Title and establishment (Sec. 2201–2204, 2209):
- Establishes the Medicare Exchange health plan within Title XXII of the Social Security Act.
- The plan would be available in the individual market and the small group market starting plan year 2028, in all rating areas.
- Administrative framework allowing the Secretary of Health and Human Services to contract for administrative functions and to manage the plan.
- The Secretary must promulgate regulations within 180 days of enactment, finalized within 270 days.
Plan eligibility and availability (Sec. 2202):
- Eligibility: individuals must be eligible under the ACA’s 1312 framework and not eligible for traditional Medicare.
- Plan is to be offered through the ACA exchanges (including Small Business Health Options Program).
Plan design and coverage (Sec. 2203):
- Must comply with applicable ACA/PHSA requirements for qualified health plans.
- Provides at least a silver and gold level, with the possibility of up to two additional versions for the four levels of coverage described in ACA.
- Primary care services must be covered with no cost-sharing.
Administrative contracting and risk transfer (Sec. 2204):
- The Secretary may contract for plan administration; contracts cannot transfer traditional Medicare risk to the plan except under certain alternative payment models.
Data collection and premiums (Sec. 2205, 2206):
- Data collection to establish premiums and improve quality, with a focus on addressing disparities.
- Establishes a Plan Reserve Fund and a Data and Technology Fund, including initial targeted appropriations for 2027.
Premiums, risk pool, and pricing (Sec. 2206):
- Premiums must cover actuarial costs and administrative costs, varying by geography and market (individual vs small group).
- After 2028, enrollees in a state would be in a single risk pool (with possible separate pools if a state does not adopt certain ACA authority).
Reimbursement and benefits (Sec. 2207):
- Reimbursement rates default to Medicare Part A/B FFS rates, with potential up to 50% higher payments in rural areas.
- Prescription drug payments are negotiated by the Secretary.
- New and additional services may have separate reimbursement methods.
- Allows innovative payment methods (value-based, ACOs, MCOs, telehealth, etc.).
Delivery-system reforms and integration (Sec. 2209):
- Encourages and enables delivery-system reforms, including patient-centered medical homes, ACOs, bundled payments, and other innovative payment models.
- Promotes integration with social services (food, housing, transportation, income supports) where it could reduce costs or disparities.
- Establishes grant programs to support accountable communities for health and social-detector data systems.
- Telehealth integration emphasized to improve access, especially in remote areas.
Provider participation and opt-out (Sec. 2208):
- Beginning January 1, 2028, providers must participate in the Medicare Exchange to be enrolled in Medicare or Medicaid programs (with an opt-out mechanism under exceptional circumstances).
No impact on traditional Medicare trust funds (Sec. 2210):
- explicitly states the plan does not affect Medicare benefits under title XVIII or the Medicare Trust Funds (HI/SMI).
Exclusion provisions for plan enrollees (Sec. 2203(c) [in practice Sec. 1128 addition]):
- Prohibits providers or entities from restricting Medicare Exchange patients in ways not applied to other patients, ensuring parity in treatment restrictions.
Miscellaneous authorities and studies (Sec. 2207, Sec. 2210):
- Authority to investigate and implement alternative payment models; study on additional benefits (long-term care, home and community-based services, assistive technologies, vision/hearing/dental) with a 2-year congressional report on costs and risk-pool implications.
- Strengthening anti-trust enforcement in health care markets to study and enforce competition (funding to DOJ and FTC; annual reporting requirements).
Tax provisions (Sec. 5): Expansion of premium tax credits:
- Expands premium tax credits under the ACA by adjusting income-based eligibility and sliding-scale percentages to increase affordability for more households.
- Reforms cap calculation for the premium credit to allow larger families and higher incomes within specified tiers.
- Extends adjustment for family coverage affordability tests and related tax rules, with effective dates for taxable years beginning after December 31, 2025.
Reinsurance and high-cost risk pools (Sec. 4):
- Establishes a nationwide reinsurance mechanism to pool high-cost enrollees in individual plans to reduce premiums, with substantial federal funding appropriations for 2028–2030.
Prescription drug price negotiation (Sec. 6):
- Removes a subparagraph from a preexisting section to enable negotiation for Medicare prescription drugs, aligning with broader cost-control strategies.
The Medicare-X Choice Act of 2025 proposes a federally run public health option, starting in 2028, with the aim of providing affordable, quality coverage through ACA exchanges, supported by a national reinsurance mechanism, enhanced data collection, and delivery-system reforms. It contemplates significant changes in provider participation, payment reform, and integration with social determinants of health, while expanding premium subsidies and negotiating drug prices.
