Medicare Advantage Integrity Act of 2025
- Sponsor
- Rescom. Hernández, Pablo Jose [D-PR-At Large]
- Committees
- Energy and Commerce Committee (primary)
- Last action
- Nov 12, 2025
Bottom line
The bill aims to increase Medicare Advantage payments in certain underserved regions by setting a minimum geographic adjustment, with a portion of the increased funds earmarked for basic enrollee benefits.
What it actually does
This bill amends the Social Security Act to establish a floor for Medicare Advantage (MA) benchmark rates in regions characterized by low Medicare fee-for-service (FFS) penetration. Specifically, it mandates that the average geographic adjustment used in calculating MA payments shall not be less than 0.70 for any area, starting in 2026. Furthermore, it requires that at least 50 percent of the increase in the blended benchmark amount attributable to this new floor must be directed towards basic benefits for enrollees.
Proponents argue
Supporters argue that this legislation addresses existing disparities in Medicare Advantage payments, particularly in rural or underserved areas where lower fee-for-service penetration often leads to reduced benchmark rates. By establishing a floor, the bill would stabilize and potentially enhance MA plan offerings and benefits in these regions, improving access to care for beneficiaries. The mandate to direct funds towards basic benefits ensures that patients directly benefit from the increased federal investment.
Opponents contend
Critics might contend that artificially raising benchmark rates could lead to increased federal spending without a clear guarantee of improved care quality or efficiency. They may also argue that the 50% requirement for basic benefits is insufficient, or that the criteria for 'low FFS penetration' might not precisely target the areas most in need, potentially resulting in unnecessary subsidies for some plans.
The bill is very concise and can be read and understood quickly, allowing ample time for a thorough evaluation of its core provisions.
Section 2(a), amending Section 1853(n) of the Social Security Act
Establishes a Floor for Medicare Advantage Geographic Adjustment
This provision sets a minimum value for the 'average geographic adjustment' component used when calculating Medicare Advantage benchmark rates. For 2026 and all subsequent years, this adjustment cannot be lower than 0.70 for any given area. This means that regions with historically lower geographic adjustments, often those with fewer Medicare fee-for-service enrollees, will see their benchmark rates increase to at least this established floor.
Supporters argue
Supporters argue this provision corrects an inequity where areas with low FFS penetration (often rural or underserved) receive lower MA benchmarks, making it harder for plans to offer competitive benefits. This floor would stabilize and improve MA offerings in these areas, ensuring more equitable access to care.
Critics contend
Critics might contend that this is an artificial subsidy that could inflate MA payments beyond what is actuarially necessary in some regions, leading to increased federal expenditures without a clear demonstration of improved value or patient outcomes.
Tradeoffs
The tension lies between ensuring equitable MA payments in all regions to support plan viability and managing federal spending, as setting a floor could increase costs regardless of actual service costs in those areas.
Section 2(b), amending Section 1854(a)(6) of the Social Security Act
Mandates Increased Payments Support Basic Benefits
This provision requires that at least 50% of any increase in the blended benchmark amount, specifically the portion attributable to the new geographic adjustment floor, must be directed towards payment for 'basic benefits' as defined under existing law. The intent is to ensure that the additional federal funding directly translates into improved or expanded core health services for Medicare Advantage enrollees, rather than being used for other purposes.
Authorizes the Secretary of Health and Human Services to define the term 'average geographic adjustment' by program instruction or otherwise.
Section 2(a)(2), new paragraph (6), last sentence
Why it matters:This is a common legislative practice to allow administrative agencies the necessary flexibility to implement complex payment formulas and adapt them based on data and evolving market conditions, rather than codifying every technical detail in statute.
Case for: Proponents argue that granting the Secretary this flexibility allows for a more responsive and data-driven approach to defining the adjustment, ensuring the floor is applied effectively and can be updated without requiring further legislative action.
Case against: Critics might argue that this grants too much power to the Secretary, potentially allowing for definitions that could be manipulated or that deviate from congressional intent without direct legislative oversight, leading to uncertainty or unintended consequences.
Estimated impact: The specific definition chosen by the Secretary will significantly influence which areas qualify for the payment floor and the precise magnitude of the payment increase, potentially impacting billions in federal spending.