Ruiz Introduces Bipartisan Bill to Fix Medicare Advantage Payments in Puerto Rico

WASHINGTON, D.C. Today, Congressman Raul Ruiz, M.D. (CA-25), joined by Congressman Gus Bilirakis (R-FL), Congressman Darren Soto (D-FL), and Resident Commissioner Pablo José Hernández (D-PR), introduced the Puerto Rico Medicare Advantage Fairness Act. This bipartisan bill would correct a long-standing formula gap that underpays Medicare Advantage in Puerto Rico.

How it works
Medicare Advantage plans receive a fixed monthly payment from the federal government for each senior they enroll. Part of that payment is based on the local cost of care, which is measured by the average geographic adjustment (AGA). Puerto Rico's AGA is much lower than it should be. The formula relies on spending in traditional Medicare (fee-for-service), but very few beneficiaries in Puerto Rico use fee-for-service, since most are enrolled in MA. Basing the AGA on such a small population understates what care actually costs on the island, and MA plans receive a lower benchmark payment for each senior as a result.

This bill would set Puerto Rico's AGA equal to that of the U.S. Virgin Islands, a territory with similar socioeconomic circumstances, so that payments reflect the true cost of delivering care.

The problem

• Over 650,000 Puerto Rico beneficiaries rely on Medicare Advantage, over 90 percent of all Medicare beneficiaries on the island.

• Puerto Rico receives about 40 percent less per beneficiary than the U.S. average.

• Benchmark rates run roughly 20 percent below those in the U.S. Virgin Islands.

• The payment gap has led to smaller provider networks and reduced benefits, and doctors and hospitals absorb lower reimbursements. This threatens the quality and availability of healthcare services in Puerto Rico.

"As an emergency physician, I know that when care is out of reach, seniors pay the price," said Congressman Raul Ruiz, M.D. "Puerto Ricans pay into Medicare on the same terms as every American, yet their Medicare Advantage plans are paid about 40 percent less. That gap has shrunk provider networks, cut benefits, and strained doctors and hospitals. This bill is a targeted, common-sense fix. I thank Representatives Bilirakis and Soto and Resident Commissioner Hernández for working with me to give seniors the fair coverage they have earned."

"Seniors deserve reliable access to the high-quality health care they have earned through Medicare, regardless of where they live," said Congressman Gus Bilirakis. "Medicare Advantage plays an important role in delivering care to beneficiaries across Puerto Rico, and we must ensure the program is funded fairly and sustainably so seniors can continue accessing the doctors, treatments, and benefits they rely upon. I'm proud to join Representatives Ruiz and Soto in introducing the bipartisan Puerto Rico Medicare Advantage Fairness Act to address longstanding disparities, strengthen access to care and provide greater stability for patients and providers."