To amend title XVIII to reform the Medicare Advantage program.
H.R. 3467 proposes a broad set of reforms to the Medicare Advantage (MA) program under Title XVIII. The core changes, slated to take effect for plan years beginning in 2028 and later, would shift MA plans to entirely capitated payments (fixed per-member payments), tighten how risk is adjusted, limit premium growth tied to quality benchmarks, and introduce automatic enrollment into the lowest-cost MA plan with a 3-year period of continuous enrollment. The bill also lays out new protections (and carve-outs) related to hospice care, and adds a Stark law exemption for certain services furnished through MA plans (notably durable medical equipment and some Part D drugs). Overall, the bill aims to reshape how MA plans are paid, how beneficiaries are enrolled, and how various rules interact with plan design and provider arrangements. Key elements include: requiring capitated payments for MA plans starting in 2028 (with certain grandfathered plans and specialized needs plans exempted); altering payment formulas and risk adjustment to rely on claims data from a 2-year look-back and excluding certain assessment methods; creating automatic enrollment into the lowest-premium MA option (with opt-out) and a 3-year continuous-enrollment rule; introducing an MA stop-loss mechanism to manage high expenditures in a budget-neutral way; expanding hospice-related requirements within MA; and adding a Stark exception for specific services furnished under MA plans.
Key Points
- 1Capitated payment requirement for MA plans starting in plan year 2028, with exemptions for certain plans (e.g., those already available in the area or specialized needs plans).
- 2Payment modifications:
- 3- Reduced blended benchmark component (nationwide change to how the benchmark is calculated starting 2028).
- 4- Risk adjustment overhaul: beginning 2028, risk scores based on diagnoses from claims from face-to-face or telehealth visits, not from chart reviews or standalone health risk assessments, and using a 2-year look-back period.
- 5Stop-loss payments: the Secretary may establish stop-loss payments for MA plans with expenditures significantly higher than their risk-adjusted expectations, with requirements that payments be data-auditable and budget-neutral.
- 6Automatic enrollment and plan-change limitations (starting 2028):
- 7- Automatic enrollment into the MA plan with the lowest premium for individuals entitled to Part A and enrolled in Part B, with an option to opt out.
- 8- If multiple plans share the lowest premium, enrollment is allocated among them as determined by the Secretary.
- 9- After automatic enrollment, individuals are subject to a 3-year continuous enrollment rule, prohibiting switching MA plans or reverting to traditional fee-for-service Medicare, with hardship exceptions.
- 10Hospice care: the bill expands considerations around hospice care within MA, with specific changes to 1852 to reflect hospice coverage in MA plans, including a transitional exception related to MA plans offered in 2028 or later.
- 11Stark exception: adds a new exception to the Stark law for certain services (durable medical equipment and covered Part D drugs) furnished under MA plans, allowing referrals or arrangements that might otherwise be restricted.