H.R. 8129

[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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