To amend title XVIII of the Social Security Act to establish certain requirements with respect to the average monthly cost to provide coverage to an enrollee under Medicare Advantage plans.
- Bill Number
- H.R. 6112
- Origin Chamber
- House
- Congress
- 119th Congress, Session 1
- Policy Area
- Health
- Status
- Introduced
- Latest Action
- 2025-11-18: Referred to the Committee on Ways and Means, and in addition to the Committee on Energy 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.
- Last Updated
- 2025-12-02T09:05:50Z
AI-Generated Summary
Purpose
This bill aims to ensure that Medicare Advantage (MA) plans, which are private health insurance options under Medicare, do not receive payments from the government that exceed the average cost of providing similar coverage through the traditional Medicare program (also known as original Medicare, which includes hospital insurance under Part A and medical insurance under Part B). By tying enrollment eligibility to cost efficiency, the legislation seeks to protect federal spending and promote fair use of public funds for Medicare beneficiaries.
Key Provisions
- Cost Comparison Requirement: Starting one year after the bill's enactment, the Secretary of Health and Human Services (HHS) must compare the average monthly payment made to an MA plan (under section 1853 of the Social Security Act) with the average monthly cost of providing equivalent coverage under original Medicare Parts A and B for the same plan year.
- Enrollment Restrictions: If the average payment to the MA plan exceeds the original Medicare cost, the Secretary cannot allow new enrollments or reenrollments in that specific MA plan for the following plan year.
- Exception for Specialized Plans: The restriction does not apply to specialized MA plans designed for individuals with special needs (such as those with chronic conditions or living in institutions), allowing these plans to continue operating without the cost-based enrollment limit.
Significant Changes to Existing Law
- This amends section 1857(e) of the Social Security Act (42 U.S.C. 1395w-27(e)) by adding a new paragraph (6), introducing a direct cost-efficiency check for MA plans that did not previously exist.
- Previously, MA plans received payments based on benchmarks and risk adjustments, but there was no automatic enrollment prohibition if payments exceeded original Medicare costs; this creates a new enforcement mechanism to curb potential overpayments to private insurers.
Potential Impacts
- On Government Agencies: The Centers for Medicare & Medicaid Services (CMS), part of HHS, would face additional administrative responsibilities to calculate and monitor average costs annually, potentially increasing oversight workload but helping control Medicare expenditures (which total hundreds of billions annually).
- On Citizens: Medicare beneficiaries enrolled in overpaid MA plans might need to switch to other plans or original Medicare, potentially limiting choices but ensuring plans are cost-effective; those in specialized plans would be unaffected, preserving access for vulnerable groups.
- On International Relations: No direct impacts, as this is a domestic health policy focused on U.S. Medicare programs.
- Broader effects could include reduced profits for some MA insurers, possibly leading to fewer plan options in certain areas and influencing how private companies bid for Medicare contracts.
Main Stakeholders Affected
- Medicare Beneficiaries: Primarily older adults and people with disabilities who rely on MA plans for coverage; they may experience changes in plan availability.
- Medicare Advantage Plan Providers: Private insurance companies (e.g., UnitedHealth, Humana) that offer MA plans, facing potential enrollment losses and financial incentives to control costs.
- Federal Government (HHS/CMS): Responsible for implementing the cost comparisons and enforcement, with implications for budget management.
- Taxpayers: Indirectly affected through potential savings on Medicare spending, as overpayments to private plans could be reduced.
- Advocacy Groups and Lawmakers: Sponsors (e.g., Representatives Pocan and others) represent progressive interests focused on curbing privatization in Medicare.
Notable Legal, Constitutional, or Political Implications
- Legal: The bill relies on the Secretary's authority under existing Medicare statutes to regulate plans, but it could face challenges if deemed to infringe on contractual rights of insurers or beneficiaries; it aligns with congressional power to regulate interstate commerce and spending under the Constitution.
- Constitutional: No major issues anticipated, as it modifies an established federal entitlement program without altering core eligibility or due process rights.
- Political: This could intensify debates over the role of private insurers in Medicare, appealing to those favoring traditional Medicare while drawing opposition from the insurance industry and proponents of MA expansion; it may influence future healthcare funding discussions in Congress, especially amid rising Medicare costs projected to exceed $1 trillion annually by 2030.
This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.
Sponsor
Cosponsors (15)
Rep. Carson, André [D-IN-7], Rep. Cohen, Steve [D-TN-9], Rep. DeLauro, Rosa L. [D-CT-3], Rep. Doggett, Lloyd [D-TX-37], Rep. Jayapal, Pramila [D-WA-7], Rep. Khanna, Ro [D-CA-17], Del. Norton, Eleanor Holmes [D-DC-At Large], Rep. Ocasio-Cortez, Alexandria [D-NY-14], Rep. Schakowsky, Janice D. [D-IL-9], Rep. Takano, Mark [D-CA-39], Rep. Thanedar, Shri [D-MI-13], Rep. Tlaib, Rashida [D-MI-12], Rep. Omar, Ilhan [D-MN-5], Rep. Dingell, Debbie [D-MI-6], Rep. Casar, Greg [D-TX-35]
Recent Actions
- 2025-11-18: Referred to the Committee on Ways and Means, and in addition to the Committee on Energy 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.
- 2025-11-18: Referred to the Committee on Ways and Means, and in addition to the Committee on Energy 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.
- 2025-11-18: Introduced in House
- 2025-11-18: Introduced in House
Bill Versions
- To amend title XVIII of the Social Security Act to establish certain requirements with respect to the average monthly cost to provide coverage to an enrollee under Medicare Advantage plans. — issued 2025-11-18 — PDF (3 pages)