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The bill aims to reduce Medicare Advantage overpayments and lower premiums for some beneficiaries while expanding hospice coverage, but it also locks many enrollees into plans for up to three years and makes payment and referral rule changes that risk reduced access, narrower benefits, conflicts of interest, and implementation complexity.
Medicare beneficiaries with low premiums will be automatically enrolled into the lowest‑premium Medicare Advantage (MA) plan, lowering their monthly out‑of‑pocket premium costs if they remain enrolled.
Medicare Advantage contracts will be required to include hospice care, ensuring hospice services are covered for MA enrollees.
Limiting risk adjustment to diagnoses from face‑to‑face or telehealth claims with a 2‑year lookback is intended to reduce upcoding and lower improper payments to MA plans, supporting program integrity.
Medicare beneficiaries face automatic enrollment combined with a 3‑year lock‑in that can trap them in plans with worse networks, benefits, or drug coverage and limit access to traditional Medicare or preferred providers — particularly harming patients with complex or changing care needs.
Restricting risk adjustment to claim‑based diagnoses and eliminating chart review/HRA sources risks understating beneficiaries' true health needs, which can reduce payments to plans that serve sicker patients and lead to narrower benefits or reduced access.
A capitated‑only payment requirement may reduce provider flexibility and incentivize narrower networks or limits on services as providers try to control costs.
Based on analysis of 2 sections of legislative text.
Overhauls Medicare Advantage: shifts most payments to capitation, narrows risk-adjustment diagnoses, auto-enrolls beneficiaries into the lowest-premium MA plan with opt-out and a 3-year lock-in, and adds hospice/limited anti-kickback changes.
Introduced May 15, 2025 by David Schweikert · Last progress May 15, 2025
Makes major changes to how Medicare Advantage (MA) plans are paid, how beneficiaries enroll, and what MA plans must cover. It requires most MA benefits to be paid on a capitated basis, narrows the kinds of diagnoses that count for risk-adjustment, creates mandatory automatic enrollment into the lowest-premium MA plan (with an opt-out) and a three-year lock-in for new enrollees, adds a statutory requirement that MA contracts cover hospice, and adds a narrow exception for certain durable medical equipment and Part D drugs furnished through MA. Most of the changes take effect for plan years beginning on or after January 1, 2028. The bill shifts payment and enrollment rules, directs CMS to use encounter data for limited stop-loss payments (budget-neutral), and restricts some coding methods (no chart-review or stand-alone HRAs) used to set plan payments.