Excludes specific diagnostic data streams. Currently, risk adjustment scores incorporate patient conditions identified during alternative assessments. Starting in 2028, this provision prohibits the Centers for Medicare & Medicaid Services (CMS) from factoring diagnoses collected from chart reviews or health risk assessments into payment calculations.

Mandates a verification process. Currently, explicit tracking frameworks for data origin sources are left to administrative discretion. This provision commands the Secretary of Health and Human Services to establish definitive procedures to identify and verify all diagnostic data compiled through chart reviews and health risk assessments.

Eliminates the county quartile benchmarking framework. Currently, the federal government uses a county quartile system to determine base financial benchmarks for private insurance plans. This provision removes that framework to fundamentally recalculate how baseline payment allocations are scaled.

Imposes a selection-adjusted baseline formula. Currently, base rates do not feature a structural discount to account for differences in patient care utilization between programs. This provision requires multiplying the baseline payment amount by a distinct selection percentage to establish a selection-adjusted base rate.

Requires funding for enforcement reviews. Currently, explicit funding metrics for contract audit timelines are managed under broad agency budgets. This provision cuts a specific portion of payments to Medicare Advantage organizations to directly fund ongoing Risk Adjustment Data Validation (RADV) audits—federal audits designed to cross-check patient health data against actual medical charts to catch and claw back artificial overpayments to insurers.

Impact if passed: Private insurance plans face tighter structural boundaries on what diagnosis codes they can submit, absorb a dedicated funding reduction to bankroll federal enforcement audits, and lose the right to seek judicial review over final RADV audit determinations.

Impact if failed: Private insurers retain current payment structures, regional baseline calculation models, and existing data collection streams.

Governing section: Section 2 and Section 3.

Impact if passed: Mandates that the agency review diagnosis codes annually via public rulemaking to adjust codes prone to inflation. It also requires an annual analysis of plan selection differences across socio-demographic subgroups (including race, gender, zip code, income level, and health conditions) and forces a strict one-year timeline to complete contract audits.

Impact if failed: Operational guidelines, data modeling protocols, and regulatory oversight timelines remain within existing agency boundaries.

Governing section: Section 2 and Section 3.

Impact if passed: Eliminating the county-level quartile benchmark changes payment dynamics in localized insurance markets across the Ohio Valley and surrounding states. High-cost or rural counties that previously qualified for elevated funding benchmarks under the old framework will see base payment levels contract, potentially impacting localized plan availability, regional benefit designs, or out-of-pocket premium costs.

Impact if failed: Localized funding benchmarks remain tied to the established county quartile metrics, preserving existing market premium baselines and local plan options.

Governing section: Section 3.

Impact if passed: Permits the Department of Veterans Affairs to collect cost-recoveries and bill Medicare Advantage or prescription drug plans for medical care delivered directly to dually enrolled veterans at VA facilities.

Impact if failed: Present statutory billing barriers remain intact, preventing the VA from recovering care costs from private plans when dually enrolled veterans use VA services.

Governing section: Section 3 (amends 38 U.S.C. Chapter 17).

Total estimated cost or savings over 10 years: Independent analysis by the Brown University Center for Advancing Health Policy through Research estimates the legislation would reduce net Medicare spending by approximately $2.5 trillion over a ten-year period (2028–2037). Macroeconomic policy groups estimate a baseline savings of at least $1 trillion over the next decade by curtailing projected excess costs.

Which accounts or programs are affected and by what amount: Reduces federal outlays within the Medicare Advantage program by curbing upcoding, favorable selection margins, and ending the Quality Bonus Program. Capital is redirected to the Medicare general funds to extend trust fund solvency.

Who bears the cost: Private insurance corporations operating Medicare Advantage plans bear the primary financial impact through reduced capitated payments, lower benchmark rates, and mandatory audit clawbacks.

Citation: Representative Lloyd Doggett introduced text; analysis by the Brown University Center for Advancing Health Policy through Research and the Committee for a Responsible Federal Budget.

Section 2 mandates that the Secretary of Health and Human Services "shall establish procedures to provide for the identification and verification of diagnoses." Because the bill leaves the mechanical parameters of this verification structure open to agency execution, it is required to track subsequent CMS rulemaking.

Section 3 states that "there shall be no judicial review... of any determination of the Administrator of the Centers for Medicare and Medicaid Services under the Risk Adjustment Data Validation audit program." This complete restriction of legal remedy overrides standard administrative law procedures, requiring us to monitor any constitutional or legal precedent challenges.

Does not alter Traditional Medicare eligibility requirements. The bill aims to level the playing field between public and private options, but it contains no provisions changing age, income, or disability qualifications for standard fee-for-service Medicare.

Does not terminate the Medicare Advantage program. While public debates occasionally frame payment reform as an effort to dismantle private options, the statutory text leaves the underlying Medicare Advantage program framework intact while adjusting how payments are formulated.

Does not reduce statutory health benefits for veterans. Although the bill changes fiscal billing rules within Chapter 17 of Title 38, it does not alter, restrict, or revoke any medical care benefits or coverage criteria guaranteed to veterans by the VA.