A preventive-participation framework designed to coexist with the Affordable Care Act — rewarding early engagement, protecting guaranteed benefits, and aligning federal spending with better health outcomes.
© 2026 Edward Reese. All rights reserved. This document and its contents are proprietary and confidential. No part of this document may be copied, reproduced, distributed, transmitted, published, or reused in any form or by any means — electronic, mechanical, or otherwise — without the prior written consent of the author.
This is a pre-legislative working draft and does not constitute legal advice, an official bill, or a government publication. All sections are subject to legislative counsel review prior to any bill introduction.
A summary of the framework in plain terms. The complete legislative text — all seventeen sections, with revision tags — is available below.
The Act leaves the ACA’s benefit architecture, eligibility rules, and coverage guarantees untouched. It adds an accountability and incentive layer on top of the existing subsidy structure to close the gap between being enrolled and being engaged.
Sections 1–2One qualifying preventive visit a year earns enhanced federal support of up to 120% of the ACA baseline. Chronic non-participation adjusts support downward to no less than 80%. Nobody loses coverage, and no adjustment reaches anyone before the grace period ends.
Section 8Physicians, NPs, and PAs in ACA networks are enrolled automatically and may formally opt out. Maintaining annual patient engagement earns up to a 10% reimbursement premium; each consecutive year without a visit steps the premium down 5% to the same 80% floor. Compliance turns on visit occurrence — never on outcomes.
Sections 5–6The Prevention Participation Reserve Fund is established in the Treasury and financed by a bridge appropriation, differential subsidy savings, and realized outcome savings. It is CMS-administered and sunsets in four years absent reauthorization, with a transition report to Congress 180 days prior.
Section 4AThe National Patient Registry System records only whether a visit occurred, plan status, and exemption flags — no clinical or diagnostic information — across independent medical and dental tracks. Enrollment is administrative; HIPAA compliance is built in.
Section 12Refusing care remains a protected decision, with one consequence-free refusal each year. Telehealth counts where geography, physical, or mental barriers apply; cultural and religious objections carry neither penalty nor reward. Appeals run on a binding 30/60/90-day schedule with ALJ review.
Sections 7, 10, 11, 13The Act takes effect alongside the ACA. Providers in ACA networks are enrolled automatically, with a formal opt-out available to CMS during the grace period.
For one to two years — set by CMS on implementation readiness — registry enrollment completes and no subsidy adjustment or reimbursement reduction may be imposed.
One comprehensive preventive evaluation per calendar year by an MD/DO, NP, or PA. Mental and behavioral health screenings qualify; telehealth qualifies where accommodation applies.
Participation status moves federal support within the 80–120% band, on aligned patient and provider timelines, with appeals, equity audits, and fraud safeguards attached.
The framework applies exclusively to federally subsidized coverage. A future expansion clause lets Congress extend these principles only after fiscal and operational evaluation.
The complete pre-legislative review draft — Congressional Findings and Sections 1 through 15, roughly 6,700 words — with the canvas key marking every original, revised, and new provision.
The United States spends more per capita on healthcare than any other developed nation, yet measurable health outcomes for preventable conditions consistently lag behind comparable economies that spend far less. A significant portion of this expenditure is concentrated in the late-stage treatment of conditions that were clinically detectable and addressable at substantially lower cost at earlier stages. The federal government, as the primary funder of ACA-subsidized coverage through premium tax credits, Medicaid, and CHIP, bears a disproportionate share of these avoidable costs — costs that represent not a failure of medicine, but a failure of engagement.
The findings that follow are grounded in peer-reviewed public health evidence, actuarial analysis of federally subsidized healthcare expenditure patterns, and established constitutional precedent governing conditional federal spending. They are intended to establish the evidentiary and legal foundation for the participation incentive framework created by this Act, to make clear that the incentive structure emerges from demonstrable public health need rather than ideological preference, and to provide a complete record of legislative intent for purposes of regulatory implementation and judicial review.
Congress finds the following:
The legislation is titled the American Healthcare Act (AHA). The naming intentionally avoids partisan framing and signals a national, outcomes-oriented approach to healthcare improvement rather than insurance restructuring. The Act is designed to coexist with the ACA rather than supplant it.
The Affordable Care Act addressed one of American healthcare’s most persistent structural failures: the absence of a coverage floor. It established that enrollment could not be denied based on pre-existing conditions, that a minimum set of benefits must be covered, and that federal subsidies would make that coverage financially accessible to millions who lacked it. These were foundational achievements.
What the ACA did not — and by design could not — address is the gap between enrollment and engagement. Coverage is not the same as care. Millions of Americans who are enrolled in ACA-subsidized plans do not use them for routine preventive services. They remain enrolled but unengaged, reaching the healthcare system primarily at moments of acute need, when intervention is most expensive, outcomes are least favorable, and the opportunity to avert serious illness has already passed.
The purpose of the American Healthcare Act is to close that gap. The AHA does not restructure the ACA’s benefit architecture, alter its eligibility framework, or create new entitlement obligations. It operates as an accountability and incentive layer within the existing ACA subsidy structure, designed to encourage enrolled participants to use the coverage they already have — before conditions that are detectable and manageable become chronic, debilitating, or terminal.
The AHA proceeds from a foundational principle: publicly subsidized healthcare creates mutual obligations. The public funds the access. The participant engages with it. The provider facilitates that engagement. When all three fulfill their role, the system produces better outcomes at lower total cost. This Act is designed to make that principle structural rather than aspirational.
Key objectives include:
The Act explicitly avoids benefit elimination, entitlement restructuring, or universal mandates. It is not a coverage bill. It is an engagement bill — and that distinction is the foundation of everything that follows.
Clear definitions are foundational to the AHA’s legal and operational stability.
The AHA applies exclusively to ACA-subsidized or ACA-funded programs. This includes Marketplace plans, Medicaid, and CHIP. The Act explicitly excludes employer-sponsored insurance, Medicare, VA healthcare, TRICARE, and uninsured individuals.
A future expansion clause allows Congress to extend AHA principles to other systems only after fiscal and operational evaluation.
States participating in Medicaid shall implement the participation incentive framework at no less than the federal baseline established by CMS. States may adopt enhanced incentives or expanded accommodations, provided they do not fall below federal minimums. States may seek waiver authority under Section 1115 of the Social Security Act for implementation modifications, subject to CMS approval.
There is established in the United States Treasury a Prevention Participation Reserve Fund (PPRF) for the purpose of financing the incentive premium structure during the initial implementation period. The PPRF shall be funded through three concurrent mechanisms:
The PPRF shall be administered by CMS and shall sunset not later than four years following the effective date of this Act unless reauthorized. A transition assessment shall be submitted to Congress no later than 180 days before the sunset date.
All licensed physicians (MD/DO), nurse practitioners (NP), and physician assistants (PA) currently participating in ACA-affiliated networks are automatically enrolled in the AHA provider incentive structure upon the effective date of this Act. Providers may formally opt out by submitting written notice to CMS within the grace period. Opt-out elections shall be tracked by CMS and reported annually to Congress. Providers who opt out are not eligible for incentive premiums but are also not subject to reimbursement reductions under this Act.
Following expiration of the grace period, providers receive a structured reimbursement incentive for maintaining annual patient preventive care engagement. A provider receives a reimbursement premium of up to 10% when a patient completes at least one qualifying preventive care visit per calendar year. Each consecutive year without a qualifying visit reduces the provider’s applicable premium by 5%, to a floor of 80% of the ACA baseline. This reduction schedule runs parallel to the patient participation timeline under Section 8 to ensure symmetric accountability.
Compliance is based solely on visit occurrence, not medical outcomes. Provider reimbursement reductions reflect the engagement record for each patient individually and do not aggregate across a provider’s patient panel.
Dental reimbursement is restructured to emphasize thorough evaluation. Sixty percent of reimbursement is base-paid, while forty percent is tied to per-tooth evaluation. Biannual visits qualify providers for incentive premiums identical to the medical structure.
This approach encourages preventive oral health monitoring, highlights missing teeth as a health indicator, and integrates dentistry into broader healthcare accountability without imposing mandates.
Children enrolled in ACA-linked plans receive standardized pediatric vision benefits. Coverage includes one comprehensive eye exam per year and one basic pair of eyeglasses every three years. Lens coverage includes 50% cost sharing and mandatory UV protection. Elective enhancements and cosmetic options are excluded unless medically necessary.
Where the participant is a minor, the participation obligation established under this Act shall be the responsibility of the parent or legal guardian of record on the participant’s ACA enrollment. Participation compliance for minors shall be assessed at the household level and shall not result in an adverse participation status determination against the minor independently.
Patients share responsibility for engagement. Following expiration of the grace period, participation yields enhanced federal subsidy support of up to 120% of the ACA baseline. Chronic non-participation results in a federal subsidy adjustment to no less than 80% of the ACA baseline.
The patient participation assessment timeline is aligned with the provider reimbursement adjustment timeline established under Section 5. Both timelines begin running from the expiration of the grace period. No participation-based subsidy adjustment or reimbursement reduction shall be imposed prior to the expiration of the grace period.
Premium adjustments under this section shall be applied exclusively to the federal subsidy component of the enrollee’s qualified health plan contribution. Adjusted subsidies shall result in a corresponding increase in the enrollee’s required out-of-pocket premium contribution to cover the difference between the adjusted subsidy and the full plan cost.
Illustrative example: Where a covered service carries a total plan-covered cost of $1,000 and the enrollee’s participation status reflects full subsidy (100%), the enrollee’s financial responsibility is limited to the applicable copayment. Where the subsidy has been adjusted to 80% due to chronic non-participation, the enrollee bears an additional out-of-pocket obligation equal to 20% of the covered cost — $200 in this example — in addition to the applicable copayment.
No reduction in covered benefits, essential health benefits, or plan-level coverage structure shall result from participation adjustments under this Act. Coverage is never terminated; only the federal subsidy component is adjusted. All ACA-guaranteed benefits remain available regardless of participation status.
Enrollees shall receive written notice of any subsidy adjustment no less than 60 days prior to the effective date of the change, including a specific statement of the participation requirement necessary to restore full subsidy status.
A participant’s medical participation status and any subsidy adjustment applied under this section shall have no effect on the participant’s dental opt-in status or adult dental subsidy under Section 9. The medical and dental participation tracks are fully independent.
Adult dental participation under this section is voluntary. No enrolled participant is required to opt into the adult dental program. Individuals who do not elect dental opt-in status face no penalty, no adjustment to their medical subsidy, and no change to their NPRS medical participation record.
This Act assumes good faith on the part of all dental opt-in participants. Upon election of dental opt-in status, the 25% adult dental subsidy is available immediately, without a waiting period and without a requirement to first complete a qualifying dental visit prior to initial use. A participant is presumed to be in good standing at the moment of enrollment. No administrative delay, pre-authorization, or prior participation verification shall be imposed as a condition of receiving the dental subsidy in the enrollment year. The intent of this provision is to ensure that the benefit is accessible from day one and that no participant is discouraged from opting in by the prospect of a deferred benefit.
The adult dental subsidy covers 25% of eligible dental costs for dental opt-in participants. This subsidy is available immediately upon opt-in under the good faith enrollment provision above, and is maintained through annual dental participation as defined in this section and tracked through the NPRS dental compliance flag. A dental opt-in participant who completes at least one qualifying in-person dental visit during their enrollment year — including a visit for which the subsidy was used — shall be considered compliant for that calendar year. The participation requirement governs the maintenance of the benefit in subsequent years, not the initial receipt of the benefit.
At minimum, one in-person dental evaluation per calendar year by a licensed dental provider constitutes qualifying dental participation for purposes of maintaining the adult dental subsidy. Telehealth encounters do not qualify as dental participation visits under this section, as dental evaluation requires physical examination. Biannual in-person visits represent the recommended standard and qualify dental providers for incentive premiums under Section 6, but a single annual in-person visit meets the participant participation threshold.
Dental opt-in elections and annual dental visit compliance shall be recorded in the NPRS as a dedicated dental compliance track, fully separate from the medical participation compliance record. A participant’s NPRS dental compliance flag shall reflect one of three states: (a) Not Enrolled — participant has not elected dental opt-in; (b) Compliant — participant is enrolled and has completed a qualifying dental visit in the current calendar year; or (c) Non-Compliant — participant is enrolled but has not completed a qualifying dental visit in the current calendar year. Dental compliance status is assessed independently of medical compliance status at all times.
A dental opt-in participant who does not complete a qualifying annual dental visit shall be assessed as a dental non-participant. Upon a dental non-participation determination, the 25% adult dental subsidy shall be suspended prospectively. No retroactive adjustment shall be made to claims already processed prior to suspension. Participants shall receive written notice of pending dental subsidy suspension no less than 60 days prior to the effective date of the suspension.
A dental opt-in participant whose subsidy has been suspended may reinstate the 25% subsidy at any time by completing a qualifying in-person dental visit. The NPRS dental compliance flag shall be updated to compliant status upon verification of the qualifying visit. The dental subsidy shall be reinstated within 30 days of the compliant status update. There is no waiting period, penalty period, or re-enrollment requirement following reinstatement. The intent of this provision is to encourage re-engagement, not to permanently exclude participants who lapsed.
Dental participation status has no effect on the participant’s medical subsidy under Section 8. Medical participation status has no effect on the participant’s dental subsidy under this section. These are parallel, fully independent participation tracks within NPRS. A participant may be compliant in one track and non-compliant in the other without consequence to the track in which they are compliant.
The general grace period established under Section 10 applies equally to dental opt-in participants. No dental subsidy suspension shall occur during the grace period.
Because adult dental care is not currently designated as an Essential Health Benefit under the ACA and adult dental coverage under Medicaid varies significantly by state, a unified federal adult dental incentive structure above the 25% baseline does not yet exist to model from. The established relationship between oral health and systemic health outcomes — including cardiovascular disease, diabetes management, and infection risk — supports the long-term development of a more robust dental participation incentive layer. CMS shall, within two years of the effective date of this Act, submit to Congress a report evaluating the feasibility of establishing participation incentive tiers above the 25% baseline, modeled on the medical participation framework of Sections 5 and 8.
A grace period of no less than one year and no more than two years from the effective date of this Act shall apply to all participants and providers before any participation-based subsidy adjustment or reimbursement reduction may be imposed. The exact duration shall be established by CMS by regulation, based on NPRS implementation readiness and enrollment completion. This flexibility is intentional: implementation readiness will vary across states, plan types, and provider categories, and the grace period is designed to absorb that variance without penalizing early participants or creating inequitable enforcement timelines. Individuals who newly enroll in ACA-subsidized plans after the effective date shall be enrolled in NPRS at the point of ACA plan enrollment and shall receive a proportional grace period not less than twelve months from their NPRS enrollment date.
Telehealth participation is fully recognized for individuals facing geographic, physical, or mental barriers. Cultural and religious objections are honored without penalty or reward; such individuals remain on their existing ACA plan and are not subject to NPRS participation incentive adjustments. Language access obligations are delegated to regulatory implementation by CMS.
Mental health screenings and behavioral health evaluations conducted by licensed providers and covered under applicable ACA essential health benefit requirements shall qualify as preventive care participation for purposes of this Act. No distinction shall be made between mental health and physical health preventive visits for participation compliance purposes.
Nothing in this Act shall modify the eligibility criteria, enrollment procedures, or coverage protections established under the ACA for individuals in non-standard housing situations, mixed immigration status households, or other circumstances addressed by applicable ACA regulations. Participation evaluation for such individuals shall be administered consistent with guidance issued by CMS in coordination with relevant state agencies.
The right to refuse medical treatment is among the most fundamental expressions of patient autonomy in American medical ethics and law. No provision of this Act shall be construed to require a participant to accept, consent to, or remain engaged with any medical recommendation as a condition of maintaining coverage or receiving benefits. The AHA does not mandate treatment; it incentivizes engagement. Refusal of a recommended course of care is a protected patient decision.
At the same time, the participation framework established by this Act creates a legitimate interest in ensuring that refusals are informed, voluntary, and not the product of provider coercion, systemic barrier, or passive disengagement of the kind the Act’s accessibility provisions are designed to address. The refusal process established under this section balances these interests by providing a structured, deliberate pathway for refusal without punitive consequences for participants who exercise it in good faith.
One refusal per calendar year is permitted without consequence and does not trigger the documentation requirements, second-opinion process, or any effect on participation status described below. This grace provision recognizes that refusals are sometimes temporary, fear-driven, or situationally rational, and that a system which aggressively penalizes first refusals creates adversarial provider-patient dynamics inconsistent with the purpose of this Act.
When a participant declines a provider’s recommendation for care that constitutes or is associated with qualifying preventive participation, the provider shall document the refusal in writing and provide the participant with written notification of: (a) the care being declined and the provider’s clinical basis for the recommendation; (b) the participant’s right to seek an independent second opinion at no additional cost; and (c) the potential effect on participation status if the refusal is not affirmed through the second-opinion process.
Following documentation of a refusal beyond the annual grace, the participant is entitled to an independent second-opinion review. The second opinion shall be conducted by a licensed provider in the same or a directly related specialty who is not affiliated with the participant’s primary provider or plan administrator. The participant shall have no less than 30 days to complete the second-opinion consultation.
A participant whose refusal is affirmed by the independent reviewer as clinically reasonable, consistent with the patient’s informed personal values, or otherwise defensible shall not experience any adverse participation status determination as a result of the refusal. The second-opinion process is not a mechanism for overriding patient judgment; it is a mechanism for ensuring that patient judgment is fully informed.
Where the second-opinion review produces a finding that materially contradicts the original provider’s recommendation — whether with respect to diagnosis, indicated treatment, or the clinical necessity of the recommended preventive care — a third-opinion consultation shall be available to the participant at no additional cost.
A material contradiction exists where: (a) the two providers reach different diagnostic conclusions regarding the same presenting condition or risk factor; (b) the two providers recommend materially different courses of care; or (c) one provider recommends care that the other expressly advises against. Differences in approach, emphasis, or sequencing that do not reflect an underlying disagreement about diagnosis or clinical necessity do not constitute a material contradiction for purposes of this subsection.
The third-opinion provider shall be selected through a CMS-administered independent provider registry and shall have no affiliation with either the original provider or the second-opinion provider. The participant shall have no less than 30 days from the date of the second-opinion determination to initiate the third-opinion consultation. No adverse participation status determination shall be imposed during the pendency of the third-opinion consultation. The third-opinion determination shall serve as the final clinical record for purposes of participation status assessment under this section.
Where a participant follows the clinical recommendation of any one of the three consulting providers, no adverse participation status determination shall result from that choice. A patient caught between genuinely competing medical recommendations has exercised neither negligence nor disengagement — they have navigated a clinical dispute that licensed professionals themselves could not resolve. This Act does not adjudicate competing medical opinions; it requires engagement with the healthcare system, and engagement with three independent providers constitutes engagement in full.
Where all three opinions are in material conflict — a circumstance that is medically rare but possible — the participant shall be held harmless with respect to participation status for the care in question. Genuine disagreement among three independent licensed providers regarding the same condition or recommended care constitutes a clinical ambiguity that the participation framework is neither designed nor equipped to resolve, and for which no administrative consequence shall attach to the participant.
If the second-opinion review upholds the original recommendation and the participant continues to decline, the participant may appeal to CMS within 60 days. The appeal shall be reviewed by an independent clinical panel and shall consider whether the participant’s refusal was informed, voluntary, and free of coercive pressure from any party. A participant who prevails on appeal shall be restored to compliant participation status for the period under review.
A participant whose refusal is neither affirmed by the second-opinion review nor upheld on appeal shall be assessed as non-compliant with respect to the specific care that was declined. This assessment applies only to the participation compliance record for the current calendar year; it does not eliminate, reduce, or restructure any ACA-guaranteed benefit. The participant may restore compliant status in a subsequent calendar year by completing a qualifying preventive care visit, regardless of the prior refusal determination. Non-participant status under this section is not equivalent to chronic non-participation as defined in Section 3 and does not carry the same subsidy adjustment consequences unless chronic non-participation thresholds are separately met.
Providers shall not initiate, encourage, facilitate, or document refusals as a mechanism for managing patient caseloads, reducing visit complexity, or artificially maintaining participation compliance records. Providers found upon audit or investigation to have: (a) documented refusals that did not occur; (b) pressured participants into declining care to avoid administrative obligations; (c) manipulated refusal documentation to affect NPRS compliance records; or (d) used the refusal process to discriminate against or constructively disenroll difficult-to-serve participants, shall be subject to mandatory audit, referral to applicable state professional licensing boards, and removal from AHA provider incentive participation. Civil and criminal liability under existing law is not precluded by the administrative remedies available under this section.
The NPRS tracks participation status without collecting medical data. The system is designed to prevent gaming while preserving privacy and HIPAA compliance.
NPRS enrollment for individuals currently enrolled in ACA-subsidized plans shall be completed during the grace period established under Section 10. No separate application or action is required of the participant; enrollment is executed administratively by CMS. Individuals who enroll in ACA-subsidized plans after the effective date of this Act shall be enrolled in NPRS at the point of ACA plan enrollment. NPRS enrollment is a condition of eligibility for incentive premiums under this Act; no participation-based incentive premium or penalty shall apply to any individual prior to NPRS enrollment.
The NPRS is a participation ledger only, organized into two fully independent compliance tracks:
Medical Compliance Track: Records identity basics, plan participation status, medical visit compliance markers (occurred / not occurred per calendar year), and exemption flags (telehealth eligible, cultural or religious exemption, grace period status).
Dental Compliance Track: Records dental opt-in election status and annual dental visit compliance markers (compliant / non-compliant / not enrolled) for dental opt-in participants only. The dental compliance track is activated only upon a participant’s election of dental opt-in status under Section 9 and is inactive for participants who have not elected dental opt-in.
These two tracks are stored, assessed, and reported independently within NPRS. A compliance determination in one track has no effect on the other track. No aggregation, cross-reference, or combined scoring of the two tracks is permitted for the purpose of participation status determination or subsidy adjustment. CMS system architecture shall enforce this separation at the data level, and no regulatory guidance or implementation rule may override the independence of the two tracks.
The NPRS does not store diagnoses, clinical notes, medications, procedures, mental health history, or any other clinical or medical information. No data element stored in either compliance track shall be derivable into clinical information by inference, combination, or analysis.
The NPRS shall be designed, maintained, and operated in compliance with applicable federal cybersecurity standards, including NIST Special Publication 800-53 and FedRAMP authorization requirements. CMS shall designate a system security officer responsible for annual security assessments and breach notification protocols consistent with federal PII protection standards. No medical or clinical information shall be stored, transmitted, or derived from NPRS data. The explicit statutory prohibition on clinical data storage is the primary legal and security boundary of the system. No regulatory guidance or CMS implementation rule may expand NPRS data collection beyond the participation ledger scope defined in this section.
CMS oversees implementation, appeals, and audits. Annual equity assessments evaluate impact on rural, disabled, and underserved populations. Providers serving high-need communities may receive additional incentives of up to 5% above the standard premium ceiling.
Appeals of participation status determinations, subsidy adjustments, or exemption denials shall be processed according to the following schedule:
Failure by CMS or the administering state agency to meet these timelines shall result in automatic continuation of the enrollee’s prior participation status and subsidy level until a determination is issued. Enrollees may request review by an HHS Administrative Law Judge where a final determination is disputed.
CMS shall monitor primary care access capacity as a component of its annual equity audit and shall report to Congress on any capacity constraints identified that may materially limit participant access to qualifying preventive care services.
The AHA is designed with the understanding that any initial demand increase from newly engaged preventive care participants will be temporary and self-correcting. Qualifying preventive visits — particularly annual wellness evaluations conducted by nurse practitioners and physician assistants in addition to physicians — are among the least burdensome clinical encounter types. The downstream effect of sustained preventive engagement is expected to free provider capacity at a rate that exceeds the initial demand increase within the program’s review cycle. The inclusion of nurse practitioners and physician assistants as qualifying providers directly expands the workforce available to absorb preventive visit demand without increasing physician load.
The provisions of this Act shall be subject to comprehensive programmatic review and reauthorization on the same schedule established for review of the programs authorized under the Affordable Care Act, offset by twelve months to allow for collection of sufficient implementation data. CMS shall submit a report to Congress no later than 90 days prior to the reauthorization date detailing:
The integrity of the participation framework established by this Act depends on the accuracy of the records held in the NPRS and the authenticity of compliance claims submitted by participants and providers. Fraudulent manipulation of the participation system harms the Prevention Participation Reserve Fund established under Section 4A, distorts the equity monitoring required under Section 13, and erodes the public accountability rationale on which the incentive structure is premised.
This section addresses program integrity through two parallel tracks: participant fraud and provider fraud. These are treated separately because they arise from different motivations, involve different actors, and require different detection and response mechanisms.
Participant fraud includes, without limitation: (a) claiming to have completed a qualifying preventive care visit that did not occur; (b) misrepresenting exemption status, including telehealth eligibility, cultural or religious objection status, or grace period status; (c) submitting or facilitating the submission of falsified records to the NPRS; (d) using another participant’s identity or enrollment information to obtain incentive premiums; and (e) coordinating with a provider to generate false compliance documentation.
Provider fraud includes, without limitation: (a) submitting or authorizing NPRS compliance markers for visits that did not occur or did not constitute qualifying preventive care; (b) issuing false exemption certifications for participants who do not meet applicable criteria; (c) billing for dental per-tooth evaluation services not rendered in order to qualify for dental provider incentive premiums under Section 6; (d) manipulating visit records to maintain or enhance reimbursement premiums under Section 5 or Section 6; and (e) documenting false refusals of care under Section 11 for the purpose of affecting participation status determinations.
CMS shall establish a program integrity unit within the NPRS administration responsible for: (a) conducting routine anomaly detection across NPRS compliance records, including cross-referencing participation markers against actual claims data submitted to ACA-affiliated plans; (b) initiating investigations upon identification of anomalous patterns, participant or provider complaints, or referrals from state Medicaid agencies or plan administrators; (c) providing written notice to any participant or provider under investigation, including a description of the alleged violation and the evidence supporting the investigation; (d) affording the subject of investigation no less than 30 days to submit a written response prior to any penalty determination; and (e) issuing written determinations that include findings, evidence relied upon, and the specific penalty imposed. No penalty established under this section shall be imposed without prior written notice and an opportunity to respond.
Fraudulent conduct under this section that involves misrepresentation to a federally subsidized program may also constitute a violation of the False Claims Act (31 U.S.C. §§ 3729–3733) and may expose the responsible party to civil penalties, treble damages, and qui tam actions under that statute. The administrative penalties established under this section do not constitute the exclusive remedy for program fraud and do not preclude civil or criminal prosecution under any applicable federal or state law.
No participant, provider, employee, contractor, or covered entity shall be subject to retaliation, adverse action, loss of benefits, or discriminatory treatment for reporting in good faith a suspected violation of this section to CMS, a state Medicaid agency, or any other appropriate federal or state oversight authority. CMS shall establish a confidential fraud reporting mechanism integrated with existing federal healthcare fraud reporting infrastructure, and shall publish the reporting mechanism alongside participant-facing materials distributed under this Act.
CMS shall conduct annual program integrity audits of a statistically representative sample of NPRS compliance records and shall report findings to Congress as part of the annual oversight report required under Section 13. Audit findings that identify systemic vulnerabilities in the NPRS compliance tracking architecture shall be addressed within 180 days of identification. Providers with anomalous participation compliance rates — including rates that are statistically improbable given practice size, patient population, or geographic context — shall be flagged for priority audit review.
If any provision of this Act, or the application of any provision to any person or circumstance, is held to be unconstitutional or otherwise invalid, the remainder of this Act and the application of its provisions to any other person or circumstance shall not be affected. The remaining provisions shall be construed to give maximum effect to the purposes of this Act.
| # | Item | Resolution |
|---|---|---|
| 1 | NP/PA as qualifying preventive care providers | Sections 3 and 5 |
| 2 | Provider vs. patient timeline alignment | Both run from grace period expiration; Sections 5 and 8 |
| 3 | NPRS enrollment timing | Bill effective date with grace period; new enrollees at ACA enrollment; Section 12 |
| 4 | Dependent minor guardian responsibility | Section 7 |
| 5 | Provider enrollment opt-out model | Automatic with formal opt-out; Section 5 |
| 6 | Adult dental current law status | Not an ACA EHB; no existing federal incentive model; dental held harmless; CMS study directed |
| 7 | NPRS dual-track architecture | Medical and dental tracks independent at data level; Section 12 |
| 8 | Adult dental as earned benefit | 25% earned by annual in-person visit; good faith enrollment; suspends on non-participation; reinstates on re-engagement; fully independent from medical track; Section 9 |
| 9 | Grace period flexibility | 1-2 year CMS-set range with rationale in statute; Section 10 |
| A | Telehealth exclusion for dental | In-person only for dental participation; Section 9 |
| B | Future dental incentive pathway | CMS 2-year study directive; Section 9 |
| C | Good faith enrollment — immediate dental benefit availability | Benefit available on day of opt-in; no waiting period; first-year visit counts as compliance; Section 9 |
© 2026 Edward Reese. All rights reserved. This document and its contents are proprietary and confidential. No part of this document may be copied, reproduced, distributed, transmitted, published, or reused in any form or by any means — electronic, mechanical, or otherwise — without the prior written consent of the author.
This is a pre-legislative working draft and does not constitute legal advice, an official bill, or a government publication. All sections are subject to legislative counsel review prior to any bill introduction.
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