I 

118TH CONGRESS 

1ST SESSION H. R. 5013 

To direct the Secretary of Health and Human Services to revise certain 

regulations in relation to the Medicare shared savings program and 

other alternative payment arrangements to encourage participation in 

such program, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JULY 27, 2023 

Mr. LAHOOD (for himself, Ms. DELBENE, Mr. WENSTRUP, Ms. SCHRIER, Mr. 

BUCSHON, and Mr. BLUMENAUER) 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 direct the Secretary of Health and Human Services to 

revise certain regulations in relation to the Medicare 

shared savings program and other alternative payment 

arrangements to encourage participation in such program, 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 ‘‘Value in Health Care 

5 Act of 2023’’. 


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1 SEC. 2. ENCOURAGING PARTICIPATION IN THE MEDICARE 

2 SHARED SAVINGS PROGRAM. 

3 (a) REMOVING BARRIERS TO SHARED SAVINGS PRO4 GRAM PARTICIPATION.—Prior to the beginning of the first 

5 performance year (as defined in section 425.20 of title 42, 

6 Code of Federal Regulations (or a successor regulation)) 

7 that begins at least 90 days after the date of enactment 

8 of this Act, the Secretary of Health and Human Services 

9 shall revise part 425 of title 42, Code of Federal Regula10 tions, or any successor regulation, to— 

11 (1) eliminate any distinction in requirements in 

12 such part between a low revenue ACO and a high 

13 revenue ACO (as such terms are defined in section 

14 425.20 of title 42, Code of Federal Regulations, or 

15 a successor regulation) and, with respect to such a 

16 low revenue ACO or high revenue ACO and except 

17 as otherwise modified in this Act, apply the require18 ments of such part as such requirements applied to 

19 low revenue ACOs on July 1, 2024, except that the 

20 Secretary of Health and Human Services may, if the 

21 Secretary determines appropriate, apply less strin22 gent requirements than those requirements that ap23 plied to low revenue ACOs as of such date; and 

24 (2) remove any provision requiring an account25 able care organization to assume responsibility for 

26 repayment of any shared losses or participate in a 


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1 two-sided risk model before the organization has 

2 participated for at least 3 years in any program sub3 ject to the provisions of part 425 of title 42, Code 

4 of Federal Regulations, or any successor regulation, 

5 provided that such an organization shall be allowed 

6 to elect to participate in such two-sided risk models 

7 or models requiring repayment of such losses. 

8 (b) FINANCIAL METHODOLOGY ENHANCEMENTS TO

9 PROMOTE SUCCESS OF SHARED SAVINGS PROGRAM.— 

10 Prior to the beginning of the first performance year (as 

11 defined for purposes of subsection (a)) that begins at least 

12 90 days after the date of enactment of this Act, the Sec13 retary shall— 

14 (1) ensure that any methodology used to estab15 lish, adjust, or update benchmark expenditures be 

16 developed and implemented in a clear and trans17 parent manner, including by making publicly avail18 able sufficient information and data to allow inter19 ested members of the public to replicate the method20 ology used by the Secretary and to evaluate the ac21 curacy of the Secretary’s benchmark expenditure 

22 calculations; 

23 (2) implement a process that allows ACOs to 

24 appeal the accuracy of benchmark expenditures in a 

25 hearing before an administrative law judge, and enVerDate Sep 11 2014 20:12 Aug 15, 2023 Jkt 039200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H5013.IH H5013

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1 sure that any such appeal be heard within a 90-day 

2 period beginning on the date a request for hearing 

3 is filed; and 

4 (3) require that any regional contributions or 

5 expenditures (below the national level) used directly 

6 or indirectly to establish, update, or adjust bench7 mark expenditures be calculated in a manner that 

8 excludes the expenditure impact of ACOs in the ap9 plicable region, including any regional expenditures 

10 associated with Medicare fee-for-service beneficiaries 

11 assigned to such ACOs. 

12 (c) SHARED SAVINGS OPTION.—Prior to the begin13 ning of the first performance year (as defined for purposes 

14 of subsection (a)) that begins after the date of the enact15 ment of this Act, and notwithstanding any other provision 

16 of law, the Secretary of Health and Human Services shall 

17 establish a voluntary full-risk option under the Medicare 

18 Shared Savings Program (as described in section 1899 of 

19 the Social Security Act (42 U.S.C. 1395jjj) under which 

20 the percent of shared savings paid to an ACO under sec21 tion 1899(d)(2) of the Social Security Act (42 U.S.C. 

22 1395jjj(d)(2)) shall be set at 100 percent, with the ACO 

23 bearing commensurate risk of any shared losses. 

24 (d) REPORT.—Not later than 90 days after the date 

25 of enactment of this Act, the Administrator of the Centers 


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1 for Medicare & Medica Services shall submit to the appro2 priate committees of Congress a report on mechanisms 

3 that the agency can take to avoid penalizing ACOs for 

4 achieving cost savings and account for regional variations 

5 in spending in a manner that prevents arbitrary Medicare 

6 Shared Savings Program outcomes for ACOs. Such report 

7 shall include specific actions that the Centers for Medicare 

8 & Medicaid Services can take to develop and implement 

9 effective benchmarks and guardrails for any changes made 

10 to the agency’s benchmarking policies. 

11 SEC. 3. ADVANCED PAYMENT MODEL INCENTIVE, PARTICI12 PATION, AND THRESHOLD MODIFICATIONS. 

13 (a) IN GENERAL.—Section 1833(z) of the Social Se14 curity Act (42 U.S.C. 1395l(z)) is amended— 

15 (1) in paragraph (1)(A), by striking ‘‘2025’’ 

16 and inserting ‘‘2027’’ and by adding after ‘‘5 per17 cent (or, with respect to 2025, 3.5 percent’’ and be18 fore the close parenthesis ‘‘or, with respect to 2026 

19 and any subsequent year, the scaled percentage 

20 amount’’; 

21 (2) in paragraph (2)(C)— 

22 (A) in clause (i), by striking ‘‘75 

23 percent’’and inserting ‘‘the applicable percent 

24 (as defined in clause (iv)) for such year’’; 

25 (B) in clause (ii)(I)— 


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1 (i) in the matter preceding item (aa), 

2 by striking ‘‘75 percent’’ and inserting 

3 ‘‘the applicable percent (as defined in 

4 clause (iv)) for such year’’; and 

5 (ii) in item (bb)— 

6 (I) by striking ‘‘and other than 

7 payments made under title XIX’’ and 

8 inserting ‘‘other than payments made 

9 under title XIX’’; and 

10 (II) by striking ‘‘State program 

11 under that title),’’ and inserting 

12 ‘‘State program under that title, and 

13 other than payments made by payers 

14 in which no payment or program 

15 meeting the requirements described in 

16 clause (iii)(II) is available from the 

17 payer for participation by the eligible 

18 professional)’’; and 

19 (C) by adding at the end the following new 

20 clause: 

21 ‘‘(iv) APPLICABLE PERCENT DE22 FINED.—For purposes of clauses (i) and 

23 (ii), the term ‘applicable percent’ means— 

24 ‘‘(I) for 2026 through 2027, 50 

25 percent; and 


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1 ‘‘(II) for 2028 and any subse2 quent year, a percent specified by the 

3 Secretary, but in no case less than the 

4 percent specified under this clause for 

5 the preceding year or more than the 

6 lesser of 75 percent or 5 percentage 

7 points higher than the percent speci8 fied under this clause for the pre9 ceding year. 

10 ‘‘(v) ALTERNATIVE APPLICABLE PER11 CENT.—Notwithstanding any other provi12 sion of law, the Secretary may define the 

13 applicable percent for purposes of a given 

14 alternative payment model (or for purposes 

15 of partial qualifying APM participants 

16 under section 1848(q)(1)(C)(iii)(III)) to 

17 mean a percentage amount that is lower 

18 than the amount (or range) otherwise spec19 ified in such preceding clause (or, as appli20 cable, under section 

21 1848(q)(1)(C)(iii)(III)), if there is good 

22 cause to support such alternative applica23 ble percent, including where an alternative 

24 payment model’s design warrants use of 

25 such alternative applicable percent. In no 


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1 case shall the Secretary designate an alter2 native applicable percent that exceeds the 

3 maximum applicable percent specified in 

4 the preceding clause (or, as applicable, 

5 under section 1848(q)(1)(C)(iii)(III)) for 

6 the applicable year; and 

7 ‘‘(vi) SCALED PERCENTAGE

8 AMOUNT.—For purposes of this subsection 

9 (including paragraph (1)), the term ‘scaled 

10 percentage amount’ means a progressively 

11 scaled percentage amount designated by 

12 the Secretary. The Secretary shall deter13 mine an appropriate progressive percent14 age scale for different categories of eligible 

15 professionals based on programmatic inter16 ests in efficiency, equity, and alignment of 

17 appropriate incentives. The maximum 

18 scaled percentage amount shall be 5 per19 cent, and such maximum amount shall 

20 apply to an eligible professional that meets 

21 or exceeds the applicable percent (as de22 fined in paragraph (2)(C)(iv)). In no case 

23 may an eligible professional below the ap24 plicable percent qualify for the maximum 

25 scaled percentage amount’’; and 


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1 (3) in paragraph (4)(B), by adding after ‘‘5 

2 percent (or, with respect to 2025, 3.5 percent’’ and 

3 before the close parenthesis ‘‘or, with respect to 

4 2026 and any subsequent year, the scaled percent5 age amount’’. 

6 (b) TECHNICAL ASSISTANCE.—The Secretary of 

7 Health and Human Services shall provide education and 

8 technical assistance to ACOs and other types of providers 

9 (as defined under section 414.1305 of title 42, Code of 

10 Federal Regulations (or a successor regulation)) that the 

11 Secretary determines to target or otherwise operate in 

12 rural or medically underserved areas or to involve material 

13 participation by small practice or safety net groups of pro14 viders of services and suppliers. Such education and tech15 nical assistance may include infrastructure support or ac16 cess to data analytics to support ACO implementation in 

17 such rural or medically underserved areas or to benefit 

18 small practice or safety net groups of providers of services 

19 and suppliers, or other groups of providers of services and 

20 suppliers deemed to require additional support, such as 

21 providers of services or suppliers that are new to APMs, 

22 including specialists. 

23 (c) PARTIAL QUALIFYING APM PARTICIPANT MODI24 FICATION.—Section 1848(q)(1)(C)(iii)(III) of the Social 


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1 Security Act (42 U.S.C. 1395w–4(q)(1)(C)(iii)(III)) is 

2 amended— 

3 (1) in item (aa), by striking ‘‘50 percent was 

4 instead a reference to 40 percent’’ and inserting 

5 ‘‘the applicable percent were instead a reference to 

6 10 percentage points less than the applicable per7 cent’’; and 

8 (2) in item (bb)— 

9 (A) by striking ‘‘75 percent’’ and inserting 

10 ‘‘the applicable percent’’; and 

11 (B) by striking ‘‘50 percent’’ and inserting 

12 ‘‘10 percentage points less than the applicable 

13 percent’’. 

14 SEC. 4 STUDY ON ALTERNATIVE PAYMENT MODELS AND 

15 MEDICARE+CHOICE. 

16 Not later than 18 months after the date of enactment 

17 of this Act, the Comptroller General of the Government 

18 Accountability Office shall study and submit to the appro19 priate committees of Congress a report evaluating the ben20 efits and flexibilities provided to support alternative pay21 ment models (as defined under section 414.1305 of title 

22 42, Code of Federal Regulations (or a successor regula23 tion)) and Medicare+Choice Organizations (as defined in 

24 section 1859(a)(1) of the Social Security Act (42 U.S.C. 

25 1395w–28(a)(1)). The objective of such report shall be to 


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1 better understand the effect of these programs’ different 

2 policies on different types of participating patients and 

3 providers, including specialty, safety net, small practice, 

4 and rural providers, with the goal of identifying areas to 

5 enhance alignment between such programs’ policies and 

6 benchmarks including through mechanisms that could fa7 cilitate greater alignment in policies and benchmarks and 

8 to encourage the adoption of value-based arrangements 

9 across payers or that could otherwise increase parity in 

10 the flexibilities available to alternative payment models 

11 and Medicare+Choice Organizations. 

Æ 


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