To amend title XVIII to reform the Medicare Advantage program.
Sponsored By: Representative Schweikert
Introduced
Summary
Moves Medicare Advantage toward capitated payments. This bill would require most Medicare Advantage plans to pay benefits on a capitated basis starting January 1, 2028 and would add automatic enrollment into the lowest-premium MA plan with an opt-out and a 3-year continuous enrollment rule.
Show full summary
- Seniors and beneficiaries: Auto-enrollment would place people entitled to Part A and enrolled in Part B into the lowest-premium MA plan by default, and enrollees could opt out. The 3-year continuous enrollment period would generally prevent switching to another MA plan or traditional Medicare for that period except for hardship cases.
- MA plans and insurers: Plans would face a capitated payment mandate with a lower blended benchmark beginning in 2028 and tighter risk adjustment rules that use only diagnoses from face-to-face or telehealth claims over a two-year look-back. The bill also removes future increases to the quality benchmark and creates a stop-loss payment system based on audited encounter data, with adjustments allowed for budget neutrality.
- Providers and hospice care: The bill adds hospice-related exceptions for plans offered in 2028 or later and creates a Stark law exception for durable medical equipment and Part D drugs furnished under MA plans.
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Bill Overview
Analyzed Economic Effects
5 provisions identified: 0 benefits, 2 costs, 3 mixed.
Lower payments to Medicare Advantage plans
Beginning in 2028, risk scores would use only diagnoses from face-to-face or telehealth claim visits from the prior two years. Chart reviews and stand‑alone health risk assessments would not count. Also starting in 2028, the payment math would use 75% of one‑twelfth of the blended benchmark amount. In addition, plans would no longer get increases to the quality‑bonus percentage for plan years on or after January 1, 2028. These changes could lead plans to adjust premiums, extra benefits, or provider networks.
Automatic Medicare Advantage enrollment and 3-year lock
Starting with plan years on or after January 1, 2028, the government would automatically enroll people who have Part A and are in Part B into the lowest-premium Medicare Advantage plan available to them. If two or more plans have the same lowest premium, the Secretary would decide how to assign people among those plans. You could opt out. If you enroll, you could not switch to another Medicare Advantage plan or return to traditional Medicare for 3 years, unless you have a qualifying hardship like a serious illness.
Medicare Advantage capitation with stop-loss
For plan years starting January 1, 2028, Medicare Advantage plans would have to pay for benefits using capitation (a set payment per person). Specialized plans for people with special needs would be exempt, and plans from the prior year could keep limited reenrollment of their existing members. The Secretary could create stop-loss payments for plans that spend much more than expected, using audited encounter data and budget‑neutral rules. These changes could affect provider contracts, networks, and plan design.
Hospice may be outside Medicare Advantage
For plan years beginning on or after January 1, 2028, Medicare Advantage plans would no longer be required to include hospice care. People who need hospice might have to get it outside their Medicare Advantage plan, which could change where they get care or what they pay.
Stark exception for Medicare Advantage drugs and equipment
The bill would add a narrow exception to the physician self‑referral (Stark) rules for durable medical equipment and covered Part D drugs when given under a Medicare Advantage plan. This mainly affects provider contracting and legal compliance and could indirectly influence access.
Sponsors & CoSponsors
Sponsor
Schweikert
AZ • R
Cosponsors
There are no cosponsors for this bill.
Roll Call Votes
No roll call votes available for this bill.
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