Puerto Rico Medicare Advantage Fairness Act of 2026

Core Policy Mechanism Top 1

Equalize Medicare Advantage Geographic Adjustment for Puerto Rico

Changes how Medicare Advantage (MA) payment benchmarks are calculated in Puerto Rico by requiring the same geographic adjustment used for the U.S. Virgin Islands, starting in 2027. This could increase payments to MA health plans serving Puerto Rico seniors.

• Population Scope Low Directly affects Medicare Advantage enrollees and health plans in Puerto Rico, a population well under 1% of the U.S. total.
• Budgetary Magnitude Medium Raises MA benchmark payments for all Puerto Rico plan years beginning 2027 onward by aligning the geographic adjustment upward to the Virgin Islands rate — a recurring mandatory spending increase with no stated dollar cap, but limited to a single territory's plans.
• Legal / Regulatory Depth Medium Creates a new statutory mandate binding Centers for Medicare & Medicaid Services (CMS) to apply a specific geographic adjustment formula to Puerto Rico, constraining existing agency discretion over benchmark-setting without restructuring the broader MA program.
• Degree of Discretion Granted Low Uses mandatory 'shall' equivalence language ('shall be equal to'), leaving CMS no discretion over the adjustment rate to apply.
• Implementation & Enforcement Burden Low CMS administers MA benchmarks through existing infrastructure, and the change requires only a formula update with no new compliance mechanisms, penalties, or reporting requirements.
• Temporal Commitment High Persists indefinitely once effective January 1, 2027, binding future Congresses until affirmatively repealed or amended.