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Changes how Medicare Advantage (MA) works starting for plan years on or after January 1, 2028 by requiring MA plans to be paid mostly on a capitated (per-enrollee) basis, tightening how plans are paid and risk-adjusted, and creating automatic enrollment into the lowest-premium MA plan with a limited 3-year lock-in (with an opt-out and hardship exceptions). The bill also requires MA plans to cover hospice, allows the Secretary to set auditable stop-loss payments and budget-neutral adjustments, and creates a narrow exception to the physician self-referral (Stark) rule for certain items when furnished under an MA plan. These changes affect beneficiaries (who may be auto-enrolled and face limited switching), MA insurers (payment and reporting rules change, encounter data audits), providers (hospice inclusion and a new Stark exception), and CMS (new implementation, audit, and payment-authority responsibilities).
The bill could lower premiums and expand hospice coverage for many Medicare beneficiaries while stabilizing MA plan finances, but it also limits beneficiary choice through automatic enrollment/lock‑in and introduces payment and incentive changes that risk reduced access, under‑payment for sicker patients, and potential conflicts of interest.
Medicare beneficiaries could be auto-enrolled into the Medicare Advantage (MA) plan with the lowest premium available to them starting in 2028, which may lower their monthly premiums and simplify plan selection.
Medicare beneficiaries (including patients with serious or terminal illness) would have hospice services covered within MA plans, simplifying and improving access to hospice care for enrollees.
MA plans would receive stop‑loss payments based on auditable encounter data, which helps protect plans from catastrophic losses and maintain plan solvency without increasing overall federal spending.
Medicare beneficiaries placed into MA via automatic enrollment could be stuck for three years and end up in plans with narrow networks or higher out‑of‑pocket costs, substantially reducing their ability to switch to traditional Medicare or better-suited MA options.
Limiting risk‑adjustment to diagnoses from face‑to‑face or telehealth claims with a two‑year lookback risks undercounting complex or under‑documented conditions, reducing payments to plans that serve sicker patients and potentially narrowing provider networks or services.
Requiring capitated payments for most MA plans may reduce plan flexibility to reimburse for complex care, potentially discouraging provider participation in some areas and harming patient access.
Introduced May 15, 2025 by David Schweikert · Last progress May 15, 2025