I 
119TH CONGRESS 
1ST SESSION H. R. 3467 
To amend title XVIII to reform the Medicare Advantage program. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 15, 2025 
Mr. SCHWEIKERT introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on En-
ergy and Commerce, for a period to be subsequently determined by the 
Speaker, in each case for consideration of such provisions as fall within 
the jurisdiction of the committee concerned 
A BILL 
To amend title XVIII to reform the Medicare Advantage 
program. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. REFORMING MEDICARE ADVANTAGE. 
(a) REQUIREMENT
TO
USE
CAPITATED
PAY-
MENTS.—Section 1852 of the Social Security Act (42 
U.S.C. 1395w–22) is amended by adding at the end the 
following new subsection: 
‘‘(o) REQUIREMENT
TO
USE
CAPITATED
PAY-
MENTS.— 
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‘‘(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: 
‘‘(A) An MA plan that was made available 
in such area during the preceding plan year, ex-
cept that the only individuals eligible to enroll 
in such plan shall be individuals who were en-
rolled in such plan during such preceding plan 
year. 
‘‘(B) A specialized MA plan for special 
needs individuals.’’. 
(b) PAYMENT MODIFICATIONS.— 
(1) REDUCING
BLENDED
BENCHMARK.—Sec-
tion 1853(j)(1)(A) of the Social Security Act (42 
U.S.C. 1395w–23(j)(1)(A)) is amended by inserting 
‘‘(or, beginning with 2028, 75 percent of 1⁄12 of such 
blended benchmark amount)’’ after ‘‘for the area for 
the year)’’. 
(2) RISK ADJUSTMENT MODIFICATIONS.—Sec-
tion 1853(a)(3) of the Social Security Act (42 
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U.S.C. 1395w–23(a)(3)) is amended by adding at 
the end the following new subparagraph: 
‘‘(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 ob-
tained 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
IN-
CREASES.—Section 1853(o) of the Social Security 
Act (42 U.S.C. 1395w–23(o)) is amended by adding 
at the end the following new paragraph: 
‘‘(8) NONAPPLICATION OF INCREASE TO QUALI-
FIED MA PLANS.—No increase to the applicable per-
centage under subsection (n)(2)(B) shall be made 
under this subsection for a plan for plan years be-
ginning on or after January 1, 2028.’’. 
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(4) STOP-LOSS
PAYMENTS.—Section 1853 of 
the Social Security Act (42 U.S.C. 1395w–23) is 
amended by adding at the end the following new 
subsection: 
‘‘(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 man-
ner.’’. 
(c) AUTOMATIC ENROLLMENT; PLAN CHANGE LIMI-
TATIONS.—Part C of title XVIII of the Social Security 
Act (42 U.S.C. 1395w–21 et seq.) is amended by adding 
at the end the following new section: 
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‘‘SEC. 1859A. AUTOMATIC ENROLLMENT; PLAN CHANGE 
LIMITATIONS. 
‘‘(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 enti-
tled 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 quali-
fied MA plan under this subsection with an oppor-
tunity to decline such enrollment. 
‘‘(b) MANDATORY CONTINUOUS ENROLLMENT.— 
‘‘(1) IN GENERAL.—Notwithstanding any other 
provision of this title, except as provided in para-
graph (2), in the case of an individual who enrolls 
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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— 
‘‘(A) enroll in any other MA plan under 
this part; or 
‘‘(B) 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 speci-
fied by the Secretary)).’’. 
(d) REQUIRED INCLUSION OF HOSPICE CARE.—Sec-
tion 1852 of the Social Security Act (42 U.S.C. 1395w– 
22) is amended— 
(1) in subsection (a)(1)(B)(i), by inserting ‘‘(ex-
cept in the case of an MA plan offered in a plan 
year beginning on or after January 1, 2028)’’ after 
‘‘hospice care’’; and 
(2) in subsection (m)(6), by inserting ‘‘(except 
in the case of an MA plan offered in a plan year be-
ginning on or after January 1, 2028)’’ after ‘‘hos-
pice care’’. 
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(e) STARK EXCEPTION.—Section 1877(b) of the So-
cial Security Act (42 U.S.C. 1395nn(b)) is amended by 
adding at the end the following new paragraph: 
‘‘(6) EXCEPTION FOR CERTAIN SERVICES FUR-
NISHED
UNDER
MA
PLANS.—In the case of des-
ignated health services consisting of durable medical 
equipment or covered part D drugs, if such services 
are furnished under an MA plan.’’. 
Æ 
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