I 

118TH CONGRESS 

1ST SESSION H. R. 6732 

To amend title XI of the Social Security Act to clarify parameters for 

model testing and add accountability to model expansion under the Center for Medicare and Medicaid Innovation, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

DECEMBER 12, 2023 

Mr. SMITH of Nebraska (for himself, Mr. BUCHANAN, and Mr. WENSTRUP) 

introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and 

Means, and Rules, 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 XI of the Social Security Act to clarify 

parameters for model testing and add accountability to 

model expansion under the Center for Medicare and 

Medicaid Innovation, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Strengthening Innova5 tion in Medicare and Medicaid Act’’. 


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1 SEC. 2. SENSE OF CONGRESS. 

2 It is the sense of Congress that: 

3 (1) The Center for Medicare and Medicaid In4 novation (CMI) represents a valuable tool for testing 

5 innovative health care payment and service delivery 

6 models which can improve the coordination, quality, 

7 and efficiency of health care services. 

8 (2) The model testing process is intended to 

9 test concepts on a limited scale first in Phase I, then 

10 assess initial results, and, if results merit, expand 

11 the model to a larger test in Phase II to confirm the 

12 initial results. 

13 (3) Starting model testing on a limited scale, 

14 assessing results, and then expanding the model to 

15 confirm initial results protects the integrity of the 

16 Medicare program by minimizing unintentional 

17 losses or negative impacts to the patients or pro18 viders participating in Phase I model testing. 

19 (4) CMI should focus its attention on models 

20 most likely to succeed and should continually assess 

21 models and terminate those which are not gener22 ating results in keeping with its purpose—lowering 

23 costs while maintaining or preserving patient out24 comes. 

25 (5) Mandatory models may be necessary to test 

26 certain payment models but should be used judiVerDate Sep 11 2014 04:33 Dec 29, 2023 Jkt 049200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H6732.IH H6732

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1 ciously and be as limited in scope as possible to min2 imize accidental adverse impacts. 

3 (6) As CMI may waive certain provisions of 

4 Medicare regulations, Congress may block models 

5 which functionally alter or change the underlying ex6 isting statutes. 

7 SEC. 3. DEFINING CMI MODEL TESTING PARAMETERS. 

8 (a) SCOPE AND DURATION OF MODELS.—Section 

9 1115A(a) of the Social Security Act (42 U.S.C. 1315a(a)) 

10 is amended by adding at the end the following new para11 graph: 

12 ‘‘(6) SCOPE AND DURATION OF MODELS TEST13 ED.—beginning on or after the date of the enact14 ment of the Strengthening Innovation In Medicare 

15 and Medicaid Act, for purposes of testing new pay16 ment and service delivery models, the Secretary shall 

17 limit testing of a Phase 1 model to— 

18 ‘‘(A) a period not to exceed 5 years; and 

19 ‘‘(B) to the lesser of ten percent of appli20 cable individuals or 500,000 beneficiaries.’’. 

21 (b) CAP ON PHASE 1 MODEL TESTING.—Section 

22 1115A(a) of the Social Security Act (42 U.S.C. 1315a(a)), 

23 as amended by subsection (a), is further amended by add24 ing at the end the following new paragraph: 


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1 ‘‘(7) PHASE 1 MODEL LIMITATIONS.—During 

2 each fiscal year starting with Fiscal Year 2023, CMI 

3 shall initiate Phase 1 testing of no more than six 

4 new models each fiscal year. Additionally, CMI shall 

5 not concurrently test more than five Phase 1 models 

6 which involve mandatory, involuntary, or compulsory 

7 participation.’’. 

8 (c) REQUIRED WAIVERS FOR HARDSHIP.—Section 

9 1115A(a) of the Social Security Act (42 U.S.C. 1315a(a)), 

10 as amended by subsection (a), is further amended by add11 ing at the end the following new paragraph: 

12 ‘‘(8) HARDSHIP WAIVERS.—Not later than 60 

13 days after the enactment of the Strengthening Inno14 vation in Medicare and Medicaid Act, the Secretary 

15 shall develop and implement a plan to allow applica16 ble providers of services or supplies to request a 

17 waiver from any requirement of a model if the Sec18 retary determines that such requirement would re19 sult in undue economic hardship to such provider or 

20 supplier or loss of access to such healthcare services 

21 or supplies for vulnerable populations.’’. 

22 (d) MONITORING IMPACT.—Section 1115A(a) of the 

23 Social Security Act (42 U.S.C. 1315a(a)), as amended by 

24 subsections (a) and (b), is further amended by adding at 

25 the end the following new paragraph: 


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1 ‘‘(9) MONITORING IMPACT.—Not later than 60 

2 days after the enactment of the Strengthening Inno3 vation in Medicare and Medicaid Act, the Secretary 

4 shall develop and implement a plan to— 

5 ‘‘(A) monitor continuously and on a real6 time basis the effect of a model under sub7 section (b) on applicable individuals, and miti8 gate any adverse impact, such as inappropriate 

9 reductions in care or reduced access to care; 

10 ‘‘(B) assess and track the impact of deliv11 ery and payment models on health disparities, 

12 using existing measures such as, but not limited 

13 to, the National Quality Forum Healthcare Dis14 parities and Cultural Competency Measures; 

15 and 

16 ‘‘(C) mitigate any adverse impact that the 

17 Secretary determines could affect beneficiary 

18 health.’’. 

19 SEC. 4. IMPLEMENTATION OF TESTING AND EXPANSION OF 

20 MODELS WITH CONGRESSIONAL INACTION. 

21 Section 1115A(d) of the Social Security Act (42 

22 U.S.C. 1315a(d)) is amended by adding at the end the 

23 following new paragraph: 


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1 ‘‘(4) IMPLEMENTATION OF TESTING AND EX2 PANSION OF MODELS WITH CONGRESSIONAL INAC3 TION.— 

4 ‘‘(A) The Secretary shall transmit a pro5 posal for the testing, expansion, or modification 

6 of a model under subsections (b) and (c), in7 cluding a proposed effective date and a sum8 mary of the determinations and certification 

9 made under paragraphs (1) through (3) of sub10 section (c), if applicable, to the Committee on 

11 Ways and Means and the Committee on Energy 

12 and Commerce of the House of Representatives 

13 and to the Committee on Finance and the Com14 mittee on Health, Education, Labor, and Pen15 sions of the Senate. 

16 ‘‘(B) The testing, expansion, or modifica17 tion of a model proposed in a report submitted 

18 under subparagraph (A) shall be carried out by 

19 the Secretary if Congress does not, within 45 

20 days of receiving such report, pass a joint reso21 lution disapproving of the proposed testing or 

22 expansion in accordance with the following pro23 cedure: 

24 ‘‘(i) The succeeding subparagraphs of 

25 this paragraph are enacted by Congress as 


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1 an exercise of the rulemaking power of the 

2 Senate and the House of Representatives, 

3 respectively, and as such they shall be 

4 deemed a part of the rules of each House, 

5 respectively, but applicable only with the 

6 respect to the procedure to be followed in 

7 that House in the case of resolutions de8 scribed in subparagraph (B). They shall 

9 supersede other rules only to the extent 

10 that they are inconsistent therewith. They 

11 are enacted with full recognition of the 

12 constitutional right of either House to 

13 change the rules (so far as relating to the 

14 procedure of that House) at any time, in 

15 the same manner and to the same extent 

16 as in the case of any ruse of that House. 

17 ‘‘(ii) For the purpose of the suc18 ceeding paragraphs of this subsection, ‘res19 olution’ means only a joint resolution, the 

20 matter after the resolving clause of which 

21 is as follows: ‘That Congress disapproves 

22 the model expansion requested pursuant to 

23 section 1115A(c) of the Social Security Act 

24 transmitted by the Secretary on 

25 lllll, and such an expansion shall 


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1 not proceed.’, the blank space therein 

2 being filled with the date on which the Sec3 retary’s message proposing such expansion 

4 was delivered. 

5 ‘‘(iii) Upon receipt of a report sub6 mitted to Congress under subparagraph 

7 (c)(4), each House shall provide copies of 

8 the report to the chairman and ranking 

9 member of the Committee on Ways and 

10 Means and the Committee on Energy and 

11 Commerce of the House of Representatives 

12 and to the Committee on Finance and the 

13 Committee on Health, Education, Labor, 

14 and Pensions of the Senate. 

15 ‘‘(iv) A resolution shall be referred to 

16 the Committee on Ways and Means and 

17 the Committee on Energy and Commerce 

18 of the House of Representatives and to the 

19 Committee on Finance and the Committee 

20 on Health, Education, Labor, and Pen21 sions of the Senate. 

22 ‘‘(v) If a committee to which has been 

23 referred a resolution has not reported it 

24 before the expiration of 10 legislative days 

25 after its introduction, it shall then (but not 


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1 before) be in order to move to discharge 

2 the committee from further consideration 

3 of that resolution, or to discharge the com4 mittee from further consideration of any 

5 other resolution with respect to the pro6 posed expansion which has been referred to 

7 the committee. The motion to discharge 

8 may be made only by a person favoring the 

9 resolution, shall be highly privileged (ex10 cept that it may not be made after the 

11 committee has reported a resolution with 

12 respect to the same proposed expansion), 

13 and debate thereon shall be limited to not 

14 more than 1 hour, to be divided equally be15 tween those favoring and those opposing 

16 the resolution. An amendment to the mo17 tion is not in order, and it is not in order 

18 to move to reconsider the vote by which 

19 the motion is agreed to or disagreed to. If 

20 the motion to discharge is agreed to or dis21 agreed to, the motion may not be renewed, 

22 nor may another motion to discharge the 

23 committee be made with respect to any 

24 other resolution with respect to the same 

25 proposed expansion. 


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1 ‘‘(vi) When the committee has re2 ported, or has been discharged from fur3 ther consideration of a resolution, it is at 

4 any time thereafter in order (even though 

5 a previous motion to the same effect has 

6 been disagreed to) to move to proceed to 

7 the consideration of the resolution. The 

8 motion is highly privileged and is not de9 batable. An amendment to the motion is 

10 not in order, and it is not in order to move 

11 to reconsider the vote by which the motion 

12 is agreed to or disagreed to. Debate on the 

13 resolution shall be limited to not more than 

14 2 hours, which shall be divided equally be15 tween those favoring and those opposing 

16 the resolution. A motion further to limit 

17 debate is not debatable. An amendment to, 

18 or motion to recommit, the resolution is 

19 not in order, and it is not in order to move 

20 to reconsider the vote by which the resolu21 tion is agreed to or disagreed to. 

22 ‘‘(vii) Motions to postpone, made with 

23 respect to the discharge from committee, 

24 or the consideration of, a resolution and 

25 motions to proceed to the consideration of 


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1 other business shall be decided without de2 bate. Appeals from the decision of the 

3 Chair relating to the application of the 

4 rules of the Senate or the House of Rep5 resentatives, as the case may be, to the 

6 procedure relating to a resolution shall be 

7 decided without debate. 

8 ‘‘(viii) COORDINATION WITH ACTION

9 BY THE OTHER HOUSE.—If, before the 

10 passage by one House of a joint resolution 

11 of that House, that House receives from 

12 the other House a joint resolution, then 

13 the following procedures shall apply: 

14 ‘‘(I) The joint resolution of the 

15 other House shall not be referred to a 

16 committee. 

17 ‘‘(II) With respect to a joint res18 olution of the House receiving the res19 olution, the procedure in that House 

20 shall be the same as if no joint resolu21 tion had been received from the other 

22 House; but the vote on passage shall 

23 be on the joint resolution of the other 

24 House. 


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1 ‘‘(ix) If one House fails to introduce 

2 or consider a joint resolution under this 

3 section, the joint resolution of the other 

4 House shall be entitled to expedited floor 

5 procedures under this section. 

6 ‘‘(x) If, following passage of the joint 

7 resolution in the Senate, the Senate then 

8 receives the companion measure from the 

9 House of Representatives, the companion 

10 measure shall not be debatable. 

11 ‘‘(xi) If Congress passes a joint reso12 lution, the period beginning on the date 

13 the President is presented with the joint 

14 resolution and ending on the date the 

15 President takes action with respect to the 

16 joint resolution shall be disregarded in 

17 computing the 45-calendar day period de18 scribed in subsection (c)(4). 

19 ‘‘(xii) If the President vetoes the joint 

20 resolution— 

21 ‘‘(I) the period beginning on the 

22 date the President vetoes the joint 

23 resolution and ending on the date the 

24 Congress receives the veto message 

25 with respect to the joint resolution 


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1 shall be disregarded in computing the 

2 45-calendar day period described in 

3 subsection (c)(4); and 

4 ‘‘(II) debate on a veto message in 

5 the Senate under this section shall be 

6 1 hour equally divided between the 

7 majority and minority leaders or their 

8 designees.’’. 

9 SEC. 5. PUBLIC INPUT. 

10 Section 115A(d) of the Social Security Act (42 

11 U.S.C. 1315a(d)) is amended by section 3, is further 

12 amended by adding at the end of the following new para13 graphs: 

14 ‘‘(5) PUBLIC INPUT.—The Secretary shall use a 

15 process involving advance public notice and an op16 portunity for stakeholder input and public comments 

17 to ensure transparency and accountability regarding 

18 the establishment, testing, implementation, evalua19 tion, and expansion of a model under section 

20 1115A(b) and (c). Such public notice shall describe 

21 and define the standards, criteria, and processes 

22 that the Secretary will use for selecting and evalu23 ating— 

24 ‘‘(A) during initial stages of model develop25 ment; 


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1 ‘‘(B) prior to testing under subsection 

2 (b)(1); 

3 ‘‘(C) prior to modification of non-contrac4 tual models under subsection (b)(3)(B); and 

5 ‘‘(D) following evaluation of a model under 

6 subsection (b)(4) and prior to rulemaking under 

7 subsection (c). 

8 Such notice shall explain the basis for the Sec9 retary’s determination that the conditions set forth 

10 in section 115A(c) of the Social Security Act (42 

11 U.S.C. 1315a(c)) have been met. Additionally, the 

12 notice shall explain the basis for selection and the 

13 standards established by the Secretary under the 

14 regulations issued under paragraph (1), and any ad15 ditional factors that will be used to test the model’s 

16 impact on quality of care, patient-centeredness, and 

17 innovation. The notice shall provide a minimum 45- 

18 day period for public comment. The Secretary shall 

19 take stakeholder comments into consideration when 

20 determining whether or how to refine the model or 

21 whether to proceed with testing under subsection 

22 (b)(1). 

23 ‘‘(6) CONSULTATION.—In carrying out the du24 ties under this subsection, the CMI shall consult 

25 representatives of relevant Federal agencies, and 


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1 clinical and analytical experts with expertise in medi2 cine and health care management, specifically such 

3 experts with expertise in— 

4 ‘‘(A) the health care needs of minority, 

5 rural and underserved populations; and 

6 ‘‘(B) the financial needs of safety net, 

7 community-based, rural, and critical access pro8 viders, including federally qualified health cen9 ters. 

10 The CMI shall use open door forums or other mech11 anisms to seek external feedback from interested 

12 parties and incorporate that feedback into the devel13 opment of models.’’. 

14 SEC. 6. REESTABLISHING JUDICIAL REVIEW. 

15 Section 1115A(g) of the Social Security Act (42 

16 U.S.C. 1315a(g)) is amended— 

17 (1) in the matter preceding subparagraph (A) 

18 by inserting after ‘‘or otherwise’’ the following: ‘‘(ex19 cept as may be necessary to enforce requirements of 

20 this section or other laws or constitutional provisions 

21 intended to protect beneficiaries of affected pro22 grams)’’; 

23 (2) by striking subparagraph (C); 

24 (3) in subparagraph (D), by adding at the end 

25 ‘‘; and’’; 


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1 (4) by redesignating subparagraph (D) as sub2 paragraph (C); 

3 (5) in subparagraph (E), at the end, by striking 

4 ‘‘; and’’; 

5 (6) by redesignating subparagraph (E) as sub6 paragraph (D); and 

7 (7) by striking subparagraph (F). 

8 SEC. 7. REVISION OF REPORTING REQUIREMENT. 

9 Section 1115A(g) of the Social Security Act (42 

10 U.S.C. 1315a(g)) is amended— 

11 (1) by striking ‘‘and not less than once every 

12 other year thereafter’’ and inserting ‘‘and, for years 

13 before 2020, not less than once biennially (and, for 

14 years beginning with 2020, not less than annually) 

15 thereafter’’; and 

16 (2) by adding at the end the following new sen17 tence: ‘‘With respect to 2020 and each subsequent 

18 year, the Secretary shall submit each such report by 

19 not later than December 15 of such year.’’. 

20 SEC. 8. ADDRESSING OVERLAP IN VALUE-BASED CARE PRO21 GRAMS. 

22 (a) IN GENERAL.— 

23 (1) CMI.—Section 1115A(a)(5) of the Social 

24 Security Act (42 U.S.C. 1315a(a)(5)) is amended by 

25 adding at the end the following new sentence: ‘‘In 


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1 establishing such limits, the Secretary shall take into 

2 account payment and service delivery models in 

3 progress in such geographic areas.’’. 

4 (2) REPEAL OF MEDICARE DUPLICATION PRO5 HIBITION.—Section 1899(b) of the Social Security 

6 Act (42 U.S.C. 1395jjj(b)) is amended by striking 

7 paragraph (4)(A). 

8 (b) REPORT.—Not later than 60 days after the date 

9 of the enactment of this Act, the Secretary of Health and 

10 Human Services shall conduct an assessment and submit 

11 to Congress a report on alternative payment model overlap 

12 under the Medicare program under title XVIII of the So13 cial Security Act. Such report shall include a description 

14 of and recommendations relating to— 

15 (1) appropriate participation in multiple alter16 native payment models for health care providers; 

17 (2) feasibility of adequate evaluation of alter18 native payment models if participants are partici19 pating in multiple arrangements; and 

20 (3) obstacles created by competing incentives 

21 with respect to alternative payment models. 

22 SEC. 9. MODEL ELIGIBILITY AND QUALITY OF CARE. 

23 (a) CLARIFICATION OF MODEL ELIGIBILITY.—Sec24 tion 1115A of the Social Security Act (42 U.S.C. 1315a) 

25 is amended— 


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1 (1) by striking ‘‘also’’ before ‘‘improve’’; and 

2 (2) in subsection (b)(2)(A), by inserting after 

3 the second sentence the following new sentence: 

4 ‘‘The Secretary may also focus on models solely 

5 aimed at implementing practices to demonstrate ways to 

6 significantly improve the care, patient safety, and health 

7 outcomes of individuals receiving benefits under the appli8 cable title in anticipation that quality of care benefits and 

9 potential direct or indirect savings will over time accrue 

10 to the Medicare or Medicaid program.’’. 

11 (b) ADDITIONAL OPPORTUNITY.—Section 

12 1115A(b)(2)(B) of the Social Security Act (42 U.S.C. 

13 1315a(b)(2)(B)) is amended by adding at the end the fol14 lowing new clause: 

15 ‘‘(xxviii) Implementing newly recog16 nized and evidence-based, professionally 

17 supported care delivery practices and bun18 dles to improve the efficient and effective 

19 delivery of hospital-based care and lead to 

20 enhanced patient outcomes, reductions in 

21 readmissions, or avoidance of costly med22 ical errors or complications.’’. 

23 (c) INCLUSION OF INDIRECT SAVINGS.—Section 

24 1115A(b)(3)(A) of the Social Security Act (42 U.S.C. 

25 1315a(b)(3)(A)) is amended by inserting at the end ‘‘or 


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1 that savings cannot be made indirectly over time when 

2 testing quality of care delivery models.’’. 

3 (d) EVALUATING QUALITY OF CARE.—Section 

4 1115A(b)(4) of the Social Security Act (42 U.S.C. 

5 1315a(b)(4)) is amended— 

6 (1) in subparagraph (A), by amending clause (i) 

7 to read as follows: 

8 ‘‘(i) the quality of care furnished 

9 under the model, including the measure10 ment of patient-level outcomes, patient11 centeredness, and any unintended con12 sequences, such as access to services, using 

13 criteria determined appropriate by the Sec14 retary for each model; and’’; and 

15 (2) in subparagraph (C), by striking ‘‘and’’ be16 fore ‘‘patient-centered care’’ and inserting ‘‘, are ap17 propriate to issues of quality outcomes related to the 

18 medical conditions under study, and are’’. 

19 SEC. 10. GAO REPORT. 

20 Not later than 12 months after the date of enactment 

21 of this Act, the Comptroller General of the United States 

22 shall submit to Congress a report on the efforts of the 

23 Center for Medicare and Medicaid Innovation to attract, 

24 retain, and develop emerging experts, including underrep25 resented individuals in medicine, such as women, racial 


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1 and ethnic minorities, and other groups. Such report shall 

2 include an analysis of the role minority staff play in model 

3 development and operational decisions on an ongoing 

4 bases and of the impact of the existing authority provided 

5 to the Center for Medicare and Medicaid Innovation to 

6 address workforce shortages and gaps in priority areas. 

7 SEC. 11. EFFECTIVE DATE. 

8 Except as otherwise provided in the previous sections 

9 of this Act (or the amendments made by such sections), 

10 such amendments shall apply with respect to the testing, 

11 expansion, or modification of models on or after January 

12 1, 2024. 

Æ 


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