Medicare Advantage Integrity Act of 2025
Summary
What This Bill Does
The Medicare Advantage Integrity Act of 2025 amends sections 1853(n) and 1854(a)(6) of the Social Security Act. For 2026 and later years, when CMS calculates adjusted average per capita cost for the base payment amount, the average geographic adjustment may not be less than 0.70 for any area. The Secretary may define the average geographic adjustment by program instruction or another method. The bill also adds a use-of-funds rule: for the increase in blended benchmark amount attributable to the new section 1853(n)(6) floor, Medicare Advantage organizations must direct at least 50 percent toward payment for basic benefits as defined in section 1852(a)(1)(B).
Who Benefits and How
Medicare Advantage organizations in areas below the 0.70 geographic adjustment floor benefit from higher benchmark calculations. Medicare Advantage enrollees in affected areas benefit because at least half of the benchmark increase must support basic benefits. Hospitals, physicians, and other providers serving affected Medicare Advantage markets may benefit if higher benchmark amounts support plan payment for covered basic benefits. CMS benefits from explicit program-instruction authority to define the average geographic adjustment for this floor.
Who Bears the Burden and How
CMS payment staff must revise benchmark calculations, define the average geographic adjustment, and monitor use of the increase. Federal Medicare Advantage financing bears higher costs in areas where the 0.70 floor raises benchmark amounts. Medicare Advantage organizations receiving an increased blended benchmark must direct at least 50 percent of that increase to basic benefits rather than other uses. Plan bid reviewers must distinguish the benchmark increase caused by the new floor from other payment changes.
Key Provisions
- Requires a 0.70 floor for the average geographic adjustment in Medicare Advantage benchmark calculations beginning in 2026.
- Authorizes the Secretary to define the average geographic adjustment by program instruction or another method.
- Requires at least 50 percent of the resulting blended-benchmark increase to support basic benefits.
- Amends Social Security Act sections 1853(n) and 1854(a)(6).
Evidence Chain:
This summary is generated from the full bill text using AI analysis. Expand "Detailed Analysis" below for identified beneficiaries/burden bearers with clause-level evidence links.
At a Glance
What This Bill Does
Changes Medicare Advantage benchmark calculations beginning in 2026 by creating a 0.70 floor for the average geographic adjustment used in adjusted average per capita cost calculations and requiring at least half of any resulting blended-benchmark increase to be directed toward basic benefits.
Key Policy Areas
Medicare Advantage, CMS, Health Care Finance
Primary Purpose
Changes Medicare Advantage benchmark calculations beginning in 2026 by creating a 0.70 floor for the average geographic adjustment used in adjusted average per capita cost calculations and requiring at least half of any resulting blended-benchmark increase to be directed toward basic benefits.
Policy Domains
Substantive provisions
Identified Gains
- Medicare Advantage organizations in low-adjustment areas
- Medicare Advantage enrollees in affected areas
- Health care providers serving Medicare Advantage markets
- CMS payment-policy staff
Identified Costs
- CMS payment staff
- Federal Medicare Advantage financing
- Medicare Advantage organizations receiving benchmark increases
- Plan bid reviewers
Sponsors
Legislative Progress
In CommitteeMr. Hernández (for himself, Ms. Salazar, and Mr. Soto) introduced …
Referred to the Committee on Ways and Means, and in …
Introduced in House
Stakeholder Effects
cui bono?How this legislation distributes effects. Mention counts reflect frequency, not effect magnitude.
Medicare Advantage enrollees who could receive more basic benefits from the increased benchmark amounts, Medicare Advantage organizations receiving higher benchmark payments in affected areas
CMS and federal budget accounts responsible for administering and financing the payment floor
Bill Structure & Actor Mappings
Who is "The Secretary" in each section?
We use a combination of our own taxonomy and classification in addition to large language models to assess meaning and potential beneficiaries. High confidence means strong textual evidence. Always verify with the original bill text.
Learn more about our methodology