On March 2 and 3, 2026, the Medicare Payment Advisory Commission (MedPAC) held a public meeting, which included the following sessions:

• Access to hospice and certain complex palliative services for beneficiaries with end-stage renal disease and beneficiaries with cancer;
• Provider participation in Medicare Advantage networks;
• Considerations for implementing Medicare Advantage encounter data in risk adjustment; and
• The complexity of Medicare enrollment decisions for beneficiaries.

The full agenda for the meeting and presentations for the sessions are available here.

COMMISSION CONSIDERS ACCESS TO HOSPICE AND COMPLEX PALLIATIVE SERVICES

In this session, MedPAC examined whether the Medicare hospice payment system may create barriers for beneficiaries with End-Stage Renal Disease (ESRD) or cancer who require special treatments. This research aims to assess whether current payment structures disincentivize the provision of high-cost palliative care and to identify potential policy adjustments for inclusion in the June 2026 report.

In Medicare, hospice is a voluntary program and personal choice that offers palliative and support services for those at the end of life (≤6 months). Under the current hospice benefit, providers receive a flat daily payment rate regardless of the volume or intensity of services furnished.

While hospice is intended to prioritize comfort, certain intensive services—such as dialysis, radiation, chemotherapy, and blood transfusions—may serve a palliative purpose for terminally ill patients but are often cost-prohibitive for hospice providers. This has raised questions about the line between palliative care and curative treatment. Since hospice providers assume full financial risk for all services, the high cost of these interventions creates a strong financial disincentive to offer them. As a result, patients who rely on these treatments may forgo hospice altogether or experience shorter hospice stays.

In November 2023, the Commission decided to research these complex services, payment, and impact after CMS raised concerns. This session builds on work presented in the April and September 2025 meetings. The Commission used mixed methods—including literature reviews, stakeholder interviews, and data analysis—to understand the scope. Interviews revealed broad agreement that dialysis, radiation, and transfusions provide essential symptom relief, while views on chemotherapy were more mixed. Whether a service is palliative is based on clinical judgement and is dependent on an individual patient’s condition. Although hospice data are limited due to the lack of CMS reporting requirements, the analysis found that many beneficiaries with these conditions forgo hospice or experience very short stays because needed care is unavailable. After completing an illustrative cost analysis, the Commission found that these services can consume a substantial portion of a hospice’s total payment, up to 50 percent, depending on the service provided. These findings indicate that the current payment structure is not designed to support or sustain these treatments.

The Commission then evaluated several approaches to improve access without altering the fundamental structure of the hospice benefit:

1. Enhanced Data Reporting: Requiring hospices to report on the provision of complex palliative services to better inform future payment modeling.
2. Hospice Payment Changes: Exploring 1) a high-cost outlier payment to cover costs above a fixed loss, or 2) an add-on payment to the daily hospice rate for specific services.
3. Voluntary Transitional Program: Implementing a program where complex palliative services are paid outside the hospice benefit for a limited duration to ease the transition into hospice.

Commission Discussion

Overall, the Commission expressed strong support for the analysis and recommendations, citing their thoroughness and underscoring the importance of ensuring a dignified death for beneficiaries. Members emphasized that while hospice providers are required to offer all four levels of hospice care, capacity and financial constraints—particularly high-cost services—often limit access, especially in rural areas. Commissioners also raised concerns about inequitable beneficiary access, unclear communication around care options, and the lack of data on patients who forgo hospice due to treatment tradeoffs.

There was broad agreement on the need to better integrate palliative services within hospice and to pursue targeted payment solutions. Most members supported the high-cost outlier approach, noting that it preserves the bundled payment structure while directing resources to high-cost stays; the add-on payment option was also supported. While some found the transitional program concept intriguing, others cautioned that it could introduce unnecessary complexity or risk unbundling care. Members consistently emphasized the importance of maintaining budget neutrality. Overall, there was a strong consensus on the need to address these issues and advance the recommendations.

MEDPAC ANALYZES PROVIDER PARTICIPATION IN MEDICARE ADVANTAGE NETWORK

In this session, the Commission reviewed preliminary analysis on clinician participation in Medicare Advantage (MA) provider networks. Staff presented findings on the share of clinicians participating in MA networks, variation across specialties and geography, and how networks change over time. This is the initial session of a work plan for studying MA networks, following the November 2024 discussion. The work plan includes three focuses: 1) examining how MA plans construct and manage provider networks, 2) analyzing how enrollees use those networks, and 3) assessing how network adequacy standards affect access to care.

MA provider networks are used by plans to manage cost and quality, but may also create challenges for beneficiary access. When enrolling in an MA plan, beneficiaries agree to use clinicians included in the plan’s network. The annual MedPAC focus group showed that MA and Fee-for-Service (FFS) beneficiaries prioritize access to preferred providers when selecting coverage. Some FFS beneficiaries pointed to MA provider networks as a reason for choosing FFS. While networks may encourage the use of higher-performing providers and improve care coordination, they can also create barriers if clinicians leave networks or if beneficiaries cannot continue seeing their existing providers.

The analysis of provider participation in MA networks focused on evaluating PCP and specialist participation and changes in network size over the year. Using FFS claims, MA encounter data, and provider directory information, staff estimated the share of clinicians, including PCPs, Nurse Practitioners (NPs), and Physician Assistants (PAs), participating in at least one MA network. Overall, 82 percent of PCPs participated in at least one MA network in 2023. Participation rates were similar across PCPs, NPs, and PAs. Participation among specialists was also high, with 82 percent participating in at least one MA network, although rates varied widely by specialty. Cardiology had about 94 percent participation in at least one MA network, followed by Pain Medicine at about 90 percent and Rheumatology at about 88 percent. Emergency Medicine had the lowest participation rate across at least one MA network, at about 58 percent.

Participation in MA networks varied across states and local markets. State-level participation among PCPs ranged from 67 percent to 93 percent, with a median of about 85 percent. Specialist participation ranged from 66 percent to 94 percent across states, with a median of approximately 87 percent. Staff noted that rural counties were associated with roughly a 10-percent-point higher clinician participation rate compared with large metropolitan counties, suggesting differences in local market dynamics and provider-plan relationships.

In addition to measuring participation at a single point in time, staff analyzed mid-year changes to MA networks. Network size was generally stable between February and June 2023 – the median network change was an increase of about 3 percent in PCPs and about 1 percent in specialists. However, there was evidence of clinician turnover within networks during this period. Approximately 6 percent of PCPs and 4 percent of specialists exited networks during the period studied, with some variation across plans. Although most networks experienced relatively small changes, a small number of networks saw substantially larger mid-year changes in clinician participation.

Larger mid-year changes in clinician participation may be because most clinicians participating in MA networks are included in multiple plans. More than 74 percent of PCPs and 76 percent of specialists participated in networks for three or more MA organizations (MAOs). Many engage broadly with the MA market rather than limiting participation to a single plan. Some variation can be seen in the amount of turnover of provider participation in networks throughout the year. While networks may remain constant in size or even increase over the course of the year, some MA enrollees will experience disruption.

Staff emphasized that interpreting participation rates is complex. High participation could indicate broad access to providers for beneficiaries, but it may also raise questions about whether MA networks are sufficiently filtering providers based on performance. Similarly, mid-year changes in networks can occur for a range of reasons, including provider retirement or relocation, contract renegotiations, or plan decisions related to quality or cost performance. While overall access to clinicians may remain stable, the departure of a specific provider from a network may still disrupt care for affected beneficiaries.

Commission Discussion

During the discussion, Commissioners focused on how provider participation in MA networks affects beneficiary access to care and continuity of relationships with clinicians. Members noted that while participation rates appear relatively high overall, participation in a network does not necessarily guarantee real-world access to care. Commissioners emphasized concerns about “ghost networks,” situations where providers are listed in directories but may not be accepting new patients or may have limited availability.

Commissioners also discussed the methodological challenges of measuring clinician participation, including how to define active clinicians and what thresholds to use to determine meaningful participation. Several members suggested further analysis using different thresholds for claims volume, unique beneficiaries served, or differences between primary care and specialty providers, particularly in rural areas where Medicare patient volumes may be lower.

Much of the discussion focused on mid-year network changes, with commissioners expressing concern that changes outside enrollment periods could disrupt care for beneficiaries, especially those with ongoing treatment needs. Members noted that although the overall level of provider turnover appeared modest, even small changes could have significant effects for individuals who lose access to a specific clinician. Commissioners discussed whether additional protections, improved communication, or clearer policies around special enrollment periods may be needed to address these mid-year disruptions.

Several commissioners emphasized the importance of examining how network design interacts with plan strategies to manage cost and quality. Members noted that plans may increasingly use network configuration, tiered networks, and performance measurement to steer beneficiaries toward higher-performing providers. At the same time, commissioners raised concerns about how these strategies could affect underserved populations, provider negotiations, and the distribution of patients across clinicians and plans.

Commissioners also highlighted areas for future research, including analyses of provider participation among facilities such as hospitals, post-acute care providers, and cancer centers, as well as participation in MA facilities. Members expressed interest in better understanding how beneficiaries actually use providers listed in networks, the extent of out-of-network care, and how network participation relates to beneficiary experience measures such as access to care.

The Commission concluded that while the preliminary analysis provides an important foundation for understanding clinician participation in MA networks, additional work is needed to assess how network structure, participation, and midyear changes affect beneficiary access, continuity of care, and the MA market function.

MEDPAC CONSIDERS POLICY OPTIONS FOR IMPLEMENTING MEDICARE ADVANTAGE ENCOUNTER DATA IN RISK ADJUSTMENT

This session presented key issues MedPAC believes CMS must address before using Medicare Advantage (MA) encounter data for risk adjustment and offered three distinct policy scenarios for consideration, building on a topic the Commission has considered since 2016. Medicare’s existing risk adjustment method uses fee-for-service (FFS) data to calculate risk scores. MedPAC asserts that because MA plans have higher coding intensity and favorable selection, risk scores for MA beneficiaries are generally higher than those for FFS beneficiaries. The discrepancy results in higher payments to MA plans relative to what FFS would have spent for the same beneficiaries. Three policy scenarios were presented by MedPAC staff to illustrate possible paths forward:

1. The use of an MA-based risk model for all Medicare beneficiaries (partial delinking).
2. The use of separate MA-based and FFS-based risk models (partial delinking).
3. The use of an MA-based risk model with MA spending-based benchmarks (full delinking).

Commission Discussion

Many commissioners strongly preferred option two because of its incrementalism, transparency, and payment interpretability. However, some commissioners favored scenario 3. Commissioners also had mixed perspectives on the use of AI in coding. While some favored using AI to transition from discretionary coding to uniform coding, Commission Chairman Chernew argued that AI tools are vulnerable to human biases and behaviors, which can affect how they document information.

Questions were raised about whether rebate structures would change under the three policy scenarios, how “encounters” would be defined, and how potential changes may impact physician compensation under each of the three policy recommendations. No responses were given to the latter two inquiries, although MedPAC staff shared that rebate structures would remain as they are now under the presented policy pathways.

Overall, commissioners expressed support for maintaining the FFS benchmark system as a consistent reference in evaluating MA spending and interpreting county-level payments. Consensus also emerged around the need to pressure-test any proposed risk-adjustment model before it is adopted. Finally, concerns about the completeness of MA data persisted among commissioners, with many proposed ways for CMS to use its regulatory influence to enforce consistent, accurate data collection. Per the Chair, the Commission will not discuss MA risk-adjustment again until 2027.

COMMISSIONS REVIEWS COMPLEXITY OF MEDICARE ENROLLMENT DECISIONS FOR BENEFICIARIES

In this session, staffers began by giving a general overview of Medicare eligibility and enrollment periods, explaining the differences of each for Medicare Parts A, B, and D, versus those of Medicare Advantage (MA) and Medigap. They then highlighted several issues preventing beneficiaries from enrolling in a plan in the allocated timeframe, including a lack of notification of their eligibility, a complex choice architecture, and Medicare features that hinder beneficiaries from switching between MA and Fee-for-service (FFS). The lack of eligibility notifications particularly compounds broader issues for beneficiaries, including potential lifelong late-enrollment penalties.

In breaking down the choice architecture Medicare beneficiaries face, staffers identified three key factors shaping decisions: financial protection, access to care, and extra benefits. In terms of financial protection, premiums for FFS Medicare coverage average an additional $200/month for a Medigap policy and $44/month for a PDP. This contrasts with MA plans, which offer reduced premiums and cost-sharing with a maximum out-of-pocket limit. For access to care, FFS plans feature broader access to providers, while MA plans require in-network providers or higher costs, often requiring prior authorizations for coverage. Conversely, MA plans offer a broader range of extra benefits that FFS plans do not cover.

Commission Discussion

During the first round of discussion, commissioners expressed concern about the communication infrastructure beneficiaries face, from a lack of eligibility notifications to the inundation of excess information from external sources. Staffers clarified that it was not necessarily difficult to fix, but was the result of a historical artifact, given that the Social Security retirement age is no longer congruent with Medicare age eligibility. Many questions commissioners had centered on enrollment periods and the nuances of employer-sponsored insurance, as well as their implications for beneficiaries.

In the second round of discussion and comments, there was a consensus among commissioners that the Medicare enrollment decision-making process was overly complex. A few commissioners expressed the view that a complex choice architecture did not equate to a broken system. Most reinforced concerns that beneficiaries may not understand their options and eligibility, with some requesting data on beneficiary choice along with demographics.

The Chair closed the session by highlighting the complexities of choice architecture and how the benefits of offering beneficiaries multiple options may conflict with the disadvantages of a cumbersome and non-intuitive process. At the April meeting, the Commission will continue discussions on this topic, focusing on the sources of information available to beneficiaries, including the Medicare Plan Finder tool, insurance agents, and SHIPs. The session will also discuss the practices of brokers, marketing, and distribution processes as they relate to MA marketing.

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This Applied Policy® Summary was prepared by Emma Hammer with support from the Applied Policy team of health policy experts. If you have any questions or need more information, please contact her at ehammer@appliedpolicy.com or 202-820-7383.