H.R. 10369
Net Effective Cost Transparency and Prescription Drug Affordability Act of 2026
Sponsor: Ryan Mackenzie
4 cosponsors
Official summary
No official summary yet.
Text of the bill
(a) MA–PD compliance. Section 1857(f)(3)(G) of the Social Security Act (42 U.S.C. 1395w–27(f)(3)(G)) is amended by inserting and section 1860D–12(i) before the period at the end.
(b) Quality rating system for MA–PD plans. Section 1853(o) of the Social Security Act (42 U.S.C. 1395w–23(o)) is amended—
(1) in paragraph (4)(A), by inserting and, beginning January 1, 2028, with respect to an MA–PD plan, incorporating the pharmacy benefit management services performance measure described in paragraph (8) before the period at the end; and
(2) by adding at the end the following new paragraph:
(8) Prescription drug cost performance measure
(A) In general. For purposes of paragraph (4), the Secretary shall establish a performance measure for MA–PD plans for purposes of evaluating prescription drug cost variations.
(B) Measurement criteria. The performance measure established under subparagraph (A) shall evaluate—
(i) the percentage variation between the projected and actual net effective cost (as defined in section 1860D–12(i)(5)) for a year;
(ii) the timeliness and adequacy of any corrective action plans submitted in connection with such a variation (as required under section 1860D–12(j)(2)(C)(i)(II)(bb));
(iii) the extent to which implementing such corrective actions successfully reduced such variations in subsequent quarters;
(iv) the frequency and magnitude of beneficiary cost-sharing increases attributable to such a variation or a formulary change; and
(v) the plan’s compliance with the reconciliation and transparency reporting requirements under section 1860D–12(j).
(C) Rating scale. The Secretary shall establish a 5-star rating scale for the performance measure under this paragraph, where—
(i) 5 stars indicates actual costs within 2 percent of bid projections with no required corrective actions;
(ii) 4 stars indicates actual costs within 5 percent of bid projections with timely and effective corrective actions;
(iii) 3 stars indicates actual costs within 10 percent of bid projections with adequate corrective actions;
(iv) 2 stars indicates actual costs exceeding 10 percent of bid projections or inadequate corrective actions; and
(v) 1 star indicates actual costs exceeding 15 percent of bid projections, failure to submit corrective action plans, or repeated noncompliance.
(D) Integration with overall star ratings
(i) Weighting. The performance measure established under this paragraph shall be weighted at not less than the median weight of all other measures used in calculating the overall star rating under this subsection.
(ii) Bonus payment impact. Performance on this measure shall be fully integrated into the overall star ratings calculation for purposes of quality bonus payments under paragraph (4).
(E) Public reporting. The Secretary shall publicly report each MA–PD plan’s performance on this measure as part of the annual star ratings release under paragraph (3), including—
(i) specific percentage variation between projected and actual net effective costs;
(ii) corrective action outcomes; and
(iii) comparison to national and regional benchmarks.
(F) Beneficiary notification
(i) Low performance notification. MA–PD plans receiving ratings of 2 stars or below on the measure established under this paragraph shall notify enrollees of their performance and provide information on alternative plan options during the annual enrollment period.
(ii) Notification format. The Secretary shall establish standardized formats for beneficiary notifications that clearly explain the implications of low ratings on such measure, including enrollee costs for premiums, deductibles, cost sharing, and overall taxpayer burden.
(G) Implementation timeline
(i) Initial measurement. The Secretary shall begin collecting data for the performance measure established under this paragraph beginning with the first plan year beginning after the date that is 1 year after the date of enactment of the Net Effective Cost Transparency and Prescription Drug Affordability Act of 2026.
(ii) First ratings. The Secretary shall publish the first star ratings under this paragraph not later than the second plan year following the initial data collection.
(iii) Bonus payment integration. Performance on this measure shall affect quality bonus payments beginning with the third plan year following initial data collection.
(H) Application to standalone part D plans. The Secretary shall establish a comparable performance measurement and public reporting system for prescription drug plans under part D, using the same measurement criteria and rating scale established under this paragraph.