Strengthening Innovation in Medicare and Medicaid Act
- Sponsor
- Rep. Smith, Adrian [R-NE-3]
- Committees
- Ways and Means Committee (primary)
- Last action
- Oct 1, 2026
Bottom line
The bill significantly increases congressional oversight and public accountability for CMI's model testing and expansion, aiming to balance innovation with safeguards for providers and beneficiaries.
What it actually does
This bill amends the Social Security Act to impose new restrictions and oversight mechanisms on the Center for Medicare and Medicaid Innovation (CMI). It limits the scope and duration of CMI's Phase I models, caps the number of new models CMI can initiate annually, and restricts concurrent mandatory models. Crucially, it establishes a congressional disapproval process for CMI model expansions and restores judicial review over CMI actions, while also mandating enhanced public input and transparency regarding actuarial data.
Proponents argue
Proponents argue that the bill is necessary to ensure CMI operates with greater accountability and transparency, protecting Medicare and Medicaid beneficiaries and providers from potentially adverse or costly experimental models. They contend that current CMI authority is too broad, leading to mandatory models that can create undue economic hardship or reduce access to care without sufficient oversight or recourse. The bill aims to refine CMI's approach, ensuring models are rigorously tested and evaluated before widespread implementation.
Opponents contend
Opponents might argue that these new restrictions could stifle CMI's ability to innovate and respond nimbly to healthcare challenges, ultimately slowing down efforts to improve care quality and reduce costs. They may contend that adding congressional review and judicial oversight introduces unnecessary bureaucracy and politicization into a process designed for expert-driven experimentation, potentially hindering the development of beneficial payment and service delivery models.
The bill is relatively concise for its scope, allowing an informed reader to understand its core provisions within a reasonable timeframe, especially given its significant policy implications.
Section 3(a)
Limits on Phase I Model Scope and Duration
This provision amends Section 1115A(a) of the Social Security Act to limit the testing of CMI's Phase I models. Specifically, it caps the duration of a Phase I model to a maximum of 5 years and restricts its scope to the lesser of 10 percent of applicable individuals or 500,000 beneficiaries. This aims to ensure initial model tests are conducted on a smaller, more controlled scale.
Supporters argue
Proponents argue these limits protect beneficiaries and providers from widespread negative impacts of untested models, allowing CMI to refine concepts on a smaller scale before broader application. This minimizes risk to the Medicare program's integrity.
Critics contend
Opponents might argue that such strict limits could hinder CMI's ability to gather sufficient data or achieve meaningful results in its initial testing phases, potentially delaying or preventing the development of effective new models.
Tradeoffs
This provision balances the desire for cautious, risk-averse model testing with the need for CMI to gather robust data to evaluate model effectiveness. Smaller scale tests may limit generalizability but reduce potential harm.
Section 3(b)
Cap on New and Mandatory Phase I Models
This section further amends Section 1115A(a) to impose annual and concurrent limits on CMI's model testing. Starting in fiscal year 2027, CMI can initiate no more than 6 new Phase I models each fiscal year. Additionally, CMI cannot concurrently test more than 5 Phase I models that involve mandatory, involuntary, or compulsory participation.
Section 3(c)
Hardship Waivers for Providers
This amendment requires the Secretary of HHS to develop and implement a plan within 60 days of enactment to allow healthcare providers and suppliers to request a waiver from any CMI model requirement. A waiver would be granted if the Secretary determines the requirement would result in undue economic hardship for the provider/supplier or a loss of access to healthcare services/supplies for vulnerable populations.
Section 4(a)
Congressional Disapproval Process for CMI Models
This section establishes a new process requiring the Secretary to transmit proposals for CMI model testing, expansion, or modification to specific congressional committees. The proposed action can only proceed if Congress does not pass a joint resolution of disapproval within 45 days of receiving the report. It outlines detailed expedited legislative procedures for such a resolution in both the House and Senate.
Section 5
Enhanced Public Input and Consultation
This section mandates that the Secretary use a process involving advance public notice and a minimum 45-day opportunity for stakeholder input and public comments at various stages of CMI model development, testing, implementation, evaluation, and expansion. It requires the notice to define standards and criteria for selection and evaluation, explain the basis for determinations, and detail factors for assessing quality, patient-centeredness, and innovation. It also requires CMI to consult with relevant federal agencies and clinical/analytical experts, including those with expertise in the financial needs of safety net, community-based, rural, and critical access providers.
Section 6(a)
Reestablishment of Judicial Review
This section amends Section 1115A(d)(2) of the Social Security Act to reestablish judicial review over CMI actions. It inserts language allowing for judicial review "as may be necessary to enforce the requirements of this section or other laws or constitutional provisions intended to protect beneficiaries of affected programs," and strikes previous subparagraphs that explicitly limited judicial review.
Section 9(a) and (c)
Clarification of Model Eligibility and Indirect Savings
This provision clarifies that CMI models can focus solely on significantly improving care, patient safety, and health outcomes, even if direct savings are not immediately apparent, with the anticipation that quality benefits and potential indirect savings will accrue over time. It explicitly amends the Social Security Act to allow for certification of models where savings can be made indirectly over time when testing quality of care delivery models.
Section 9(d)
Availability of Actuarial Assumptions and Data
This section mandates that the Secretary provide participating providers and suppliers with the actuarial assumptions and data used by the Chief Actuary of the Centers for Medicare & Medicaid Services (CMS) when making (or declining to make) certifications for model termination, modification, or expansion. This information must also be included in any rules promulgated regarding these decisions.
These subclauses detail the specific expedited legislative procedures for a joint resolution of disapproval in Congress, including referral to committees, motions to discharge, debate limits, and procedures for handling vetoes. This is a highly technical and procedural section that defines how Congress would exercise its new disapproval power.
Section 4(a)(B)(ii) - (xii)
Why it matters:This is standard legislative drafting practice for establishing new congressional procedures, as such rules are inherently complex and detailed. It's not necessarily evasive, but it requires careful reading to understand the practical implications of the disapproval mechanism.
Case for: The detailed procedures ensure that the congressional disapproval mechanism is clear, efficient, and consistent, providing a predictable framework for legislative action on CMI models. Without these specifics, the disapproval power would be less effective.
Case against: The complexity of these procedures might make it challenging for members of Congress to fully understand and utilize the disapproval mechanism effectively, potentially leading to procedural missteps or a reluctance to engage with the process.
Estimated impact: These procedures are critical for the operationalization of the congressional disapproval power, which could significantly alter CMI's ability to expand models.
This provision repeals paragraph (4)(A) of Section 1899(b) of the Social Security Act, which prohibited the Secretary from implementing an accountable care organization (ACO) initiative if it duplicated a CMI model.
Section 8(a)(2)
Why it matters:This is a technical amendment to remove a specific statutory prohibition. While consequential, its phrasing is typical for legislative updates to existing code. It's not necessarily evasive, but it's not immediately obvious what the repealed text did without looking it up.
Case for: Repealing this prohibition could provide greater flexibility for the Secretary to implement various value-based care programs, potentially allowing for more diverse or tailored ACO initiatives even if they share some similarities with CMI models. This could foster more innovation by removing a potential barrier.
Case against: Critics might argue that removing the duplication prohibition could lead to redundant or conflicting initiatives, creating confusion for providers and potentially wasting resources if multiple programs aim to achieve similar goals without clear differentiation.
Estimated impact: This repeal could lead to a more diverse landscape of value-based care programs, potentially increasing options for providers but also requiring careful management to avoid confusion or conflicting incentives.