[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3467 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 3467
To amend title XVIII to reform the Medicare Advantage program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
May 15, 2025
Mr. Schweikert introduced the following bill; which was referred to the
Committee on Ways and Means, and in addition to the Committee on Energy
and Commerce, for a period to be subsequently determined by the
Speaker, in each case for consideration of such provisions as fall
within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend title XVIII to reform the Medicare Advantage program.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. REFORMING MEDICARE ADVANTAGE.
(a) Requirement To Use Capitated Payments.--Section 1852 of the
Social Security Act (42 U.S.C. 1395w-22) is amended by adding at the
end the following new subsection:
``(o) Requirement To Use Capitated Payments.--
``(1) In general.--Subject to paragraph (2) and section
1853(p), for plan years beginning on or after January 1, 2028,
a Medicare Advantage plan may only pay for benefits furnished
under such plan on a capitated basis.
``(2) Exceptions.--Paragraph (1) shall not apply in the
case of the following MA plans for a plan year:
``(A) An MA plan that was made available in such
area during the preceding plan year, except that the
only individuals eligible to enroll in such plan shall
be individuals who were enrolled in such plan during
such preceding plan year.
``(B) A specialized MA plan for special needs
individuals.''.
(b) Payment Modifications.--
(1) Reducing blended benchmark.--Section 1853(j)(1)(A) of
the Social Security Act (42 U.S.C. 1395w-23(j)(1)(A)) is
amended by inserting ``(or, beginning with 2028, 75 percent of
\1/12\ of such blended benchmark amount)'' after ``for the area
for the year)''.
(2) Risk adjustment modifications.--Section 1853(a)(3) of
the Social Security Act (42 U.S.C. 1395w-23(a)(3)) is amended
by adding at the end the following new subparagraph:
``(E) Risk adjustment requirements for health
status.--Beginning January 1, 2028, risk adjustment for
health status shall be determined--
``(i) using only diagnoses documented on
claims from face-to-face or telehealth visits;
``(ii) without using any diagnoses obtained
for chart reviews or stand-alone health risk
assessments; and
``(iii) using diagnoses from a 2-year
period preceding the year for which such
adjustment is made.''.
(3) Eliminating quality benchmark increases.--Section
1853(o) of the Social Security Act (42 U.S.C. 1395w-23(o)) is
amended by adding at the end the following new paragraph:
``(8) Nonapplication of increase to qualified ma plans.--No
increase to the applicable percentage under subsection
(n)(2)(B) shall be made under this subsection for a plan for
plan years beginning on or after January 1, 2028.''.
(4) Stop-loss payments.--Section 1853 of the Social
Security Act (42 U.S.C. 1395w-23) is amended by adding at the
end the following new subsection:
``(p) Stop-Loss Payments.--
``(1) In general.--For years beginning on or after January
1, 2028, the Secretary may establish stop-loss payment for
Medicare Advantage plans that experience significantly higher
expenditures compared to the risk-adjusted expected
expenditures of such plans.
``(2) Requirements.--Any payment described in paragraph (1)
shall be based on encounter data subject to audit by the
Secretary.
``(3) Adjustments.--The Secretary may make such payment
adjustments under this part as the Secretary determines
necessary to ensure that this paragraph is implemented in a
budget-neutral manner.''.
(c) Automatic Enrollment; Plan Change Limitations.--Part C of title
XVIII of the Social Security Act (42 U.S.C. 1395w-21 et seq.) is
amended by adding at the end the following new section:
``SEC. 1859A. AUTOMATIC ENROLLMENT; PLAN CHANGE LIMITATIONS.
``(a) Automatic Enrollment.--
``(1) In general.--Notwithstanding any other provision of
this title, for plan years beginning on or after January 1,
2028, the Secretary shall provide for the automatic enrollment
of each individual entitled to benefits under part A and
enrolled under part B into the MA plan with the lowest premium
available to such individual.
``(2) Special rule if multiple low-cost plans available.--
In the case that multiple MA plans are available at the lowest
premium applicable under this part for a plan year for an
individual, the Secretary shall provide for the automatic
enrollment of individuals described in paragraph (1) among such
plans in a manner determined appropriate by the Secretary.
``(3) Opt out.--The Secretary shall provide each individual
automatically enrolled into a qualified MA plan under this
subsection with an opportunity to decline such enrollment.
``(b) Mandatory Continuous Enrollment.--
``(1) In general.--Notwithstanding any other provision of
this title, except as provided in paragraph (2), in the case of
an individual who enrolls in an MA plan for a plan year
beginning on or after January 1, 2028, such individual may not,
for the 3-year period beginning on the date such individual so
enrolls in such MA plan--
``(A) enroll in any other MA plan under this part;
or
``(B) elect to receive benefits under this title
through traditional fee-for-service Medicare under part
A or B.
``(2) Exceptions.--Paragraph (1) shall not apply in the
case of an individual who experiences a hardship event (such as
a serious illness (as specified by the Secretary)).''.
(d) Required Inclusion of Hospice Care.--Section 1852 of the Social
Security Act (42 U.S.C. 1395w-22) is amended--
(1) in subsection (a)(1)(B)(i), by inserting ``(except in
the case of an MA plan offered in a plan year beginning on or
after January 1, 2028)'' after ``hospice care''; and
(2) in subsection (m)(6), by inserting ``(except in the
case of an MA plan offered in a plan year beginning on or after
January 1, 2028)'' after ``hospice care''.
(e) Stark Exception.--Section 1877(b) of the Social Security Act
(42 U.S.C. 1395nn(b)) is amended by adding at the end the following new
paragraph:
``(6) Exception for certain services furnished under ma
plans.--In the case of designated health services consisting of
durable medical equipment or covered part D drugs, if such
services are furnished under an MA plan.''.
<all>