H.R. 3467 — To amend title XVIII to reform the Medicare Advantage program.

This section reforms Medicare Advantage (MA) plans, effective generally for plan years beginning on or after January 1, 2028, by (1) requiring capitated payments for plan benefits (except for grandfathered plans open only to prior-year enrollees and specialized MA plans for special needs individuals); (2) modifying payments by reducing the blended benchmark amount used for monthly payments to 75% of 1/12 of such amount (from 100%), limiting risk adjustment for health status to diagnoses from face-to-face or telehealth visits using a two-year lookback period (excluding chart reviews and stand-alone health risk assessments), eliminating quality-based benchmark increases, and authorizing budget-neutral stop-loss payments based on audited encounter data for plans with significantly higher expenditures; (3) establishing automatic enrollment of Part A-entitled, Part B-enrolled individuals into the lowest-premium available MA plan (with opt-out rights) and a three-year lock-in prohibiting switches to other MA plans or traditional fee-for-service Medicare (except for hardship events such as serious illness); (4) requiring MA plans to furnish hospice care (previously carved out and paid on a fee-for-service basis under traditional Medicare); and (5) adding a Stark Law exception for physician referrals of durable medical equipment or covered Part D drugs furnished under an MA plan. (As background, the Stark Law generally prohibits physicians with a financial relationship from referring Medicare patients for designated health services, including durable medical equipment and prescription drugs.)