H.R. 3467

119th CONGRESS 1st Session

To amend title XVIII to reform the Medicare Advantage program.

IN THE HOUSE OF REPRESENTATIVES · May 15, 2025 · Sponsor: Mr. Schweikert

H.R. 3467
- SEC. 1. Reforming Medicare Advantage

SEC. 1. Reforming Medicare Advantage

(a) Requirement To use capitated payments
- Section 1852 of the Social Security Act () is amended by adding at the end the following new subsection: 42 U.S.C. 1395w–22
  - (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:
        
        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.
        
        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 () is amended by inserting after . 42 U.S.C. 1395w–23(j)(1)(A)
- (2) Risk adjustment modifications
  - Section 1853(a)(3) of the Social Security Act () is amended by adding at the end the following new subparagraph: 42 U.S.C. 1395w–23(a)(3)
    - (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 () is amended by adding at the end the following new paragraph: 42 U.S.C. 1395w–23(o)
    - (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 () is amended by adding at the end the following new subsection: 42 U.S.C. 1395w–23
    - (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 () is amended by adding at the end the following new section: 42 U.S.C. 1395w–21 et seq.
  - (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—
        
        enroll in any other MA plan under this part; or
        
        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 () is amended— 42 U.S.C. 1395w–22
  - in subsection (a)(1)(B)(i), by inserting after ; and
  - in subsection (m)(6), by inserting after .
(e) Stark exception
- Section 1877(b) of the Social Security Act () is amended by adding at the end the following new paragraph: 42 U.S.C. 1395nn(b)
  - (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.

H.R. 3467

Table of contents

SEC. 1. Reforming Medicare Advantage