Medicare Advantage Integrity Act of 2025
Summary
The Medicare Advantage Integrity Act of 2025 aims to amend Title XVIII of the Social Security Act, focusing on Medicare Advantage benchmark rates. Specifically, it seeks to establish a floor for these rates in regions with low Medicare fee-for-service penetration. This adjustment intends to address disparities in payment levels across different geographic areas.
The bill introduces a minimum average geographic adjustment of 0.70 for calculating per capita costs, starting in 2026. It also mandates that at least 50% of the increased payments resulting from this adjustment be directed towards basic benefits for patients.
This legislation is designed to ensure more equitable distribution of Medicare Advantage funds and improve the quality of care provided to beneficiaries in underserved regions.
Expected Effects
The act will likely increase Medicare Advantage benchmark rates in areas with low fee-for-service penetration. This could lead to higher payments to Medicare Advantage plans operating in those regions.
Furthermore, the requirement that a significant portion of the increased payments be used for basic benefits could improve patient care. It may also incentivize more providers to participate in Medicare Advantage plans in these areas.
However, the overall impact will depend on how the Secretary defines 'average geographic adjustment' and how effectively the payment allocation is monitored.
Potential Benefits
- Increased funding for Medicare Advantage plans in underserved areas.
- Potential for improved access to healthcare services for beneficiaries in those regions.
- Mandated allocation of funds towards basic benefits, enhancing patient care.
- Could incentivize greater provider participation in Medicare Advantage.
- May reduce disparities in healthcare access and quality across different geographic locations.
Most Benefited Areas:
Potential Disadvantages
- Potential for increased costs to the Medicare program overall.
- Risk that funds may not be used efficiently or effectively, despite the allocation requirement.
- Possible challenges in defining and monitoring 'average geographic adjustment'.
- Could create new incentives for gaming the system by Medicare Advantage plans.
- May not fully address the underlying issues contributing to low fee-for-service penetration.
Constitutional Alignment
The Medicare Advantage Integrity Act appears to align with the general welfare clause of the Constitution (Preamble). This clause allows Congress to enact laws that promote the health and well-being of the population.
Congress has the power to regulate Medicare through Article I, Section 8, which grants the power to collect taxes and provide for the general welfare. The act falls under this purview as it amends the Social Security Act, which is a federal program funded by taxes.
However, the specific implementation and potential for unequal application could raise concerns about equal protection under the law, potentially implicating the Fifth Amendment.
Impact Assessment: Things You Care About ⓘ
This action has been evaluated across 19 key areas that matter to you. Scores range from 1 (highly disadvantageous) to 5 (highly beneficial).