To amend title XVIII to reform the Medicare Advantage program.
HB3467 would substantially restructure Medicare Advantage beginning in 2028. The bill requires MA plans to use capitated payments for covered benefits, with limited exceptions for certain existing plans and special needs plans. It also changes how plans are paid by reducing the blended benchmark, tightening risk adjustment rules so they rely only on diagnoses from face-to-face or telehealth claims over a two-year lookback period, and eliminating certain quality-based benchmark increases. In addition, the Secretary of Health and Human Services could create budget-neutral stop-loss payments for plans with unusually high expenditures, based on auditable encounter data.
The bill also changes enrollment and benefit rules. It would automatically enroll Medicare beneficiaries who have Part A and Part B into the lowest-premium MA plan available unless they opt out, and it would impose a three-year lock-in period that limits switching to another MA plan or returning to traditional fee-for-service Medicare, except for hardship events. The bill further requires MA plans offered in 2028 and later to include hospice care, and it creates a Stark Law exception for certain durable medical equipment and Part D drugs furnished under MA plans.
If enacted, the bill would amend multiple provisions of Title XVIII of the Social Security Act governing Medicare Advantage, including payment methodology, risk adjustment, quality bonus treatment, hospice coverage, enrollment rules, and physician self-referral restrictions. It would shift MA toward a more strictly capitated model, constrain plan switching, and expand mandatory enrollment mechanisms, while also altering how plans are compensated and how certain services are treated under federal fraud-and-abuse law. The changes would directly affect Medicare Advantage organizations, Medicare beneficiaries, CMS administration, and providers furnishing services through MA plans.
No committee transcripts or recorded votes were provided, so there is no direct evidence of legislative debate or vote-based sentiment in the available record. Based on the bill text alone, the measure appears reform-oriented and prescriptive, suggesting a strong policy intent to standardize Medicare Advantage financing and enrollment. The overall tone of the proposal is structural and regulatory rather than incremental.
The most likely points of contention are the automatic enrollment provision and the three-year enrollment lock-in, which could be viewed as limiting beneficiary choice and the ability to return to traditional Medicare. The payment reforms, especially reduced benchmarks, tighter risk adjustment, and removal of some quality-based increases, may draw opposition from Medicare Advantage insurers because they could lower plan revenues or change incentives. By contrast, supporters may argue the bill reduces gaming, improves payment accuracy, and increases predictability. The hospice requirement and Stark exception may also raise implementation and provider-policy questions, but the main controversy is likely to center on beneficiary freedom of choice versus program standardization and cost control.