Bipartisan bill introduced in Congress to correct Medicare Advantage disparities
By THE STAR STAFF
A bipartisan group of lawmakers has introduced new legislation aimed at correcting long‑standing Medicare Advantage payment disparities that have left Puerto Rico at a significant disadvantage compared with the rest of the United States.
The Puerto Rico Medicare Advantage Fairness Act, filed by Rep. Gus Bilirakis (R‑Fla.), Rep. Raul Ruiz, M.D. (D‑Calif.), Rep. Darren Soto (D‑Fla.) and Resident Commissioner Pablo José Hernández Rivera (D‑P.R.), seeks to fix a structural flaw in the federal formula used to determine monthly payments to Medicare Advantage (MA) plans. The bill would align Puerto Rico’s average geographic adjustment (AGA) with that of the U.S. Virgin Islands, a territory with similar socioeconomic conditions but substantially higher MA benchmarks.
At the heart of the issue is how the federal government calculates local healthcare costs. The AGA is based on spending in traditional Medicare fee‑for‑service — a model used by only a small fraction of Puerto Rico’s Medicare population, since more than 90% of beneficiaries on the island are enrolled in MA. Because the formula relies on such a limited pool of fee‑for‑service data, it significantly understates the true cost of care, resulting in lower payments to MA plans and fewer resources for providers and patients.
The consequences are well‑documented: Puerto Rico receives about 40% less per MA beneficiary than the national average, and benchmark rates run roughly 20% below those in the U.S. Virgin Islands. The funding gap has contributed to narrower provider networks, reduced benefits and lower reimbursements for doctors and hospitals — pressures that have strained the island’s healthcare system for years.
“Seniors deserve reliable access to the high‑quality health care they have earned through Medicare, regardless of where they live,” Bilirakis said, noting that MA is the dominant coverage option for Puerto Rico’s older adults. “We must ensure the program is funded fairly and sustainably so seniors can continue accessing the doctors, treatments and benefits they rely upon.”
Ruiz, an emergency physician, emphasized the real‑world impact of the disparity.
“Puerto Ricans pay into Medicare on the same terms as every American, yet their Medicare Advantage plans are paid about 40 percent less,” he said. “That gap has shrunk provider networks, cut benefits and strained doctors and hospitals. This bill is a targeted, common‑sense fix.”
Soto called the legislation an important step toward parity between Puerto Rico and the mainland.
“Puerto Ricans are American citizens, and they deserve access to the same healthcare benefits as all Americans,” he said.
Hernández Rivera said the measure builds on recent progress, including a notable increase in MA funding for Puerto Rico earlier this year.
“Now, we are taking the next step to fix a longstanding funding disparity that has affected the island for years,” he said.
Gov. Jenniffer González Colón also endorsed the bill, calling it a needed correction to a formula that has never reflected the island’s true healthcare costs.
“MA rates in Puerto Rico are approximately 41 percent below the national average and 20 percent below those in the U.S. Virgin Islands,” she said. “This bill proposes a fix that would provide a much‑needed boost to our residents, health care sector and economy.”
The legislation would create a self‑adjusting link between Puerto Rico and the U.S. Virgin Islands: if the Virgin Islands’ adjustment changes, Puerto Rico’s would move in tandem. Supporters say the approach offers a practical, durable solution to a problem that has undermined the island’s healthcare system for more than a decade.
