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
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:
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.