S. 3369: Medicare-X Choice Act of 2025

The Medicare-X Choice Act of 2025 proposes the establishment of a new public health plan called the "Medicare Exchange health plan." This plan aims to provide access to affordable and quality health care for individuals who are not eligible for Medicare benefits. Here are the key aspects of the bill:

Establishment of the Health Plan

The bill mandates the Secretary of Health and Human Services to set up a coordinated and low-cost health plan known as the Medicare Exchange health plan. The plan is intended to be available in the individual and small group markets starting in 2028. The bill allocates $1 billion for establishing the plan and another $1 billion for updating technology and data collection for premium setting.

Eligibility and Availability

To enroll in the Medicare Exchange health plan, individuals must meet the criteria of being a qualified individual as defined under the Affordable Care Act and not be eligible for Medicare. The health plan will be offered through American Health Benefit Exchanges, which include options for small businesses.

Plan Requirements

The health plan must comply with existing requirements applicable to qualified health plans under the Affordable Care Act. Specifically:

• It will provide at least a silver and gold level of coverage.
• Enrollees will not face any cost-sharing for primary care services.

Administrative Contracts

The Secretary may enter into contracts for administrative functions related to the health plan while maintaining authority over the public health insurance option without transferring insurance risk to these contracted entities.

Data Collection and Premium Setting

The Secretary will collect data to establish premium rates and address health disparities among various populations. Premiums will be set to cover the full actuarial costs and will vary geographically. All enrollees within a state will be part of a single risk pool to manage costs more effectively.

Reimbursement Rates

Providers will be reimbursed at rates determined under the Medicare fee-for-service program, with potential increases in rural areas. The Secretary will also negotiate payment rates for prescription drugs.

Provider Participation Requirements

Health care providers must participate in the Medicare Exchange health plan to be eligible for enrollment in Medicare or Medicaid by 2028, although there will be processes for opting out under special circumstances.

Delivery System Reform

The Secretary is empowered to use innovative payment mechanisms that improve health outcomes, reduce costs, and reduce health disparities. This includes models such as accountable care organizations and patient-centered medical homes.

Telehealth Integration

The plan will promote telehealth services, particularly for remote areas, to improve access and reduce overall costs without compromising quality.

Funding and Appropriations

To support the program, a period of appropriations is set from fiscal years 2027 through 2036, with significant funding designated to support the Medicare Exchange health plan and other related activities.

Expansion of Tax Credit and Fixing the Family Glitch

The bill expands eligibility for tax credits under the Affordable Care Act for individuals with higher incomes and addresses issues related to affordability for families where employees cover dependents under expensive employer-sponsored plans.

Negotiating Drug Prices and Antitrust Enforcement

The bill includes provisions that allow for negotiating better prices for Medicare prescription drugs. It also provides funding to strengthen antitrust enforcement in healthcare markets to promote fair competition.

Reports and Accountability

The Department of Justice and the Federal Trade Commission are directed to report on the use of funds and studies on healthcare markets to ensure effective oversight and implementation.

Relevant Companies

• UNH - UnitedHealth Group may experience significant changes in its business model with the introduction of a government health plan options that could affect its market share.
• ANTM - Anthem, Inc. could face increased competition from the Medicare Exchange health plan, influencing its pricing strategies and enrollment figures.
• CNC - Centene Corporation may need to adapt its services and pricing in response to the new public health plan offering.