Insights^

On January 16, 2026, the Medicare Payment Advisory Commission (MedPAC) met to see presentations and discuss findings on the Medicare Advantage (MA) program and Dual-Eligible Special-Needs Plans (D-SNPs). The information from the presentations and discussion will be included in the March 2026 report to Congress.

THE MA PROGRAM: STATUS REPORT

MedPAC staff offered a comprehensive overview of the MA program. MedPAC staff shared that in 2025, MA plans enrolled 55% of eligible beneficiaries, with the beneficiaries having an average of 42 plans to choose from. They also predicted that MA rebates will reach a historic high in 2026, which they said could help in reducing cost sharing as well as providing beneficiaries supplemental benefits such as dental and vision services. MedPAC staff also noted that MA spending has been greater than traditional Medicare Fee-for-Service (FFS) spending, which may be attributed to upcoding. They also noted that the new V28 reduced coding-intensity model appears to help control MA costs while maintaining stable supplemental benefits and MA plan availability. It is expected that the V28 model will continue to reduce MA coding intensity effects in coming years.

The Chair opened Commissioner discussion by sharing that he thinks about MA plans as an indirect way to provide access to care. He differentiated this from more direct ways MedPAC examines, such as hospital payments and the post-acute care space.

Multiple Commissioners were interested in the excess administrative expenses expected with MA plans, seeking clarification on how administrative costs are accounted for in the medical-loss ratio and how savings can be passed on to beneficiaries.

There was also interest in the V28 service model due to its relative newness. MedPAC staff clarified that there are plans to compare the effects of the V24 model to the V28 model to see if there are code discrepancies between the models and that the V28 model uses Medicare FFS data to periodically update the model calibration. Some Commissioners raised concerns that the model is affecting MA plans that have not been found to be upcoding and wondered if there was a way to make plan-specific adjustments in those cases. MedPAC staff shared that such changes would need to be a change in policy, not just a change in the data model.

One Commissioner requested that in the future MedPAC take a closer look at other Medicare populations such as those with permanent disabilities, as much of the previous and current work focuses on the older adult population.

There were also broad concerns from the Commissioners about the profit margin of MA plans, especially when compounded with concerns about MA plans having a much higher spending amount per beneficiary than those enrolled in Medicare FFS. It was suggested that future work could provide a clear breakdown of how money flows through MA plans, as well as taking a closer look at the star rating system which some Commissioners believe is helping to accelerate payment rates. Receiving clearer data from reliable sources was highlighted as a need from staff and Commissioners. It was also suggested that the use of supplemental benefits and clear beneficiary-level data could be helpful to the Commission. Another thought was that the Commission needs to understand how supplemental benefits are used to market MA plans and how beneficiaries shop for plans.

The Commissioners shared a wide variety of ideas about how to transform the MA space to work better for beneficiaries. These included flexible spending accounts to allow supplemental benefits to be purchased directly, going back to encounter-based coding, revisiting out-of-pocket maximum policies to contain costs, and reconsidering whether the quality payment system should be budget-neutral. Another suggestion made was to streamline the plan choices and create better materials to explain the differences between types of care plans.

Overall, the Commissioners shared the sentiment that MA plans are somewhat overfunded, and that program changes are needed to ensure quality care is still delivered while costs are contained.

MANDATED REPORT: D-SNPS

MedPAC staff began the session with an overview of D-SNPs, sharing that nearly half of dually eligible beneficiaries are enrolled and use has tripled over the last decade. MedPAC staff shared how each type of D-SNP plan had various results on Healthcare Effectiveness Data and Information Set (HEDIS) quality measures, which can make it difficult to directly compare across plan types. It was also noted that look-alike plans offer an alternative to D-SNPs and Chronic Condition Special-Needs plans (C-SNPs) are becoming more popular in the market.

The Commissioners questioned how integration for D-SNPs can be best measured, but MedPAC staff shared that the plan providers are very aware of the quality incentives that relate to higher payments and will focus their efforts on those measures, which can make it difficult. One Commissioner shared that they were not surprised that there is no correlation between increased integration and broad quality measures, stating that integration is not the only or strongest way to create value for challenged populations.

Multiple Commissioners had questions about D-SNP marketability to beneficiaries and would like to see some qualitative data from plans and beneficiaries in the future. MedPAC staff shared that current reports indicate that care coordination benefits are hard to explain to beneficiaries so many beneficiaries still make their plan decisions on supplemental benefit access.

There was conversation about the ability to join C-SNPs in the middle of the year which MedPAC staff clarified was not a new policy. MedPAC staff also explained that the rationale is that they are specific, specialized plans for those with health needs and the policy is in place to provide beneficiaries access to specialized plans for those with health needs as soon as possible.

There was also worry that these plans help with the cherry-picking of beneficiaries, leaving other plans with lower patient populations resulting in fewer plan offerings.

The discussion ended with the Commissioners agreeing that the wide variety of plan options can make the process of picking one difficult to navigate, and some streamlining would be helpful. However, it was also agreed that this must be balanced with providing a variety of plan specifications so each beneficiary can find one that best suits their needs.

On January 8, 2026, the House Energy and Commerce Health Subcommittee held a hearing to examine 10 bills related to Medicare services, including clinical lab services, home infusion, oxygen therapy, and more. Many committee members were eager to take the next steps in the legislative process.

OPENING STATEMENTS

• Subcommittee Chairman Morgan Griffith (R-VA-09)

• Ranking Member Frank Pallone (D-NJ-06)

WITNESS TESTIMONY

• Ms. Susan Van Meter, President, American Clinical Laboratory Association – Testimony

• Ms. Connie Sullivan, President and CEO, National Home Infusion Association – Testimony

• Mr. Thomas Ryan, President and CEO, American Association for Homecare – Testimony

• Mr. David Lipschutz, JD, Attorney and Co-Director of Law and Policy, Center for Medicare Advocacy – Testimony

MEMBER DISCUSSION

H.R.1703, Choices for Increased Mobility Act of 2025

This legislation would require the Centers for Medicare & Medicaid Services to establish specific Medicare billing codes for certain materials used in ultralightweight manual wheelchairs.

Rep. John Joyce (R-PA-13) asked Mr. Ryan to explain the benefits of lighter-weight wheelchairs for patients. Mr. Ryan answered that patients suffer additional wear and tear when ambulating using a wheelchair, and when patients can use a lighter wheelchair, they suffer less.

H.R.2005, DMEPOS Relief Act of 2025

This bill would extend the higher payment rate, known as the 75/25 blended rate, for durable medical equipment in nonrural or noncontiguous areas under Medicare.

Subcommittee Vice Chair Diana Harshbarger (R-TN-01) asked how reimbursement cuts undermine Medicare’s goal of keeping patients safely at home and avoiding extra costs. Mr. Ryan stated that the service model has changed drastically over the years, with patients receiving equipment later and increasing the need for more equipment repairs.

Rep. Mariannette Miller-Meeks (R-IA-01) voiced support for the bill and asked how current reimbursement rates are affecting access to care. Mr. Ryan stated that durable medical equipment companies are reducing their offerings and using personal savings to sustain their business.

H.R.2172, Preserving Patient Access to Home Infusion Act

This bill provides technical clarifications that remove the requirement that a nurse be physically present in a patient’s home for providers to be reimbursed for home infusion drugs.

Subcommittee Ranking Member Diana DeGette (D-CO-01) stated that she felt this bill is a commonsense expansion of the 21st Century Cures Act.

Subcommittee Vice Chair Harshbarger voiced support for the bill and asked about the current process for patients seeking home infusion therapy. Ms. Sullivan stated that it becomes very difficult and almost impossible for Medicare patients.

Rep. Raul Ruiz (D-CA-25) expressed his support for the bill, noting its positive impact on his constituents. Rep. Ruiz then asked Ms. Sullivan to expand on how the bill would make home infusion a more dependable option for patients. Ms. Sullivan shared that, currently, patients are often placed in a skilled facility, and the bill would remove the barriers, stress, and burden that families and patients experience, allowing them to receive treatment at home.

Rep. Buddy Carter (R-GA-01) asked how home infusion pharmacies aid patients in receiving proper treatment at home. Ms. Sullivan answered that currently, Medicare only pays for these services when they take place face-to-face. She said that the bill’s expanded scope would ensure that pharmacies’ oversight of the benefit is useful. Additionally, she said that the bill would provide continuous support for both patients and physicians, which prevents patients from returning to the emergency room. She also stressed that this bill is important because Medicare patients often do not have this benefit covered in the same way that individuals with private insurers do.

Rep. Nicholas Langworthy (R-NY-23) asked how the legislation would keep patients on track with their treatment plans. Ms. Sullivan shared that home infusion is extremely efficient for patients, as support comes from a local pharmacy without providers needing to travel to the home for treatment.

H.R.2477, Portable Ultrasound Reimbursement Equity Act of 2025

This bill provides a separate payment for the transportation and setup services of portable ultrasound equipment.

Rep. Lori Trahan (D-MA-03) asked how important timely care is for fragile patients and how this legislation can support timely care. Mr. Ryan shared that he felt care in the home was where money should be going, and travel time reimbursement is needed for access to care, especially for medically fragile patients.

H.R.2902, Supplemental Oxygen Access Reform (SOAR) Act of 2025

This bill establishes certain requirements for the payment and provision of supplemental oxygen and related services under Medicare.

Rep. Troy Balderson (R-OH-12) asked how the SOAR Act can help address current industry issues. Mr. Ryan shared that suppliers are not currently able to support liquid oxygen requirements, and the bill would move portable oxygen out of the competitive bidding process, which would help to push innovation and new technology back in the sector. Mr. Ryan continued that while it would only affect a small group of patients, it would allow them to have a much greater quality of life.

Rep. Dwight Evans (D-PA-03) emphasized the need for accessible liquid oxygen and asked how patients are affected by the lack of access. Mr. Ryan shared that the service model for respiratory therapy has changed, and patients are suffering from poor quality of care.

H.R.5243, to amend title XVIII of the Social Security Act to increase data transparency for supplemental benefits under Medicare Advantage

This bill would require companies that offer Medicare Advantage plans to submit enrollee-level data on supplemental benefits to the Department of Health and Human Services (HHS). The bill would mandate reporting on data such as eligibility for supplemental benefits, the types of benefit categories offered, and utilization and payments for supplemental benefits. HHS would also be required to publish annual data reports.

Rep. Troy Carter (D-LA-02) questioned how individuals perceive supplemental benefits. Mr. Lipschultz shared that companies encourage people to enroll in plans because of their supplemental benefits. However, Mr. Lipschultz argued these benefits are often difficult to access or understand, and this legislation would provide better data to educate people about Medicare Advantage options.

H.R. 5269, Reforming and Enhancing Sustainable Updates to Laboratory Testing Services (RESULTS) Act of 2025

This bill aims to improve Medicare reimbursements for clinical laboratory testing. The act aims to ensure a Medicare Clinical Laboratory Fee Schedule (CLFS) rate- setting process that is representative of commercial market rates, reduce the administrative data collection and reporting burden on clinical laboratories, and limit future annual payment cuts to 5%.

Subcommittee Chairman Griffith asked about the proposed 11% payment cut to the complete blood count (CBC) test and how patient access would be affected if action is not taken. Ms. Van Meter shared that a CBC is the most common test ordered by providers, and the cut could lead to negative downstream effects due to reduced compensation.

Vice Chair Harshbarger asked what Ms. Van Meter expects for the next data collection cycle. Ms. Van Meter stated that a major flaw in the current system is that data from 2019 must be reported. Additionally, the training on how to report this has not been shared, which will cause issues for many clinical laboratories.

Chairman Guthrie asked Ms. Van Meter to describe the current reporting process. Ms. Van Meter shared that the data that originally determined Medicare reimbursement rates were much higher than private insurance rates was flawed and that the RESULTS Act would ensure that CMS had widespread, accurate data to properly set reimbursement rates. When asked about using an independent claims database, Ms. Van Meter said the data would come directly from private health plans and be representative of the entire field, providing CMS with widely representative, statistically significant data. Chairman Guthrie then asked about the importance of clinical innovation and how it supports patient access to care. Ms. Van Meter stated that clinical innovation drives personalized medicine as diagnostics are extremely important to determine the correct treatment, and with the current unstable payment system, there is no capacity to have long-term research and development of innovation.

Rep. Gus Bilirakis (R-FL-12) shared that he was very supportive of the legislation and asked about the effects of the bill on patients with rare diseases. Ms. Van Meter shared that patients and providers need access to both routine and rare disease tests to create the best treatment plans and prevent unnecessary deaths. Tests for rare diseases such as rapid genomic sequencing can yield actionable results for patients and families but innovation in the sector will be curtailed by deep price reductions.

Rep. Joyce voiced his support for the RESULTS Act, sharing that he believes it will support patient access to lab services and that under-reimbursement for laboratory tests poses barriers for seniors. Rep. Joyce asked Ms. Van Meter to speak on the impact of price cuts on access to clinical laboratory tests for patients. Ms. Van Meter said that cuts will lead to longer turnaround times, smaller test offering lists, decreased viability of laboratories, and reduced innovation in the sector.

Rep. Balderson emphasized the importance of data collection and asked if there was a chance we would be returning to Medicare paying higher rates than other insurers. Ms. Van Meter shared that the Office of Inspector General (OIG) report mentioned in her testimony lacked the level of data needed to set payment rates. The RESULTS Act would allow CMS to use a more comprehensive set of data and set Medicare rates more accurately.

Rep. Thomas Kean (R-NJ-07) asked about the urgency of reforming the schedule. Ms. Van Meter stated the cuts will begin on tests that beneficiaries rely on as of January 31, 2026. Rep. Kean questioned how innovations in biomarker tests provide hope for patients and families. Ms. Van Meter shared that they are the foundation for precision medicine to ensure the best treatments for a patient’s specific condition, and the current Medicare fee schedule negatively affects innovation due in the long-term.

Rep. Langworthy asked what the unique challenges are for rural communities for clinical lab testing. Ms. Van Meter shared that the infrastructure in rural communities is not ideal and could be compromised due to payment cuts, leading to longer turnaround times for results and a lack of access to services.

Rep. Jay Obernolte (R-CA-23) asked about the use of Artificial Intelligence (AI) in the clinical lab industry and how best to leverage it. Ms. Van Meter shared that leveraging AI tools for genomics and large datasets for diagnostics is common and continues to expand.

H.R.6210, Senior Savings Protection Act

This bill reauthorizes outreach and assistance programs under the Medicare Improvements for Patients and Providers Act (MIPPA) by extending funding for 5 years at the current levels. MIPPA grants funding for community-based organizations that provide in-person counseling, education, eligibility screening, benefit explanation, application and enrollment assistance, and outreach to promote Medicare enrollment.

Rep. Bilirakis voiced his support for the bill.

Rep. Doris Matsui (D-CA-07) asked how low-income subsidies and other programs help seniors afford their health care and how funds are used to help beneficiaries. Mr. Lipschutz shared that these programs help to reduce costs as well as give seniors cost-sharing options for the entire year. The funding connects beneficiaries with local organizations that can help them meet their needs.

H.R.6361, Ban AI Denials in Medicare Act

This bill would prohibit the testing of the Wasteful and Inappropriate Service Reduction (WISeR) Model and prohibit the implementation of payment models testing prior authorization under traditional Medicare.

Rep. Kim Schrier (D-WA-08) shared that one of the most common complaints she has from constituents is the denial of care, especially for those enrolled in Medicare Advantage. She said she is supportive of the legislation due to the high rate of inappropriate denials of care.

Rep. Greg Landsman (D-OH-01) voiced his worries that the WISeR model would soon be expanded to other types of care and that providers would be incentivized not to provide care. He questioned the panel on their knowledge of how the model would approve or deny authorization. Mr. Lipschutz shared that the only information known about the model is that 3rd parties will be incentivized to deny care to patients.

Rep. Jake Auchincloss (D-MA-04) voiced his support for this legislation and said he was working on additional legislation to place guardrails on prior authorization. Rep. Auchincloss asked whether current AI models learn from their mistakes, and Mr. Lipschutz said no: the model will continually deny authorized AI models learn from their mistakes, and Mr. Lipschutz said no: the model will continually deny authorized care.