H.R. 5269: RESULTS Act

Medicare prices most clinical lab tests using a system built in 2014: labs report what private insurers pay them, and Medicare averages that into its own rate. The bill's sponsors argue the reporting has skewed toward large national labs, producing rates that don't reflect the broader market. H.R. 5269, the RESULTS Act, rebuilds the data source.

Starting with reporting periods on or after January 1, 2028, Medicare would stop relying on lab self-reporting for common tests and instead pull pricing from a national private-claims database run by an independent nonprofit. A test counts as "widely available" — and moves to the database — if more than 100 providers or suppliers were paid for it in the first half of the prior year.

The database has to be enormous. The bill requires at least 50 billion claims from more than 50 private payors and claims administrators, coverage of all 50 states and D.C., version control so only final paid amounts are used, and validation by an entity with no ties to government, insurers, or providers.

Before that, a transition: for reporting periods on or after January 1, 2027, labs would report payment for each test that received a final Medicare payment, and the reporting cycle stretches from every 3 years to every 4. HHS has until December 31, 2026, to write the rules.

There's a backstop. If HHS can't get the contract in place or the database has no usable data for a widely available test, Medicare would hold the prior year's rate and bump it by CPI-U inflation instead of cutting. Tests that aren't widely available and lack data get priced by comparison to a similar test or through a gapfilling process.

The bill also makes Medicare's cut limit permanent. Current law caps annual reductions at 15% through 2028 and then lets the limit lapse; H.R. 5269 replaces that with a 5% cap for 2029 and every year after. It adds public explanations of each rate and the data behind it, and reopens pricing decisions to administrative and court review for determinations on or after January 1, 2029.