of
carrying out Risk Adjustment Data Validation audits.
``(E) Limitation on review.--There shall be no
judicial review under section 1869, section 1878, or
otherwise of any determination of the Administrator of
the Centers for Medicare and Medicaid Services under
the Risk Adjustment Data Validation audit program.
``(F) Authority to extrapolate.--The Secretary may
extrapolate the results of audited samples to the
general Medicare Advantage population and
retroactively, as the Secretary determines
appropriate.''.
(b) Enhancing Audit Process.--Section 1853(a)(1)(C) of the Social
Security Act, as amended by subsection (a), is amended by adding at the
end the following new paragraph:
``(8) Identification and recoupment of overpayments.--
``(A) In general.--The Secretary shall enter into
contracts with one or more recovery audit contractors
under section 1893(h) for the identification and
recoupment of overpayments, including penalties as
defined under subparagraph (B), with respect to items
and services for which payment is made under this part.
``(B) Penalty.--With respect to any overpayment
identified under subparagraph (A), the Secretary shall
provide for the imposition a penalty in an amount equal
to the total amount of overpayment and the rate of
interest as defined under section 405.378(d) of title
42, Code of Federal Regulations (or a successor
regulation).
``(C) Contingency fees.--The Secretary may provide
contingency fees to recovery audit contractors in an
amount equal to no more than 20 percent of recouped
overpayments made by such contractor.''.
SEC. 6. GUARD VETERANS HEALTH CARE ACT.
(a) Cost-Recovery From Medicare Advantage and Medicare Prescription
Drug Plans.--
(1) Cost recovery.--
(A) In general.--Subchapter III of chapter 17 of
title 38, United States Code, is amended by inserting
after section 1729B the following new section:
``Sec. 1729C. Cost-recovery from Medicare Advantage and Medicare
prescription drug plans
``(a) In General.--Notwithstanding sections 1814(c), 1835(d), and
1862(a)(3) of the Social Security Act (42 U.S.C. 1395f(c), 1395n(d),
and 1395y(a)(3)), if the Secretary provides under this chapter any
health care item or service (including for a service-connected
disability or a non-service-connected disability) covered under the
Medicare program under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.), including outpatient and inpatient care,
prescription drugs, medical devices, lab testing, and items or services
delivered in post-acute and long-term care settings, to any individual
who is enrolled in a Medicare Advantage plan, including an MA-PD plan,
offered by a MA organization under part C of such title or a
prescription drug plan offered by a PDP sponsor under part D of such
title, such organization or sponsor shall, to the extent such item or
service is covered under such Medicare Advantage plan or prescription
drug plan, reimburse the Secretary for such item or service regardless
of any additional documentation, utilization management, or other
administrative requirement the plan may impose on the item or service.
``(b) Recovery of Amounts.--
``(1) In general.--The Secretary shall recover amounts
required to be reimbursed under subsection (a) through the use
of procedures under section 1729 of this title to the same
extent as those procedures are used to recover amounts
authorized to be recovered under that section.
``(2) Amount and process.--Except as provided in paragraph
(1), recovery under that paragraph of amounts reimbursed under
subsection (a) shall be in such an amount, and occur in
accordance with such procedures, as the Secretary shall
prescribe for purposes of this section.
``(c) Application.--The provisions of subsection (a) shall apply to
Medicare Advantage and prescription drug plan years beginning on or
after January 1, 2028.
``(d) Treatment of Amounts.--Amounts reimbursed to the Secretary
under subsection (a) shall be deposited in the Department of Veterans
Affairs Medical Care Collections Fund under section 1729A of this
title.''.
(B) Clerical amendment.--The table of sections at
the beginning of such chapter is amended by inserting
after the item relating to section 1729B the following
new item:
``1729C. Cost-recovery from Medicare Advantage and Medicare
prescription drug plans.''.
(2) Medicare conforming amendments.--
(A) Part a.--Section 1814(c) of the Social Security
Act (42 U.S.C. 1395f(c)) is amended by inserting ``and
section 1729C of title 38, United States Code'' after
``section 1880''.
(B) Part b.--Section 1835(d) of the Social Security
Act (42 U.S.C. 1395n(d)) is amended by inserting ``and
section 1729C of title 38, United States Code'' after
``section 1880''.
(C) Exclusions from coverage.--Section 1862(a)(3)
of the Social Security Act (42 U.S.C. 1395y(a)(3)) is
amended by inserting ``in the case of items and
services and prescription drugs for which reimbursement
is made under section 1729C of title 38, United States
Code,'' after ``section 1880(e),''.
(b) Modification of Authority for Recovery by United States of
Reasonable Charges for Certain Care or Services Furnished to Veterans
for Non-Service-Connected Disabilities.--Section 1729 of title 38,
United States Code, is amended--
(1) in subsection (a)--
(A) by amending paragraph (1) to read as follows:
``(1)(A) Subject to the provisions of this section, the United
States has the right to recover or collect the reasonable charges for
care or services that the United States is required by law to furnish
or pay for under this chapter for a non-service-connected disability.
``(B) The United States has the right to recover or collect from a
third party the reasonable charges for care or services furnished as
described in subparagraph (A) to the extent that the recipient or
provider of the care or services would be eligible to receive payment
from a third party.
``(C) The right to recover or collect reasonable charges for care
or services under this section shall apply to any and all causes of
action or recovery rights in tort or under any policy, plan, or
contract providing benefits for health care or injury, which accrue to
the individual to whom the care or services were furnished, or to the
legal representatives of the individual, as a result of the non-
service-connected disability that necessitated the care or services.'';
and
(B) in paragraph (2)--
(i) in subparagraph (D), by striking ``;
or'' and inserting a semicolon;
(ii) in subparagraph (E)(2), by striking
the period at the end and inserting ``; or'';
and
(iii) by adding at the end the following
new subparagraph:
``(F) that is incurred by an individual who is entitled to
care (or payment of expenses of care) under circumstances
creating a tort liability upon a third party.'';
(2) in subsection (b), by amending paragraph (2) to read as
follows:
``(2)(A) The United States may take any action necessary to enforce
the subrogation interests of the United States under this section,
including by intervening or joining in an action or proceeding.
``(B) A proceeding under this section may not be brought after the
end of the six-year period beginning on the last day on which the care
or services for which recovery is sought are furnished. Notwithstanding
the previous sentence, subject to section 2415 of title 28, and except
as otherwise provided by law, any action for money damages under this
section brought by the United States or an officer or agency thereof
that is founded upon a tort shall be barred unless the complaint is
filed within three years after the right of action first accrues.'';
(3) in subsection (c)(1), by inserting ``or penalty'' after
``claim'';
(4) by redesignating subsections (h) and (i) as subsections
(l) and (m), respectively;
(5) by inserting after subsection (f) the following new
subsections:
``(g)(1) Not later than 45 days after receipt of a claim to recover
or collect the reasonable charges for care or services described in
subsection (a), or in the case of a tort, not later than 45 days after
settlement, judgment, award, liability determination, or resolution
relating to the cause of action, a third party shall--
``(A) pay a clean claim for reimbursement in accordance
with this section;
``(B) pay the amount agreed to in writing by the
Department; or
``(C) provide notice of the date the third party received
the claim and include a statement that--
``(i) the third party refuses to reimburse all or
part of the claim and specify each reason for the
refusal to pay; or
``(ii) additional information is necessary to
determine if all or part of the claim will be
reimbursed and what specific additional information is
necessary.
``(2) Paragraph (1) shall not apply to a claim if there is a good
faith dispute about the legitimacy of the claim.
``(3)(A) If any third party fails to comply with paragraph (1),
such third party shall be required to pay interest to the United States
at the rate established by the Secretary of the Treasury under section
3717 of title 31 per month on the amount of the claim that remains
unpaid at the end of the 45-day period specified in such paragraph.
``(B) The interest paid pursuant to subparagraph (A) shall be
included in any late reimbursement from a third party without requiring
the Secretary to make any additional claim for such interest.
``(4)(A) Upon receiving a request for additional information by a
third party pursuant to paragraph (1)(C)(ii), the Secretary shall
provide the additional information, if determined relevant by the
Secretary, not later than 45 days after receipt of the request for
additional information.
``(B) Failure to furnish relevant information within the time
required under subparagraph (A) shall not invalidate or reduce any
claim in connection with such information.
``(C)(i) Not later than 15 days after receipt of additional
relevant information under subparagraph (A), a third party shall pay a
clean claim in accordance with this subsection or send a written or
electronic notice that--
``(I) such third party refuses to reimburse all or part of
the claim; and
``(II) specifies each reason for refusal to pay.
``(ii) Any third party that fails to comply with clause (i) shall
pay interest to the United States on any amount of the claim that
remains unpaid at the rate established by the Secretary of the Treasury
under section 3717 of title 31.
``(5) A third party shall not be entitled to request a refund to
correct a payment error to the Department if the request by the third
party for such payment correction is submitted more than 18 months
after the date that the Department received payment from the third
party.
``(6) Any claim by the Department under this section shall not be
subject to non-Department claims processes, policies, or forms.
``(h) The recovery rights of the United States under this section
are not limited to the amounts paid to non-Department providers and are
not subject to non-Department fee schedules or non-Department
reimbursement rates, including those administered under workers'
compensation plans or automobile accident reparations insurance.
``(i)(1) A third party shall--
``(A) determine whether a recipient of care or services
covered by this section (including a recipient whose claim is
unresolved) has received benefits under this chapter; and
``(B) submit the information described in paragraph (2)
with respect to the recipient to the Secretary in a form and
manner (including frequency) specified by the Secretary.
``(2) The information required to be submitted under this paragraph
with respect to a recipient of care or services is--
``(A) the identity of the recipient; and
``(B) such other information as the Secretary shall specify
in order to enable the Secretary to make an appropriate
determination concerning coordination of benefits, including
any applicable recovery claim.
``(3) A third party shall submit the information required under
paragraph (1)(B) with respect to a recipient of care or services
covered by this section (including a recipient whose claim is
unresolved) not later than 30 days, or such other time period as
prescribed by the Secretary, after the date on which the third party
knows or has reason to know that the recipient has received benefits
under this chapter.
``(4) A third party shall not distribute proceeds of a settlement,
judgment, award, or other payment in connection with a recipient of
care or services covered by this section (including a recipient whose
claim is unresolved), regardless of whether there has been a
determination or admission of liability, without satisfaction of a
claim by the Department.
``(j)(1) A third party that fails to comply with the requirements
under this section, including any regulations prescribed to implement
this section, with respect to any individual receiving care furnished
or paid for by the Department as described in this section, shall be
subject to a civil penalty in an amount published on a website of the
Department for each day of noncompliance with respect to each claim
violation. A civil penalty under this paragraph shall be in addition to
any other penalties prescribed by law.
``(2)(A) A third party that willfully fails or refuses to pay a
clean claim under this section, including any regulations prescribed to
implement this section, with respect to any individual receiving care
furnished or paid for by the Department as described in this section,
shall be subject to paying the higher of triple the amount of the claim
or an amount not to exceed $50,000, which may be adjusted for
inflation, for each claim violation.
``(B) A penalty under subparagraph (A) is in addition to any other
penalty under this subsection and any other penalty prescribed by law.
``(C) Before enforcing any penalty under this paragraph with
respect to a third party, the Secretary shall provide to the third
party written notice of the amount due and a 30-day opportunity to pay
the clean claim, including penalties, interests, and costs.
``(3) Notwithstanding any other applicable civil or criminal
remedies, the United States shall have a cause of action for damages
(which shall be in an amount double the amount otherwise provided) in
the case of a third party that fails to provide payment, or appropriate
reimbursement, for the reasonable value of the care or services
furnished, to be furnished, paid for, or to be paid for in accordance
with a clean claim.
``(k) Notwithstanding any other provision of law, the Secretary may
implement this paragraph by prescribing regulations, program
instructions, or otherwise.''; and
(6) in subsection (m), as redesignated by paragraph (4)--
(A) in paragraph (3)--
(i) in subparagraph (C), by striking ``;
or'' and inserting a semicolon;
(ii) in subparagraph (D), by striking the
period at the end and inserting a semicolon;
and
(iii) by adding at the end the following
new subparagraphs:
``(E) a person or entity responsible in tort for
damages incurred as a result of negligence; or
``(F) a person or entity responsible for payment of
medical expenses other than under a health-plan
contract, including medical expenses coverage, medical
payments coverage, or underinsured motorist
coverage.''; and
(B) by adding at the end the following new
paragraphs:
``(4) The term `clean claim' means a claim to recover or
collect reasonable charges under subsection (a) that can be
processed without obtaining additional information.
``(5) The term `non-service-connected disability'
includes--
``(A) a non-service-connected disability, injury,
illness, health care need, or condition; and
``(B) an aggravation or exacerbation of a service-
connected disability.''.
(c) Conforming Amendment.--Section 1853(c)(1)(D)(iii) of the Social
Security Act (42 U.S.C. 1395w-23(c)(1)(D)(iii)) is amended by inserting
``(before 2028)'' after ``for a year''.
SEC. 7. ALLOWING STATES TO ENFORCE MEDICARE ADVANTAGE PLAN
REQUIREMENTS.
Section 1856(b)(3) of the Social Security Act (42 U.S.C. 1395w-
26(b)(3)) is amended--
(1) by striking ``The standards'' and inserting the
following:
``(A) In general.--Subject to subparagraph (B), the
standards''; and
(2) by adding at the end the following new subparagraphs:
``(B) State enforcement.--Each State may require
that MA organizations that issue, sell, renew, or offer
MA plans in the State meet the requirements of this
part with respect to such MA plans.
``(C) Coordination of enforcement.--The Secretary
shall coordinate enforcement of the standards
established under this part with the State in which an
MA organization is licensed and any State in which the
MA organization issues, sells, renews, or offers MA
plans. The Secretary may enter into a collaborative
enforcement agreement with any State to further
coordinate enforcement.''.
SEC. 8. PROVIDER INCENTIVE CONTRACTS.
Section 1857(e) of the Social Security Act (42 U.S.C. 1395w-27(e))
is amended by adding at the end the following new paragraph:
``(7) Prohibiting percentage of premium contracts or other
financial incentives for coding.--Beginning with plan years
beginning on or after January 1, 2028, a contract under this
section with an MA organization shall prohibit the use of
percentage of premium contracts or other financial incentives
for providers related to coding items and services furnished to
enrollees under this part.''.
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