Summary

Prohibits federal agencies, the CMS Innovation Center, states, Medicaid managed care organizations, Medicare Advantage plans, and prescription drug plans from using dollars‑per‑quality‑adjusted‑life‑year (QALY) measures or similar cost‑per‑QALY metrics in coverage, reimbursement, or incentive programs, with that ban taking effect January 1, 2027. Adjusts annual funding levels for the Prevention and Public Health Fund for FY2026–FY2031 and requires the Government Accountability Office to deliver an initial report within one year and then annual reports on how QALYs negatively affect individuals with intellectual and developmental disabilities (IDD).

Key Points

• Bans use of QALYs or similar cost‑per‑QALY measures in coverage, payment, and incentive decisions across Medicaid, CHIP, Medicare Advantage, and Medicare Part D.
• Prohibition applies to federal agencies, the CMS Innovation Center, states, Medicaid MCOs, MA plans, and Part D plans.
• Waivers and demonstrations (including 1115 and 1115A authorities) cannot be used to bypass the QALY ban.
• QALY prohibition becomes effective January 1, 2027.
• Sets specific annual funding amounts for the Prevention and Public Health Fund for FY2026–FY2031.
• Requires the GAO to report within one year and annually thereafter on how QALYs negatively affect people with intellectual and developmental disabilities (IDD).
• Does not provide separate appropriations for the GAO report or add enforcement funding.
• Mainly changes statutory language governing program decision‑making and fund levels rather than creating new benefit programs.

Categories & Tags