RESULTS Act (H.R. 5269)

Summary

Changes how Medicare pays for lab tests by using data from private insurance companies to set fair and stable prices for patients.

What problem does this solve?

The current method for setting Medicare payment rates for lab tests relies on data that can be difficult to collect and may not accurately reflect market prices. This bill creates a new system using a large, independent database of private insurance claims to set more accurate and stable payment rates for these tests.

What does this bill do?

Uses a national database for common test pricing

Requires Medicare to use a large, independent database of private insurance claims to set payment rates for widely available lab tests, starting in 2028.

Changes limits on annual payment cuts

Adjusts the maximum amount that Medicare payments for a lab test can be reduced in a single year, setting the cap at 5% for 2029 and all following years.

Sets a default payment update

Establishes a default payment for common lab tests if data is unavailable. The payment will be the previous year's rate, increased by the consumer price index.

Excludes Medicaid rates from calculations

Stops including payment rates from Medicaid managed care organizations when calculating Medicare payment rates for lab tests, starting with data collected for 2028.

Allows for legal review of payment rates

Removes the current ban on administrative and judicial review of the lab test payment system, allowing for legal challenges starting January 1, 2029.

Updates which labs must report data

Changes the definition of which laboratories are required to report their private insurance payment data to Medicare for reporting periods beginning in 2028.

Who does this affect?

Clinical laboratories
Medicare patients
Private health insurance companies

What is the real world impact?

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Ensures fair payment for lab tests

Aims to make Medicare payments for lab tests more accurate and stable by basing them on what private insurance companies pay. This helps ensure that labs are paid fairly and that patients can continue to get the tests they need.

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Centralizes data collection for common tests

Shifts the data collection for widely used lab tests from individual labs to a single, large national database. This could streamline the process but also gives one entity significant influence over the data used to set Medicare rates.

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Limits future payment cuts to laboratories

Changes the rules to limit how much Medicare can reduce payments for lab tests in future years. While this provides stability for labs, it could also mean that Medicare pays more for these services over time than it would under the old rules.

When does this start?

The bill's changes are phased in over several years, with major new data collection rules starting in 2027 and 2028.

New data collection rules deadline

The Secretary of Health and Human Services must establish new rules for data collection periods by December 31, 2026.

National database use begins

Medicare will start using a national claims database for setting rates for common tests for reporting periods beginning on or after January 1, 2028.

New payment reduction cap

The maximum annual payment reduction for a lab test is set to 5% for 2029 and each subsequent year.

End of review limitations

The ban on administrative and judicial review of the payment system ends on January 1, 2029.