Sponsor
David Schweikert
Representative · R-AZ
Representative · R-AZ
The bill tightens MA payment and enrollment rules to curb overpayments and lower premiums for some beneficiaries, but it does so by locking beneficiaries into plans, changing how health risk is measured and paid for, and introducing provider‑payment and incentive shifts that risk reduced access and increased conflicts of interest.
Medicare beneficiaries with low premiums will be automatically enrolled into the lowest‑premium MA plan, reducing their monthly out‑of‑pocket premium costs if they remain enrolled.
Medicare Advantage enrollees will have hospice services covered because MA contracts are required to include hospice care, improving end‑of‑life coverage.
The bill limits risk‑adjustment to diagnoses from face‑to‑face or telehealth claims with a two‑year lookback, which can reduce upcoding and lower improper payments to MA plans, protecting program integrity and federal spending.
Medicare beneficiaries may be automatically enrolled and then locked into a plan for up to three years, trapping them in plans with worse networks, benefits, or drug coverage and reducing beneficiary choice.
Patients with complex or changing care needs (e.g., chronic conditions) may lose access to traditional Medicare and preferred providers for up to three years due to the lock‑in, harming continuity and quality of care.
Restricting risk adjustment to claim‑based diagnoses and removing chart review/HRA inputs may understate beneficiaries' true health needs, reducing payments to plans that serve sicker patients and potentially narrowing benefits or access.
Based on analysis of 2 sections of legislative text.
Imposes capitated payment rules, tighter risk‑adjustment standards, automatic enrollment into lowest‑premium MA with a 3‑year lock‑in, hospice contract language, and a narrow DME/Part D exception, effective 2028.
Official title: To amend title XVIII to reform the Medicare Advantage program.
Introduced May 15, 2025 by David Schweikert · Last progress May 15, 2025
Makes multiple major changes to Medicare Advantage starting for plan years on/after January 1, 2028. It requires most MA benefits to be paid on a capitated basis, narrows allowable risk-adjustment sources to face-to-face or telehealth claims, authorizes budget‑neutral stop‑loss payments, adds mandatory automatic enrollment into the lowest‑premium MA plan with an opt‑out and a three‑year lock‑in, requires MA contracts to include hospice language, and creates a limited exception for certain DME and Part D drugs furnished under MA plans.