H.R. 4093 — Apples to Apples Comparison Act of 2025

This section amends Section 1874(g) of the Social Security Act to require the Centers for Medicare & Medicaid Services (CMS), beginning in 2025, to publish on its public website in machine-readable files the annual report on Medicare expenditures previously required only in report form, with added breakdowns by county and Metropolitan Statistical Area (MSA) under subparagraph (A) and by each category of individuals specified in new subsection (h)(1) under subparagraph (B); and adds a special rule for the 2025 report and publication to include enrollment information submitted since 2015, broken down by county, MSA, and such categories. It further adds subsection (h) to require CMS, not later than 30 days after the end of each year (beginning with 2025), to publish on its public website in machine-readable files the total and average expenditures under Medicare for items and services furnished to beneficiaries residing in each county and MSA—for specified historical and projected months—broken down by 35 categories of individuals based on part A eligibility, part B enrollment, Medicare Advantage (part C) enrollment (including specialized plans for special needs individuals), prescription drug plan (part D) enrollment, and concurrent enrollment in Federal health care programs (as defined in SSA §1128B(f)), Federal Employees Health Benefits plans, group health plans, or Medicare supplemental policies.

This section directs the Medicare Payment Advisory Commission (MedPAC) to include in its annual reports to Congress, beginning in 2026, a retrospective analysis comparing average Medicare expenditures for individuals enrolled in Medicare Advantage plans under part C to average expenditures for comparable individuals in fee-for-service Medicare under parts A and B who are eligible for but not enrolled in Medicare Advantage. In conducting the analysis, MedPAC must (1) use data from the CMS Chief Actuary and Medicare trust fund Boards of Trustees, among other sources; (2) account for differences in plan value (e.g., out-of-pocket caps, supplemental benefits, integrated part D coverage), demographics, and Hierarchical Condition Category (HCC) risk scores, but not favorable selection in enrollment; and (3) publicly release the data (in replicable, de-identified form), methodology (60 days before submission, with 30 days for comment), and responses to comments. (MedPAC advises Congress on Medicare payment policies; Medicare Advantage plans are capitated private alternatives to traditional fee-for-service Medicare.)

This section requires the Boards of Trustees of the Federal Hospital Insurance Trust Fund and Federal Supplementary Medical Insurance Trust Fund to include, as part of their annual reports beginning in 2026, aggregate and average Medicare expenditures for three categories of individuals: (1) those entitled to benefits under part A only; (2) those enrolled under part B only; and (3) those entitled to benefits under part A, enrolled under part B, and not enrolled in a Medicare Advantage plan under part C (broken down by part A and part B expenditures). The Boards must also disaggregate all public expenditure data, to the extent practicable, by these categories.