Sponsors (2)
Last progress June 10, 2025 (8 months ago)
Introduced on June 10, 2025 by Kat Cammack
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, 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.
Bans use of dollars-per-quality-adjusted-life-year (QALY) and similar measures when making coverage, payment, reimbursement, or incentive decisions under Federal health programs (including Medicaid, CHIP, Medicare Advantage, and Medicare Part D). It prevents agencies or States from using demonstration or waiver authorities to circumvent the ban and makes the ban effective January 1, 2027. Also updates scheduled funding amounts for the Prevention and Public Health Fund for fiscal years 2026–2031 and requires the Comptroller General to deliver an initial and then annual reports to Congress on how QALYs affect people with intellectual and developmental disabilities and their access to care.
Amend Section 1182(e) of the Social Security Act to prohibit a Federal agency (including the CMI as described in section 1115A) or a State from using a dollars-per-quality-adjusted-life-year or similar measure in coverage determinations, reimbursement, or incentive programs.
Add a new sentence stating that, notwithstanding any other law, a Federal agency (including the CMI) or State may not waive the application of this subsection (or the provisions of sections 1852(o), 1860D–12(h), 1902(a)(88), 1932(b)(9), or 2102(e)) under section 1115, section 1115A, or any other demonstration or waiver authority.
Amend Section 1902(a) of the Social Security Act to add paragraph (88) requiring States to provide for compliance with the requirements of section 1182(e) (prohibiting the use of certain measures in coverage determinations, reimbursement, and incentive programs).
Add paragraph (9) to Section 1932(b) to apply the provisions of section 1182(e) to Medicaid managed care organizations and to prepaid inpatient and prepaid ambulatory health plans under contract with the State, in the same manner those provisions apply to a State.
Amend Section 2102 of the Social Security Act by adding subsection (e) requiring State child health plans to provide for compliance with section 1182(e).
Who is affected and how:
Individuals with intellectual and developmental disabilities: The bill directs regular GAO study of how QALY use harms this group and is intended to prevent QALY-based decisions that could reduce coverage or access for people with disabilities. If agencies previously used QALYs in ways that deprioritized interventions for people with lower measured QALY gains, those practices should be ended for covered federal programs.
Medicare beneficiaries and Medicare Advantage/Part D plans: Plans and program officials that rely on cost-effectiveness thresholds tied to QALYs will have to stop using those measures for coverage, formulary, or reimbursement decisions in the specified programs by Jan 1, 2027. That will change analytic practices and possibly the evidence used in coverage decisions.
Medicaid, CHIP, and State agencies: State Medicaid and CHIP programs and their contractors must avoid QALY-based decisions and cannot reintroduce them through demonstration waivers; this narrows some state-level policy options and may require revisions to state guidance and managed-care contracts.
Providers, suppliers, and payers (covered entities): Organizations that perform health technology assessment, aggregate cost‑effectiveness analyses, or set incentives based on QALY-related metrics will need to modify methods, reporting, and contractual terms to comply with the ban.
Public health programs funded by the Prevention and Public Health Fund: The bill changes the statutory funding schedule for FY2026–FY2031, which alters the resources authorized for prevention activities; agencies and grant recipients will need to adjust planning to the revised funding levels.
Federal agencies and the GAO: Agencies must update rules, guidance, and analytic standards to remove QALY-based measures; the GAO must develop and deliver an initial and annual reports analyzing harms to people with intellectual and developmental disabilities, creating recurring administrative work.
Overall effects: