[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9891 Introduced in House (IH)]
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119th CONGRESS
2d Session
H. R. 9891
To direct the Secretary of Health and Human Services to conduct a
demonstration program to share savings with plans that invest in
preventing the progression of kidney disease to end-stage renal
disease.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 22, 2026
Mr. Wilson of South Carolina introduced the following bill; which was
referred to the Committee on Energy and Commerce, and in addition to
the Committee on Ways and Means, 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 direct the Secretary of Health and Human Services to conduct a
demonstration program to share savings with plans that invest in
preventing the progression of kidney disease to end-stage renal
disease.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``PREVENT ESRD
Act''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Kidney disease listening session.
Sec. 4. Multipayer kidney care medicare savings demonstration program.
SEC. 2. FINDINGS.
Congress finds the following:
(1) Kidney disease impacts nearly 36,000,000 Americans,
with many not getting the education, screening, or care that
they need to delay or prevent progression to kidney failure or
end-stage renal disease (ESRD). Indeed, 9 in 10 United States
patients with kidney disease are unaware they have the disease.
(2) Kidney disease accounts for $126,000,000,000 in direct
health care spending each year, with an outsized impact on the
Medicare program, which covers most patients once they progress
to ESRD. Currently, Medicare spends more than $50,000,000,000
each year on treatment related to ESRD.
(3) Given the tremendous burden that ESRD places on
Medicare and the Nation's health care system, the Federal
Government has a unique role to play in advancing policies
intended to slow or prevent progression to ESRD.
(4) A voluntary payment model that allows health insurance
plans, including group health insurance and individual health
insurance plans sold in the commercial market, to share in the
savings they create for Medicare by preventing or delaying ESRD
could help promote earlier screening and enhanced treatment for
patients with kidney disease.
SEC. 3. KIDNEY DISEASE LISTENING SESSION.
Not later than 180 days after the date of enactment of this Act,
the Secretary of Health and Human Services shall host a listening
session to raise awareness regarding kidney disease and to identify
policy solutions to improve rates of screening, diagnosis, and
treatment of earlier stages of kidney disease in an effort to prevent
or delay the onset of ESRD. The Secretary shall include experts in all
elements of kidney disease, including clinical experts, patients and
patient advocates, health plans, and innovators, as participants in the
listening session.
SEC. 4. MULTIPAYER KIDNEY CARE MEDICARE SAVINGS DEMONSTRATION PROGRAM.
Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is
amended by inserting after section 1866G (42 U.S.C. 1395cc-7) the
following new section:
``SEC. 1866H. MULTIPAYER KIDNEY CARE MEDICARE SAVINGS DEMONSTRATION
PROGRAM.
``(a) Implementation of Demonstration Program.--
``(1) In general.--Not later than January 1, 2027, the
Secretary of Health and Human Services shall implement a 10-
year demonstration program (in this section referred to as the
`Program') for the purpose of increasing access for qualifying
kidney disease enrollees to specified kidney care services to
prevent the progression to end-stage renal disease (ESRD).
``(2) Specified kidney care services defined.--
``(A) For the purposes of this section, the term
`specified kidney care services' means items and
services furnished to individuals diagnosed with kidney
disease to prevent the progression to ESRD and that
would be covered under this title if furnished to an
individual entitled to part A or enrolled in part B, to
include prescription drugs eligible for coverage under
part D.
``(B) The Secretary shall specify the scope of
specified kidney care services, which shall include at
a minimum items and services within the following
categories and align with the typical scope of benefits
offered by insurers for each type of insurance coverage
specified in paragraph (3):
``(i) Screening measures, including
urinalysis (e.g., proteinuria and kidney-
specific dipsticks), blood-based testing,
genetic testing, and other forms of screening
necessary to screen for and diagnose kidney
disease.
``(ii) All drugs approved under section 355
of title 21, United States Code, and all
biologicals licensed under section 262 of title
42, United States Code, by the Food and Drug
Administration with an indication for slowing
the decline or loss of kidney function or to
reduce the risk of decline in kidney function.
``(ii) Nutrition services and education.
``(iii) Disease management support,
including patient education, follow-up support
to link diagnoses to care, genetic counseling,
access to community health workers, and
referrals to services to support health-related
social needs.
``(iv) Consultation and evaluation
regarding kidney health.
``(v) Other items and services specified by
the Secretary.
``(C) The specified kidney care services shall
include items and services furnished via telehealth if
medically appropriate and consistent with other
applicable requirements.
``(3) Eligible plans.--In this section, the term `eligible
plan' means a group health plan (as defined under section
2791(b)(4) of the Public Health Service Act), a plan offered by
a health insurance issuer (as defined under section 2791(b)(2)
of such Act), a State Medicaid program, a Medicaid managed care
plan, a plan that enrolls individuals under part C of this
title, or any other type of plan specified by the Secretary.
``(4) Participating plans.--In this section, the term
`participating plan' means an eligible plan that voluntarily
applied for the Program, was selected to participate pursuant
to an application and selection process established by the
Secretary, and signs an agreement with the Secretary to
participate in the Program.
``(5) Eligible enrollees.--In this section, the term
`qualifying kidney disease enrollee' means an individual who is
enrolled in a participating plan, has a current diagnosis of
kidney disease, and meets such other criteria as the Secretary
determines appropriate.
``(b) Program Design.--
``(1) Program agreement.--Under the Program, the Secretary
shall enter into agreements with participating plans, pursuant
to which the participating plans--
``(A) must implement certain activities, as
specified by the Secretary, designed to ensure access
to specified kidney care services, including to develop
a screening plan to ensure regular screening of all
enrollees for kidney disease during annual exams with
primary care providers and otherwise;
``(B) must submit historical and plan year data,
including protected health information, as necessary
(as defined in regulations issued pursuant to section
17921(12) of title 42, United States Code), in a form
and manner specified by the Secretary, subject to
verification and audit by the Secretary, including--
``(i) the prevalence and incidence of
kidney disease and ESRD and the stage of
chronic kidney disease (CKD) or other type of
kidney disease;
``(ii) the rate of transition to the next
stage of CKD (if applicable) and from CKD to
ERSD among its enrollee population;
``(iii) the utilization of specified kidney
care services by qualifying kidney disease
enrollees;
``(iv) the quality of care and health
outcomes among qualifying kidney disease
enrollees; and
``(v) kidney disease screening rates for
all plan enrollees and for specific at-risk
subpopulations as the Secretary may specify,
such as enrollees diagnosed with diabetes or
hypertension and enrollees residing in rural
areas;
``(C) must cover all specified kidney care services
and must apply the lowest level of cost sharing under
the plan's benefit design to such services and shall
not apply utilization management to specified kidney
care services that are drugs and biologicals in a
manner more restrictive than the Food and Drug
Administration-approved labeling;
``(D) must provide coverage without cost-sharing
for all plan enrollees for screening for kidney
disease; and
``(E) may be eligible to receive payment for a
portion of the savings that accrue to Medicare, as
estimated by the Secretary under subsection (c)(3), if
the number of the plan's qualifying kidney disease
enrollees who progress to the next stage of CKD or to
ESRD is below the risk-adjusted benchmark established
by the Secretary under subsection (c)(1)(C).
``(2) Termination.--
``(A) Termination by the secretary.--The Secretary
may terminate an agreement with a participating plan if
the plan fails to comply with the terms of the program
agreement described in paragraph (1).
``(B) Treatment of shared savings in the event of
termination.--If the agreement between the Secretary
and a participating plan is terminated in the middle of
a year of the Program, the participating plan is not
eligible for any shared savings payments under the
Program for that year and the Secretary may recoup
shared savings paid for a prior year.
``(3) Evaluation.--The Secretary shall design the Program
in a manner to enable independent evaluation, using novel
methods, of the extent to which the Program--
``(A) preserves kidney function or otherwise delays
the development of ESRD among qualifying kidney disease
enrollees in participating plans and matched control
groups from nonparticipating plans, with controls
selected based on demographic, clinical, and geographic
characteristics; and
``(B) reduces expenditures under the Medicare
program, as estimated through a comparison between
participating plans and appropriate control groups,
adjusting for relevant demographic, clinical, and
geographic factors.
``(4) Consultation.--In designing the Program, including in
implementing the definition of specified kidney care services
as described in subsection (a)(2), the Secretary shall, not
later than 3 months after the date of enactment of this
section, solicit public input in the form of a request for
information and public listening sessions and shall consult
with specialists in the field of kidney care, sponsors and
administrators of eligible plans, and representatives of
patient advocacy groups.
``(c) Shared Savings Payments.--
``(1) Eligibility for shared savings payments.--
``(A) In general.--Under the Program, subject to
the prohibition in this subsection on avoidance of at-
risk individuals and any other conditions established
by the Secretary, for each year a participating plan
has an agreement in effect under the Program, the plan
shall be eligible to receive a shared savings payment
under paragraph (3), provided that--
``(i) the participating plan covers
specified kidney care services, including
kidney disease screening as described in
subsection (a)(2)(B)(i); and
``(ii) the participating plan's CKD and
ESRD progression rates, adjusted for enrollee
characteristics, are below the benchmark
described in subparagraph (B) by at least the
minimum percentage specified by the Secretary.
This minimum percentage shall reflect normal
variation in kidney disease progression rates.
``(B) Benchmark.--For each year of the Program, the
Secretary shall establish a benchmark for each
participating plan based on--
``(i) the plan's historical progression
rates to the next stage of CKD or from CKD to
ESRD over the most recent 3 years using data
submitted by the plan, which may be subject to
verification and audit by the Secretary to
validate its accuracy;
``(ii) national and regional disease
prevalence over the most recent 3 years;
``(iii) adjustments for enrollee
characteristics;
``(iv) adjustments for increased screening
rates during the plan's participation in the
Program; and
``(v) such other factors as determined
appropriate by the Secretary.
The benchmark shall be reset at the start of each year
of the Program.
``(2) Quality performance standards.--The Secretary shall
establish quality performance standards to assess the quality
of care furnished by participating plans. The Secretary shall
seek to improve the quality of care furnished by participating
plans over time by specifying higher standards, new measures,
or both for purposes of assessing such quality of care.
``(3) Amount of shared savings payment.--
``(A) For each year of the Program for each
participating plan, the Secretary shall determine, and
the Chief Actuary of the Centers for Medicare and
Medicaid Services shall certify, the savings that
accrue to Medicare as a result of the participating
plan's performance exceeding the benchmark as
calculated under paragraph (1)(B), for example as a
result of an individual not obtaining Medicare
eligibility under section 1881 on the basis of
progressing to ESRD during that year.
``(B) Subject to performance with respect to the
quality performance standards established by the
Secretary under paragraph (2), if a participating plan
meets the eligibility requirements described above for
a given year of the Program, the participating plan
shall be paid 25 percent of the Medicare savings amount
described in subparagraph (A) for that plan.
``(4) Prohibition on avoidance of at-risk patients.--If the
Secretary determines that a participating plan has taken action
to avoid enrolling kidney disease patients at elevated risk of
developing ESRD, or failed to adhere to the terms of the
participation agreement specified in subsection (b)(1), or
takes other actions in order to increase the likelihood of
receiving shared savings payments under the Program, the
Secretary may reduce, recoup, or deny shared savings payments
or terminate the participating plan from the Program.
``(5) Optional advance investment payment.--The Secretary
may provide, in an amount determined by the Secretary, an
advance investment payment to each participating plan for each
qualifying kidney disease enrollee for each year of the plan's
participation with respect to such enrollee. A participating
plan must use such advance investment payment to improve the
quality, efficiency, or uptake of specified kidney care items
and services furnished to beneficiaries, which may include
coming into compliance with the plan's participation
requirements under the Program described in this section. The
participating plan must report to the Administrator of the
Centers for Medicare and Medicaid Services how the plan used
such funds not later than 180 days after the end of the
relevant year in a form and manner specified by the Secretary.
The total amount of any such advance investment payment in a
given year shall be deducted from the shared savings payment
received by the participating plan for the relevant year, if
any, up to the amount of such shared savings in the event the
amount of the advance investment payment exceeds the amount of
the shared savings payment.
``(d) Prohibition on Duplicate Payments.--The Secretary shall
ensure that no duplicate payments under this section are made by
Medicare with respect to a qualifying kidney disease enrollee.
``(e) Monitoring, Evaluation, and Reporting by the Secretary.--
``(1) Monitoring and evaluation.--The Secretary shall
monitor and evaluate the Program on an ongoing basis and shall
conduct an intermediate and final evaluation of the Program in
accordance with the requirements described in subsection
(b)(3). Each such evaluation shall determine the extent to
which the purpose of increasing access for qualifying kidney
disease enrollees to specified kidney care services to prevent
the progression to ESRD has been accomplished under the
Program.
``(2) Reporting.--The Secretary shall submit to Congress--
``(A) not later than 3 years after the date of the
implementation of the Program, a report with respect to
the intermediate evaluation; and
``(B) a report with respect to the final evaluation
not later than 6 years after such date.
``(f) Funding.--
``(1) Administrative funding.--For purposes of
administering and carrying out the Program, other than for
payments for items and services furnished under this title,
advance investment payment under subsection (c)(5), and shared
savings payment under subsection (c)(3), in addition to funds
otherwise appropriated, there shall be transferred to the
Secretary for the Centers for Medicare and Medicaid Services
Program Management Account from the Federal Hospital Insurance
Trust Fund under section 1817 and the Federal Supplementary
Medical Insurance Trust Fund under section 1841 (in proportions
determined appropriate by the Secretary) $5,000,000 for each of
fiscal years 2026 through 2038. Amounts transferred under this
subsection for a fiscal year shall be available until expended.
``(2) Shared savings payments.--The shared savings payments
and advance investment payments under the Program, for each of
program years 2027 through 2037, shall be made from the Federal
Hospital Insurance Trust Fund established under section 1817
and the Federal Supplementary Medical Insurance Trust Fund
established under section 1841 in such proportion as the
Secretary determines reflects the relative weight that benefits
under part A and under part B represents of the actuarial value
of the Medicare savings determined under subsection (c)(3) and
the advance investment payments determined under subsection
(c)(5).
``(g) Waiver and Implementation Authority.--
``(1) The Secretary may implement provisions of this
section by program instruction, agreement, or otherwise.
``(2) The Secretary may waive any requirement of titles XI
or XVIII and of sections 1902(a)(1), 1902(a)(13), and
1903(m)(2)(A)(iii) of this Act as may be necessary to carry out
the Program.
``(3) The Paperwork Reduction Act (44 U.S.C. 3501 et seq.)
shall not apply to implementation and administration of the
Program.''.
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