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The bill aims to lower Medicare Advantage premiums and stabilize plans through auto-enrollment and payment-rule changes, but does so by locking beneficiaries into plans and tightening payment rules in ways that could reduce choice, access, and plan benefits for sicker enrollees.
Medicare beneficiaries could face lower monthly costs because many would be automatically enrolled into the lowest-premium Medicare Advantage (MA) plan available to them.
Some beneficiaries (especially those with serious or chronic conditions) get clearer protections against surprise out-of-network costs because hospice, certain durable medical equipment (DME), and some Part D drug arrangements are explicitly clarified or included under MA plans.
Plans facing unusually high expenditures could receive stop-loss payments calculated from auditable encounter data, which can stabilize plan finances and reduce the risk that plans exit high-cost areas or drop beneficiaries' options.
Medicare beneficiaries who are auto-enrolled into an MA plan cannot switch plans or return to traditional Medicare for three years, substantially reducing patient choice and freedom to change providers.
Tighter risk-adjustment rules (restricting diagnoses to face-to-face/telehealth claims and shortening the lookback) may reduce payments to plans that enroll sicker beneficiaries, risking narrower benefits, reduced provider access, or weaker networks for people with chronic/complex conditions.
Requiring capitated payments for most MA plans and related payment constraints creates incentives for plans to narrow networks or reduce services to manage fixed payments, which could lower access and quality for enrollees.
Based on analysis of 2 sections of legislative text.
Overhauls Medicare Advantage for plan years starting Jan 1, 2028: mandates capitated payment, narrows risk adjustment to face‑to‑face/telehealth claims, creates automatic enrollment into lowest‑premium MA plan (opt‑out), limits switching, and adds hospice.
Introduced May 15, 2025 by David Schweikert · Last progress May 15, 2025
Changes Medicare Advantage rules for plan years beginning January 1, 2028. It requires most Medicare Advantage plans to be paid on a capitated basis, tightens risk adjustment so only diagnoses from face-to-face or telehealth claim encounters (with a two-year lookback) count, and authorizes budget‑neutral stop‑loss payments based on auditable encounter data. The bill also creates automatic enrollment of beneficiaries with Part A and B into the lowest‑premium Medicare Advantage plan (with an opt‑out) and generally bars switching plans or returning to traditional Medicare for three years except for hardship events. Other changes include restrictions on certain quality-based payment increases for 2028 plan years, addition of hospice into MA rules, and a Stark Law exception for certain durable medical equipment and Part D drug services furnished under MA plans. Several exceptions to the capitated payment rule are narrow and limited to prior enrollees or specialized plans for individuals with special needs.