119-hr3467

[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.''.
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