Medicare for All Act
This bill establishes a national health insurance program that is administered by the Department of Health and Human Services (HHS).
Among other requirements, the program must (1) cover all U.S. residents; (2) provide for automatic enrollment of individuals upon birth or residency in the United States; and (3) cover items and services that are medically necessary or appropriate to maintain health or to diagnose, treat, or rehabilitate a health condition, including hospital services, prescription drugs, mental health and substance abuse treatment, dental and vision services, long-term care, gender affirming care, and reproductive care, including contraception and abortions.
The bill prohibits cost-sharing (e.g., deductibles, coinsurance, and copayments) and other charges for covered services. Additionally, private health insurers and employers may only offer coverage that is supplemental to, and not duplicative of, benefits provided under the program.
Health insurance exchanges and specified federal health programs terminate upon program implementation. However, the program does not affect coverage provided through the Department of Veterans Affairs or the Indian Health Service.
The bill also establishes a series of implementing provisions relating to (1) health care provider participation; (2) HHS administration; and (3) payments and costs, including the requirement that HHS negotiate prices for prescription drugs.
Individuals who are age 18 or younger, age 55 or older, or already enrolled in Medicare may enroll in the program starting one year after enactment of this bill; other individuals may buy into the program at this time. The program must be fully implemented two years after enactment.
[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3069 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 3069
To establish an improved Medicare-for-All national health insurance
program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
April 29, 2025
Ms. Jayapal (for herself, Mrs. Dingell, Ms. Adams, Ms. Ansari, Ms.
Balint, Ms. Barragan, Mr. Bell, Mr. Beyer, Ms. Bonamici, Mr. Boyle of
Pennsylvania, Ms. Brown, Mr. Carbajal, Mr. Carson, Mr. Carter of
Louisiana, Mr. Casar, Mrs. Cherfilus-McCormick, Ms. Chu, Ms. Clarke of
New York, Mr. Cleaver, Mr. Cohen, Ms. Crockett, Mr. Davis of Illinois,
Ms. DeGette, Mr. Deluzio, Mr. DeSaulnier, Ms. Dexter, Mr. Doggett, Ms.
Escobar, Mr. Espaillat, Mrs. Foushee, Ms. Lois Frankel of Florida, Ms.
Friedman, Mr. Frost, Mr. Garamendi, Mr. Garcia of California, Mr.
Garcia of Illinois, Mr. Goldman of New York, Mr. Gomez, Mr. Green of
Texas, Mrs. Hayes, Ms. Hoyle of Oregon, Mr. Huffman, Mr. Jackson of
Illinois, Ms. Jacobs, Mr. Johnson of Georgia, Ms. Kamlager-Dove, Mr.
Keating, Ms. Kelly of Illinois, Mr. Kennedy of New York, Mr. Khanna,
Ms. Lee of Pennsylvania, Ms. Leger Fernandez, Mr. Levin, Mr. Lieu, Ms.
Lofgren, Ms. McCollum, Mr. McGarvey, Mr. McGovern, Mrs. McIver, Mr.
Meeks, Ms. Meng, Mr. Mfume, Mr. Min, Mr. Mullin, Mr. Nadler, Mr.
Neguse, Ms. Norton, Ms. Ocasio-Cortez, Ms. Omar, Mr. Pallone, Mr.
Panetta, Ms. Pingree, Mr. Pocan, Ms. Pressley, Mr. Quigley, Mrs.
Ramirez, Ms. Randall, Mr. Raskin, Ms. Rivas, Ms. Salinas, Ms. Sanchez,
Ms. Schakowsky, Mr. Scott of Virginia, Mr. Sherman, Ms. Simon, Mr.
Smith of Washington, Ms. Stansbury, Mr. Swalwell, Mr. Takano, Mr.
Thanedar, Mr. Thompson of Mississippi, Mr. Thompson of California, Ms.
Titus, Ms. Tlaib, Ms. Tokuda, Mr. Tonko, Mrs. Trahan, Mr. Vargas, Ms.
Velazquez, Ms. Waters, Mrs. Watson Coleman, Ms. Williams of Georgia,
Ms. Wilson of Florida, Mr. Harder of California, Mr. Ivey, and Mr.
Torres of New York) introduced the following bill; which was referred
to the Committee on Energy and Commerce, and in addition to the
Committees on Ways and Means, Education and Workforce, Rules, Oversight
and Government Reform, Armed Services, and the Judiciary, for a period
to be subsequently determined by the Speaker, in each case for
consideration of such provisions as fall within the jurisdiction of the
committee concerned
_______________________________________________________________________
A BILL
To establish an improved Medicare-for-All national health insurance
program.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Medicare for All
Act''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--ESTABLISHMENT OF THE MEDICARE FOR ALL PROGRAM; UNIVERSAL
COVERAGE; ENROLLMENT
Sec. 101. Establishment of the Medicare for All Program.
Sec. 102. Universal coverage.
Sec. 103. Freedom of choice.
Sec. 104. Non-discrimination.
Sec. 105. Enrollment.
Sec. 106. Effective date of benefits.
Sec. 107. Prohibition against duplicating coverage.
TITLE II--COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE BENEFITS AND
BENEFITS FOR LONG-TERM CARE
Sec. 201. Comprehensive benefits.
Sec. 202. No cost-sharing; other limitations.
Sec. 203. Exclusions and limitations.
Sec. 204. Coverage of long-term care services.
TITLE III--PROVIDER PARTICIPATION
Sec. 301. Provider participation and standards; whistleblower
protections.
Sec. 302. Qualifications for providers.
Sec. 303. Use of private contracts.
TITLE IV--ADMINISTRATION
Subtitle A--General Administration Provisions
Sec. 401. Administration.
Sec. 402. Consultation.
Sec. 403. Regional administration.
Sec. 404. Beneficiary ombudsman.
Sec. 405. Conduct of related health programs.
Subtitle B--Control Over Fraud and Abuse
Sec. 411. Application of Federal sanctions to all fraud and abuse under
the Medicare for All Program.
TITLE V--QUALITY ASSESSMENT
Sec. 501. Quality standards.
Sec. 502. Addressing health care disparities.
TITLE VI--HEALTH BUDGET; PAYMENTS; COST CONTAINMENT MEASURES
Subtitle A--Budgeting
Sec. 601. National health budget.
Subtitle B--Payments to Providers
Sec. 611. Payments to institutional providers based on global budgets.
Sec. 612. Payment to individual providers through fee-for-service.
Sec. 613. Ensuring accurate valuation of services under the Medicare
physician fee schedule.
Sec. 614. Payment prohibitions; capital expenditures; special projects.
Sec. 615. Office of Health Equity.
Sec. 616. Office of Primary Care.
Sec. 617. Payments for prescription drugs and approved devices and
equipment.
TITLE VII--UNIVERSAL MEDICARE TRUST FUND
Sec. 701. Universal Medicare Trust Fund.
TITLE VIII--CONFORMING AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME
SECURITY ACT OF 1974
Sec. 801. Prohibition of employee benefits duplicative of benefits
under the Medicare for All Program;
coordination in case of workers'
compensation.
Sec. 802. Application of continuation coverage requirements under ERISA
and certain other requirements relating to
group health plans.
Sec. 803. Effective date of title.
TITLE IX--ADDITIONAL CONFORMING AMENDMENTS
Sec. 901. Relationship to existing Federal health programs.
Sec. 902. Sunset of provisions related to the State Exchanges.
Sec. 903. Sunset of provisions related to pay for performance programs.
TITLE X--TRANSITION
Subtitle A--Medicare for All Transition Over 2 Years and Transitional
Buy-In Option
Sec. 1001. Medicare for all transition over two years.
Sec. 1002. Establishment of the Medicare transition buy-in.
Subtitle B--Transitional Medicare Reforms
Sec. 1011. Eliminating the 24-month waiting period for Medicare
coverage for individuals with disabilities.
Sec. 1012. Ensuring continuity of care.
TITLE XI--MISCELLANEOUS
Sec. 1101. Definitions.
Sec. 1102. Rules of construction.
Sec. 1103. No use of resources for law enforcement of certain
registration requirements.
TITLE I--ESTABLISHMENT OF THE MEDICARE FOR ALL PROGRAM; UNIVERSAL
COVERAGE; ENROLLMENT
SEC. 101. ESTABLISHMENT OF THE MEDICARE FOR ALL PROGRAM.
There is hereby established a national health insurance program to
provide comprehensive protection against the costs of health care and
health-related services, in accordance with the standards specified in,
or established under, this Act.
SEC. 102. UNIVERSAL COVERAGE.
(a) In General.--Every individual who is a resident of the United
States is entitled to benefits for health care services under this Act.
The Secretary shall promulgate a rule that provides criteria for
determining residency for eligibility purposes under this Act.
(b) Treatment of Other Individuals.--The Secretary may make
eligible for benefits for health care services under this Act other
individuals not described in subsection (a), and regulate the
eligibility of such individuals, to ensure that every person in the
United States has access to health care. In regulating such
eligibility, the Secretary shall ensure that individuals are not
allowed to travel to the United States for the sole purpose of
obtaining health care items and services provided under the program
established under this Act.
SEC. 103. FREEDOM OF CHOICE.
Any individual entitled to benefits under this Act may obtain
health services from any institution, agency, or individual qualified
to participate under this Act.
SEC. 104. NON-DISCRIMINATION.
(a) In General.--No person shall, on the basis of race, color,
national origin, age, disability, marital status, citizenship status,
primary language use, genetic conditions, previous or existing medical
conditions, religion, or sex, including sex stereotyping, gender
identity, sexual orientation, and pregnancy and related medical
conditions (including termination of pregnancy), be excluded from
participation in or be denied the benefits of the program established
under this Act (except as expressly authorized by this Act for purposes
of enforcing eligibility standards described in section 102), or be
subject to any reduction of benefits or other discrimination by any
participating provider (as defined in section 301), or any entity
conducting, administering, or funding a health program or activity,
including contracts of insurance, pursuant to this Act.
(b) Claims of Discrimination.--
(1) In general.--The Secretary shall establish a procedure
for adjudication of administrative complaints alleging a
violation of subsection (a).
(2) Jurisdiction.--Any person aggrieved by a violation of
subsection (a) by a covered entity may file suit in any
district court of the United States having jurisdiction of the
parties. A person may bring an action under this paragraph
concurrently as such administrative remedies as established in
paragraph (1).
(3) Damages.--If the court finds a violation of subsection
(a), the court may grant compensatory and punitive damages,
declaratory relief, injunctive relief, attorneys' fees and
costs, or other relief as appropriate.
(c) Continued Application of Laws.--Nothing in this title (or an
amendment made by this title) shall be construed to invalidate or
otherwise limit any of the rights, remedies, procedures, or legal
standards available to individuals aggrieved under section 1557 of the
Patient Protection and Affordable Care Act (42 U.S.C. 18116), title VI
of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title VII of
the Civil Rights Act of 1964 (42 U.S.C. 2000e et seq.), title IX of the
Education Amendments of 1972 (20 U.S.C. 1681 et seq.), section 504 of
the Rehabilitation Act of 1973 (29 U.S.C. 794), or the Age
Discrimination Act of 1975 (42 U.S.C. 611 et seq.). Nothing in this
title (or an amendment to this title) shall be construed to supersede
State laws that provide additional protections against discrimination
on any basis described in subsection (a).
SEC. 105. ENROLLMENT.
(a) In General.--The Secretary shall provide a mechanism for the
enrollment of individuals eligible for benefits under this Act. The
mechanism shall--
(1) include a process for the automatic enrollment of
individuals at the time of birth in the United States (or upon
establishment of residency in the United States);
(2) provide for the enrollment, as of the dates described
in section 106, of all individuals who are eligible to be
enrolled as of such dates, as applicable; and
(3) include a process for the enrollment of individuals
made eligible for health care services under section 102(b).
(b) Issuance of Universal Medicare Cards.--In conjunction with an
individual's enrollment for benefits under this Act, the Secretary
shall provide for the issuance of a Universal Medicare card that shall
be used for purposes of identification and processing of claims for
benefits under this program. The card shall not include an individual's
Social Security number.
SEC. 106. EFFECTIVE DATE OF BENEFITS.
(a) In General.--Except as provided in subsection (b), benefits
shall first be available under this Act for items and services
furnished 2 years after the date of the enactment of this Act.
(b) Coverage for Certain Individuals.--
(1) In general.--For any eligible individual who--
(A) has not yet attained the age of 19 as of the
date that is 1 year after the date of the enactment of
this Act; or
(B) has attained the age of 55 as of the date that
is 1 year after the date of the enactment of this Act,
benefits shall first be available under this Act for items and
services furnished as of such date.
(2) Option to continue in other coverage during transition
period.--Any person who is eligible to receive benefits as
described in paragraph (1) may opt to maintain any coverage
described in section 901, private health insurance coverage, or
coverage offered pursuant to subtitle A of title X (including
the amendments made by such subtitle) until the date described
in subsection (a).
SEC. 107. PROHIBITION AGAINST DUPLICATING COVERAGE.
(a) In General.--Beginning on the effective date described in
section 106(a), it shall be unlawful for--
(1) a private health insurer to sell health insurance
coverage that duplicates the benefits provided under this Act;
or
(2) an employer to provide benefits for an employee, former
employee, or the dependents of an employee or former employee
that duplicate the benefits provided under this Act.
(b) Construction.--Nothing in this Act shall be construed as
prohibiting the sale of health insurance coverage for any additional
benefits not covered by this Act, including additional benefits that an
employer may provide to employees or their dependents, or to former
employees or their dependents.
TITLE II--COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE BENEFITS AND
BENEFITS FOR LONG-TERM CARE
SEC. 201. COMPREHENSIVE BENEFITS.
(a) In General.--Subject to the other provisions of this title and
titles IV through IX, individuals enrolled for benefits under this Act
are entitled to have payment made by the Secretary to an eligible
provider for the following items and services if medically necessary or
appropriate for the maintenance of health or for the diagnosis,
treatment, or rehabilitation of a health condition:
(1) Hospital services, including inpatient and outpatient
hospital care, including 24-hour-a-day emergency services and
inpatient prescription drugs.
(2) Ambulatory patient services.
(3) Primary and preventive services, including chronic
disease management.
(4) Prescription drugs and medical devices, including
outpatient prescription drugs, medical devices, and biological
products, and all contraceptive items approved by the Food and
Drug Administration.
(5) Mental health and substance use treatment services,
including inpatient care.
(6) Laboratory and diagnostic services.
(7) Comprehensive reproductive care, including abortion,
contraception, and assistive reproductive technology.
(8) Maternity and newborn care.
(9) Comprehensive gender affirming health care.
(10) Oral health, audiology, and vision services.
(11) Rehabilitative and habilitative services and devices.
(12) Emergency services and transportation.
(13) Early and periodic screening, diagnostic, and
treatment services, as described in sections 1902(a)(10)(A),
1902(a)(43), 1905(a)(4)(B), and 1905(r) of the Social Security
Act (42 U.S.C. 1396a(a)(10)(A); 1396a(a)(43); 1396d(a)(4)(B);
1396d(r)).
(14) Necessary transportation to receive health care
services for persons with disabilities, older individuals with
functional limitations, or low-income individuals (as
determined by the Secretary).
(15) Long-term care services and support (as described in
section 204).
(16) Hospice care.
(17) Services provided by a licensed marriage and family
therapist or a licensed mental health counselor.
(18) Any service described in a preceding paragraph that is
furnished via telehealth, to the extent practical.
(b) Revision.--The Secretary shall, at least annually, and on a
regular basis, evaluate whether the benefits package should be improved
to promote the health of beneficiaries, account for changes in medical
practice or new information from medical research, or respond to other
relevant developments in health science, and shall make recommendations
to Congress regarding any such improvements. Such recommendations may
not include a recommendation to eliminate any benefit.
(c) Hearings.--
(1) In general.--The Committee on Energy and Commerce and
the Committee on Ways and Means of the House of Representatives
shall, not less frequently than annually, hold a hearing on the
recommendations submitted by the Secretary under subsection
(b).
(2) Exercise of rulemaking authority.--Paragraph (1) is
enacted--
(A) as an exercise of rulemaking power of the House
of Representatives, and, as such, shall be considered
as part of the rules of the House, and such rules shall
supersede any other rule of the House only to the
extent that rule is inconsistent therewith; and
(B) with full recognition of the constitutional
right of either House to change such rules (so far as
relating to the procedure in such House) at any time,
in the same manner, and to the same extent as in the
case of any other rule of the House.
(d) Complementary and Integrative Medicine.--
(1) In general.--In carrying out subsection (b), the
Secretary shall consult with the persons described in paragraph
(2) with respect to--
(A) identifying specific complementary and
integrative medicine practices that are appropriate to
include in the benefits package; and
(B) identifying barriers to the effective provision
and integration of such practices into the delivery of
health care, and identifying mechanisms for overcoming
such barriers.
(2) Consultation.--In accordance with paragraph (1), the
Secretary shall consult with--
(A) the Director of the National Center for
Complementary and Integrative Health;
(B) the Commissioner of Food and Drugs;
(C) institutions of higher education, private
research institutes, and individual researchers with
extensive experience in complementary and alternative
medicine and the integration of such practices into the
delivery of health care;
(D) nationally recognized providers of
complementary and integrative medicine; and
(E) such other officials, entities, and individuals
with expertise on complementary and integrative
medicine as the Secretary determines appropriate.
(e) States May Provide Additional Benefits.--Individual States may
provide additional benefits for the residents of such States, as
determined by such State, and may provide benefits to individuals not
eligible for benefits under this Act, at the expense of the State,
subject to the requirements specified in section 1102.
SEC. 202. NO COST-SHARING; OTHER LIMITATIONS.
(a) In General.--The Secretary shall ensure that no cost-sharing,
including deductibles, coinsurance, copayments, or similar charges, is
imposed on an individual for any benefits provided under this Act.
(b) No Balance Billing.--No provider may impose a charge to an
enrolled individual for covered services for which benefits are
provided under this Act.
(c) No Prior Authorization.--Benefits provided under this Act shall
be covered without any need for any prior authorization determination
and without any limitation applied through the use of step therapy
protocols.
SEC. 203. EXCLUSIONS AND LIMITATIONS.
(a) In General.--Benefits for items and services are not available
under this Act unless the items and services meet the standards
developed by the Secretary pursuant to section 201(a).
(b) Treatment of Experimental Items and Services and Drugs.--
(1) In general.--In applying subsection (a), the Secretary
shall make national coverage determinations with respect to
items and services that are experimental in nature. Such
determinations shall be consistent with the national coverage
determination process as defined in section 1869(f)(1)(B) of
the Social Security Act (42 U.S.C. 1395ff(f)(1)(B)).
(2) Appeals process.--The Secretary shall establish a
process by which individuals can appeal coverage decisions. The
process shall, as much as is feasible, follow the process for
appeals under the Medicare program described in section 1869 of
the Social Security Act (42 U.S.C. 1395ff).
(c) Application of Practice Guidelines.--
(1) In general.--In the case of items and services for
which the Department of Health and Human Services has
recognized a national practice guideline, such items and
services shall be deemed to meet the standards specified in
section 201(a) if they have been provided in accordance with
such guideline. For purposes of this subsection, an item or
service not provided in accordance with a practice guideline
shall be deemed to have been provided in accordance with the
guideline if the health care provider providing the item or
service--
(A) exercised appropriate professional judgment in
accordance with the laws and requirements of the State
in which such item or service is furnished in deviating
from the guideline;
(B) acted in the best interest of the individual
receiving the item or service; and
(C) acted in a manner consistent with the
individual's wishes.
(2) Override of standards.--
(A) In general.--An individual's treating physician
or other health care professional authorized to
exercise independent professional judgment in
implementing a patient's medical or nursing care plan
in accordance with the scope of practice, licensure,
and other law of the State where items and services are
to be furnished may override practice standards
established pursuant to section 201(a) or practice
guidelines described in paragraph (1), including such
standards and guidelines that are implemented by a
provider through the use of health information
technology, such as electronic health record
technology, clinical decision support technology, and
computerized order entry programs.
(B) Limitation.--An override described in
subparagraph (A) shall, in the professional judgment of
such physician, nurse, or health care professional,
be--
(i) consistent with such physician's,
nurse's, or health care professional's
determination of medical necessity and
appropriateness or nursing assessment;
(ii) in the best interests of the
individual; and
(iii) consistent with the individual's
wishes.
SEC. 204. COVERAGE OF LONG-TERM CARE SERVICES.
(a) In General.--Subject to the other provisions of this Act,
individuals enrolled for benefits under this Act are entitled to the
following long-term services and supports and to have payment made by
the Secretary to an eligible provider for such services and supports if
medically necessary and appropriate and in accordance with the
standards established in this Act, for maintenance of health or for
care, services, diagnosis, treatment, or rehabilitation that is related
to a medically determinable condition, whether physical or mental, of
health, injury, or age that--
(1) causes a functional limitation in performing one or
more activities of daily living; or
(2) requires a similar need of assistance in performing
instrumental activities of daily living.
(b) Eligibility.--An individual shall be eligible for services and
supports described in this section if such individual has one or more
medically determinable conditions described in subsection (a).
(c) Services and Supports.--Long-term services and supports under
this section shall be tailored to an individual's needs, as determined
through assessment, and shall be defined by the Secretary to--
(1) include any long-term nursing services for the
enrollee, whether provided in an institution or in a home- and
community-based setting;
(2) provide coverage for a broad spectrum of long-term
services and supports, including for home- and community-based
services and other care provided through non-institutional
settings;
(3) provide coverage that meets the physical, mental, and
social needs of recipients while allowing recipients their
maximum possible autonomy and their maximum possible civic,
social, and economic participation;
(4) prioritize delivery of long-term services and supports
through home- and community-based services over
institutionalization;
(5) unless an individual elects otherwise, ensure that
recipients will receive home- and community -based long-term
services and supports (as defined in subsection (f)(4)),
regardless of the individuals's type or level of disability,
service need, or age;
(6) be provided with the goal of enabling persons with
disabilities to receive services in the least restrictive and
most integrated setting appropriate to the individual's needs;
(7) be provided in such a manner that allows persons with
disabilities to maintain their independence, self-
determination, and dignity;
(8) provide long-term services and supports that are of
equal quality and equally accessible across geographic regions;
and
(9) ensure that long-term services and supports provide
recipients the option of self-direction of services from either
the recipient or care coordinators of the recipient's choosing.
(d) Public Consultation.--In developing regulations to implement
this section, the Secretary shall consult with an advisory commission
on long-term services and supports that includes--
(1) people with disabilities who use long-term services and
supports and older adults who use long-term services and
supports;
(2) representatives of people with disabilities and
representatives of older adults;
(3) groups that represent the diversity of the population
of people living with disabilities, including racial, ethnic,
national origin, primary language use, age, sex, including
gender identity and sexual orientation, geographical, and
socioeconomic diversity;
(4) providers of long-term services and supports, including
family attendants and family caregivers, and members of
organized labor;
(5) disability rights organizations; and
(6) relevant academic institutions and researchers.
(e) Budgeting and Payments.--Budgeting and payments for long-term
services and supports provided under this section shall be made in
accordance with the provisions under title VI.
(f) Definitions.--In this section:
(1) The term ``long-term services and supports'' means
long-term care, treatment, maintenance, or services needed to
support the activities of daily living and instrumental
activities of daily living, including home- and community-based
services and any additional services and supports identified by
the Secretary to support people with disabilities to live,
work, and participate in their communities.
(2) The term ``activities of daily living'' means basic
personal everyday activities, including tasks such as eating,
toileting, grooming, dressing, bathing, and transferring.
(3) The term ``instrumental activities of daily living''
means activities related to living independently in the
community, including meal planning and preparation, managing
finances, shopping for food, clothing, and other essential
items, performing essential household chores, communicating by
phone or other media, and traveling around and participating in
the community.
(4) The term ``home and community-based services'' means
the home and community-based services that are coverable under
subsections (c), (d), (i), and (k) of section 1915 of the
Social Security Act (42 U.S.C. 1396n), and as defined by the
Secretary, including as defined in the home and community-based
services settings rule in sections 441.530 and 441.710 of title
42, Code of Federal Regulations (or a successor regulation).
TITLE III--PROVIDER PARTICIPATION
SEC. 301. PROVIDER PARTICIPATION AND STANDARDS; WHISTLEBLOWER
PROTECTIONS.
(a) In General.--An individual or other entity furnishing any
covered item or service under this Act is not a qualified provider
unless the individual or entity--
(1) is a qualified provider of the items or services under
section 302;
(2) has filed with the Secretary a participation agreement
described in subsection (b); and
(3) meets, as applicable, such other qualifications and
conditions with respect to a provider of services under title
XVIII of the Social Security Act as described in section 1866
of the Social Security Act (42 U.S.C. 1395cc).
(b) Requirements in Participation Agreement.--
(1) In general.--A participation agreement described in
this subsection between the Secretary and a provider shall
provide at least for the following:
(A) Items and services to eligible persons shall be
furnished by the provider without discrimination, in
accordance with section 104(a). Nothing in this
subparagraph shall be construed as requiring the
provision of a type or class of items or services that
are outside the scope of the provider's normal
practice.
(B) No charge will be made to any enrolled
individual for any covered items or services other than
for payment authorized by this Act.
(C) The provider agrees to furnish such information
as may be reasonably required by the Secretary, in
accordance with uniform reporting standards established
under section 401(b)(1), for--
(i) quality review by designated entities;
(ii) making payments under this Act,
including the examination of records as may be
necessary for the verification of information
on which such payments are based;
(iii) statistical or other studies required
for the implementation of this Act; and
(iv) such other purposes as the Secretary
may specify.
(D) In the case of a provider that is not an
individual, the provider agrees not to employ or use
for the provision of health services any individual or
other provider that has had a participation agreement
under this subsection terminated for cause. The
Secretary may authorize such employment or use on a
case-by-case basis.
(E) In the case of a provider paid under a fee-for-
service basis for items and services furnished under
this Act, the provider agrees to submit bills and any
required supporting documentation relating to the
provision of covered items and services within 30 days
after the date of providing such items and services.
(F) In the case of an institutional provider paid
pursuant to section 611, the provider agrees to submit
information and any other required supporting
documentation as may be reasonably required by the
Secretary within 30 days after the date of providing
such items and services and in accordance with the
uniform reporting standards established under section
401(b)(1), including information on a quarterly basis
that--
(i) relates to the provision of covered
items and services; and
(ii) describes items and services furnished
with respect to specific individuals.
(G) In the case of a provider that receives payment
for items and services furnished under this Act based
on diagnosis-related coding, procedure coding, or other
coding system or data, the provider agrees--
(i) to disclose to the Secretary any system
or index of coding or classifying patient
symptoms, diagnoses, clinical interventions,
episodes, or procedures that such provider
utilizes for global budget negotiations under
title VI or for meeting any other payment,
documentation, or data collection requirements
under this Act; and
(ii) not to use any such system or index to
establish financial incentives or disincentives
for health care professionals, or that is
proprietary, interferes with the medical or
nursing process, or is designed to increase the
amount or number of payments.
(H) The provider complies with the duty of provider
ethics and reporting requirements described in
paragraph (2).
(I) In the case of a provider that is not an
individual, the provider agrees that no board member,
executive, or administrator of such provider receives
compensation from, owns stock or has other financial
investments in, or serves as a board member of any
entity that contracts with or provides items or
services, including pharmaceutical products and medical
devices or equipment, to such provider.
(2) Provider duty of ethics.--Each health care provider,
including institutional providers, has a duty to advocate for
and to act in the exclusive interest of each individual under
the care of such provider according to the applicable legal
standard of care, such that no financial interest or
relationship impairs any health care provider's ability to
furnish necessary and appropriate care to such individual. To
implement the duty established in this paragraph, the Secretary
shall--
(A) promulgate reasonable reporting rules to
evaluate participating provider compliance with this
paragraph;
(B) prohibit participating providers, spouses, and
immediate family members of participating providers,
from accepting or entering into any arrangement for any
bonus, incentive payment, profit-sharing, or
compensation based on patient utilization or based on
financial outcomes of any other provider or entity; and
(C) prohibit participating providers or any board
member or representative of such provider from serving
as board members for or receiving any compensation,
stock, or other financial investment in an entity that
contracts with or provides items or services (including
pharmaceutical products and medical devices or
equipment) to such provider.
(3) Termination of participation agreement.--
(A) In general.--Participation agreements may be
terminated, with appropriate notice--
(i) by the Secretary for failure to meet
the requirements of this Act;
(ii) in accordance with the provisions
described in section 411; or
(iii) by a provider.
(B) Termination process.--Providers shall be
provided notice and a reasonable opportunity to correct
deficiencies before the Secretary terminates an
agreement unless a more immediate termination is
required for public safety or similar reasons.
(C) Provider protections.--
(i) Prohibition.--The Secretary may not
terminate a participation agreement or in any
other way discriminate against, or cause to be
discriminated against, any covered provider or
authorized representative of the provider, on
account of such provider or representative--
(I) providing, causing to be
provided, or being about to provide or
cause to be provided to the provider,
the Federal Government, or the attorney
general of a State information relating
to any violation of, or any act or
omission the provider or representative
reasonably believes to be a violation
of, any provision of this title (or an
amendment made by this title);
(II) testifying or being about to
testify in a proceeding concerning such
violation;
(III) assisting or participating,
or being about to assist or
participate, in such a proceeding; or
(IV) objecting to, or refusing to
participate in, any activity, policy,
practice, or assigned task that the
provider or representative reasonably
believes to be in violation of any
provision of this Act (including any
amendment made by this Act), or any
order, rule, regulation, standard, or
ban under this Act (including any
amendment made by this Act).
(ii) Complaint procedure.--A provider or
representative who believes that he or she has
been discriminated against in violation of this
section may seek relief in accordance with the
procedures, notifications, burdens of proof,
remedies, and statutes of limitation set forth
in section 2087(b) of title 15, United States
Code.
(c) Whistleblower Protections.--
(1) Retaliation prohibited.--No person may discharge or
otherwise discriminate against any employee because the
employee or any person acting pursuant to a request of the
employee--
(A) notified the Secretary or the employee's
employer of any alleged violation of this title,
including communications related to carrying out the
employee's job duties;
(B) refused to engage in any practice made unlawful
by this title, if the employee has identified the
alleged illegality to the employer;
(C) testified before or otherwise provided
information relevant for Congress or for any Federal or
State proceeding regarding any provision (or proposed
provision) of this title;
(D) commenced, caused to be commenced, or is about
to commence or cause to be commenced a proceeding under
this title;
(E) testified or is about to testify in any such
proceeding; or
(F) assisted or participated or is about to assist
or participate in any manner in such a proceeding or in
any other manner in such a proceeding or in any other
action to carry out the purposes of this title.
(2) Enforcement action.--Any employee covered by this
section who alleges discrimination by an employer in violation
of paragraph (1) may bring an action, subject to the statute of
limitations in the anti-retaliation provisions of the False
Claims Act and the rules and procedures, legal burdens of
proof, and remedies applicable under the employee protections
provisions of the Surface Transportation Assistance Act.
(3) Application.--
(A) Nothing in this subsection shall be construed
to diminish the rights, privileges, or remedies of any
employee under any Federal or State law or regulation,
including the rights and remedies against retaliatory
action under the False Claims Act (31 U.S.C. 3730(h)),
or under any collective bargaining agreement. The
rights and remedies in this section may not be waived
by any agreement, policy, form, or condition of
employment.
(B) Nothing in this subsection shall be construed
to preempt or diminish any other Federal or State law
or regulation against discrimination, demotion,
discharge, suspension, threats, harassment, reprimand,
retaliation, or any other manner of discrimination,
including the rights and remedies against retaliatory
action under the False Claims Act (31 U.S.C. 3730(h)).
(4) Definitions.--In this subsection:
(A) Employer.--The term ``employer'' means any
person engaged in profit or nonprofit business or
industry, including one or more individuals,
partnerships, associations, corporations, trusts,
professional membership organization including a
certification, disciplinary, or other professional
body, unincorporated organizations, nongovernmental
organizations, or trustees, and subject to liability
for violating the provisions of this Act.
(B) Employee.--The term ``employee'' means any
individual performing activities under this Act on
behalf of an employer.
SEC. 302. QUALIFICATIONS FOR PROVIDERS.
(a) In General.--A health care provider is considered to be
qualified to furnish covered items and services under this Act if the
provider is licensed or certified to furnish such items and services in
the State in which the individual receiving such items or services is
located and meets--
(1) the requirements of such State's law to furnish such
items and services; and
(2) applicable requirements of Federal law to furnish such
items and services.
(b) Limitation.--An entity or provider shall not be qualified to
furnish covered items and services under this Act if the entity or
provider provides no items and services directly to individuals,
including--
(1) entities or providers that contract with other entities
or providers to provide such items and services; and
(2) entities that are currently approved to coordinate care
plans under the Medicare Advantage program established in part
C of title XVIII of the Social Security Act (42 U.S.C. 1851 et
seq.) but do not directly provide items and services of such
care plans.
(c) Minimum Provider Standards.--
(1) In general.--The Secretary shall establish, evaluate,
and update national minimum standards to ensure the quality of
items and services provided under this Act and to monitor
efforts by States to ensure the quality of such items and
services. A State may establish additional minimum standards
which providers shall meet with respect to items and services
provided in such State.
(2) National minimum standards.--The Secretary shall
establish national minimum standards under paragraph (1) for
institutional providers of services and individual health care
practitioners. Except as the Secretary may specify in order to
carry out this Act, a hospital, skilled nursing facility, or
other institutional provider of services shall meet standards
applicable to such a provider under the Medicare program under
title XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.). Such standards also may include, where appropriate,
elements relating to--
(A) adequacy and quality of facilities;
(B) mandatory minimum safe registered nurse-to-
patient staffing ratios and optimal staffing levels for
physicians and other health care practitioners;
(C) training and competence of personnel (including
requirements related to the number of or type of
required continuing education hours);
(D) comprehensiveness of service;
(E) continuity of service;
(F) patient waiting time, access to services, and
preferences; and
(G) performance standards, including organization,
facilities, structure of services, efficiency of
operation, and outcome in palliation, improvement of
health, stabilization, cure, or rehabilitation.
(3) Transition in application.--If the Secretary provides
for additional requirements for providers under this
subsection, any such additional requirement shall be
implemented in a manner that provides for a reasonable period
during which a previously qualified provider is permitted to
meet such an additional requirement.
(4) Ability to provide services.--With respect to any
entity or provider certified to provide items and services
described in section 201(a)(7), the Secretary may not prohibit
such entity or provider from participating for reasons other
than such entity's or provider's ability to provide such items
and services.
(d) Federal Providers.--Any provider qualified to provide health
care items and services through the Department of Veterans Affairs, the
Indian Health Service, or the uniformed services (with respect to the
direct care component of the TRICARE Program) is a qualifying provider
under this section with respect to any individual who qualifies for
such items and services under applicable Federal law.
SEC. 303. USE OF PRIVATE CONTRACTS.
(a) In General.--This section shall apply beginning 2 years after
the date of the enactment of this Act.
(b) Participating Providers.--
(1) Private contracts for covered items and services for
eligible individuals.--An institutional or individual provider
with an agreement in effect under section 301 may not bill or
enter into any private contract with any individual eligible
for benefits under the Act for any item or service that is a
benefit under this Act.
(2) Private contracts for noncovered items and services for
eligible individuals.--An institutional or individual provider
with an agreement in effect under section 301 may bill or enter
into a private contract with an individual eligible for
benefits under the Act for any item or service that is not a
benefit under this Act only if--
(A) the contract and provider meet the requirements
specified in paragraphs (3) and (4), respectively;
(B) such item or service is not payable or
available under this Act; and
(C) the provider receives--
(i) no reimbursement under this Act
directly or indirectly for such item or
service, and
(ii) receives no amount for such item or
service from an organization which receives
reimbursement for such items or service under
this Act directly or indirectly.
(3) Contract requirements.--Any contract to provide items
and services described in paragraph (2) shall--
(A) be in writing and signed by the individual (or
authorized representative of the individual) receiving
the item or service before the item or service is
furnished pursuant to the contract;
(B) not be entered into at a time when the
individual is facing an emergency health care
situation; and
(C) clearly indicate to the individual receiving
such items and services that by signing such a contract
the individual--
(i) agrees not to submit a claim (or to
request that the provider submit a claim) under
this Act for such items or services;
(ii) agrees to be responsible for payment
of such items or services and understands that
no reimbursement will be provided under this
Act for such items or services;
(iii) acknowledges that no limits under
this Act apply to amounts that may be charged
for such items or services; and
(iv) acknowledges that the provider is
providing services outside the scope of the
program under this Act.
(4) Affidavit.--A participating provider who enters into a
contract described in paragraph (2) shall have in effect during
the period any item or service is to be provided pursuant to
the contract an affidavit that shall--
(A) identify the provider who is to furnish such
noncovered item or service, and be signed by such
provider;
(B) state that the provider will not submit any
claim under this Act for any noncovered item or service
provided to any individual enrolled under this Act; and
(C) be filed with the Secretary no later than 10
days after the first contract to which such affidavit
applies is entered into.
(5) Enforcement.--If a provider signing an affidavit
described in paragraph (4) knowingly and willfully submits a
claim under this title for any item or service provided or
receives any reimbursement or amount for any such item or
service provided pursuant to a private contract described in
paragraph (2) with respect to such affidavit--
(A) any contract described in paragraph (2) shall
be null and void;
(B) no payment shall be made under this title for
any item or service furnished by the provider during
the 2-year period beginning on the date the affidavit
was signed; and
(C) any payment received under this title for any
item or service furnished during such period shall be
remitted.
(6) Private contracts for ineligible individuals.--An
institutional or individual provider with an agreement in
effect under section 301 may bill or enter into a private
contract with any individual ineligible for benefits under the
Act for any item or service.
(c) Nonparticipating Providers.--
(1) Private contracts for covered items and services for
eligible individuals.--An institutional or individual provider
with no agreement in effect under section 301 may bill or enter
into any private contract with any individual eligible for
benefits under the Act for any item or service that is a
benefit under this Act described in title II only if the
contract and provider meet the requirements specified in
paragraphs (2) and (3), respectively.
(2) Items required to be included in contract.--Any
contract to provide items and services described in paragraph
(1) shall--
(A) be in writing and signed by the individual (or
authorized representative of the individual) receiving
the item or service before the item or service is
furnished pursuant to the contract;
(B) not be entered into at a time when the
individual is facing an emergency health care
situation; and
(C) clearly indicate to the individual receiving
such items and services that by signing such a contract
the individual--
(i) acknowledges that the individual has
the right to have such items or services
provided by other providers for whom payment
would be made under this Act;
(ii) agrees not to submit a claim (or to
request that the provider submit a claim) under
this Act for such items or services even if
such items or services are otherwise covered by
this Act;
(iii) agrees to be responsible for payment
of such items or services and understands that
no reimbursement will be provided under this
Act for such items or services;
(iv) acknowledges that no limits under this
Act apply to amounts that may be charged for
such items or services; and
(v) acknowledges that the provider is
providing services outside the scope of the
program under this Act.
(3) Affidavit.--A provider who enters into a contract
described in paragraph (1) shall have in effect during the
period any item or service is to be provided pursuant to the
contract an affidavit that shall--
(A) identify the provider who is to furnish such
covered item or service, and be signed by such
provider;
(B) state that the provider will not submit any
claim under this Act for any covered item or service
provided to any individual enrolled under this Act
during the 2-year period beginning on the date the
affidavit is signed; and
(C) be filed with the Secretary no later than 10
days after the first contract to which such affidavit
applies is entered into.
(4) Enforcement.--If a provider signing an affidavit
described in paragraph (3) knowingly and willfully submits a
claim under this title for any item or service provided or
receives any reimbursement or amount for any such item or
service provided pursuant to a private contract described in
paragraph (1) with respect to such affidavit--
(A) any contract described in paragraph (1) shall
be null and void; and
(B) no payment shall be made under this title for
any item or service furnished by the provider during
the 2-year period beginning on the date the affidavit
was signed.
(5) Private contracts for noncovered items and services for
any individual.--An institutional or individual provider with
no agreement in effect under section 301 may bill or enter into
a private contract with any individual for a item or service
that is not a benefit under this Act.
TITLE IV--ADMINISTRATION
Subtitle A--General Administration Provisions
SEC. 401. ADMINISTRATION.
(a) General Duties of the Secretary.--
(1) In general.--The Secretary shall develop policies,
procedures, guidelines, and requirements to carry out this Act,
including related to--
(A) eligibility for benefits;
(B) enrollment;
(C) benefits provided;
(D) provider participation standards and
qualifications, as described in title III;
(E) levels of funding;
(F) methods for determining amounts of payments to
providers of covered items and services, consistent
with subtitle B;
(G) a process for appealing or petitioning for a
determination of coverage or noncoverage of items and
services under this Act;
(H) planning for capital expenditures and service
delivery;
(I) planning for health professional education
funding;
(J) encouraging States to develop regional planning
mechanisms; and
(K) any other regulations necessary to carry out
the purposes of this Act.
(2) Regulations.--Regulations authorized by this Act shall
be issued by the Secretary in accordance with section 553 of
title 5, United States Code.
(3) Accessibility.--The Secretary shall have the obligation
to ensure the timely and accessible provision of items and
services that all eligible individuals are entitled to under
this Act.
(b) Uniform Reporting Standards; Annual Report; Studies.--
(1) Uniform reporting standards.--
(A) In general.--The Secretary shall establish
uniform State reporting requirements and national
standards to ensure an adequate national database
containing information pertaining to health services
practitioners, approved providers, the costs of
facilities and practitioners providing items and
services, the quality of such items and services, the
outcomes of such items and services, and the equity of
health among population groups. Such database shall
include, to the maximum extent feasible without
compromising patient privacy, health outcome measures
used under this Act, and to the maximum extent feasible
without excessively burdening providers, a description
of the standards and qualifications, levels of finding,
and methods described in subparagraphs (D) through (F)
of subsection (a)(1).
(B) Required data disclosures.--In establishing
reporting requirements and standards under subparagraph
(A), the Secretary shall require a provider with an
agreement in effect under section 301 to disclose to
the Secretary, in a time and manner specified by the
Secretary, the following (as applicable to the type of
provider):
(i) Any data the provider is required to
report or does report to any State or local
agency, or, as of January 1, 2019, to the
Secretary or any entity that is part of the
Department of Health and Human Services, except
data that are required under the programs
terminated in section 903.
(ii) Annual financial data that includes
information on employees (including the number
of employees, hours worked, and wage
information) by job title and by each patient
care unit or department within each facility
(including outpatient units or departments);
the number of registered nurses per staffed bed
by each such unit or department; information on
the dollar value and annual spending (including
purchases, upgrades, and maintenance) for
health information technology; and risk-
adjusted and raw patient outcome data
(including data on medical, surgical,
obstetric, and other procedures).
(C) Reports.--The Secretary shall regularly analyze
information reported to the Secretary and shall define
rules and procedures to allow researchers, scholars,
health care providers, and others to access and analyze
data for purposes consistent with quality and outcomes
research, without compromising patient privacy.
(2) Annual report.--Beginning 2 years after the date of the
enactment of this Act, the Secretary shall annually report to
Congress on the following:
(A) The status of implementation of the Act.
(B) Enrollment under this Act.
(C) Benefits under this Act.
(D) Expenditures and financing under this Act.
(E) Cost-containment measures and achievements
under this Act.
(F) Quality assurance.
(G) Health care utilization patterns, including any
changes attributable to the program.
(H) Changes in the per-capita costs of health care.
(I) Differences in the health status of the
populations of the different States, including by
racial, ethnic, national origin, primary language use,
age, disability, sex, including gender identity and
sexual orientation, geographical, and income
characteristics.
(J) Progress on quality and outcome measures, and
long-range plans and goals for achievements in such
areas.
(K) Plans for improving service to medically
underserved populations.
(L) Transition problems as a result of
implementation of this Act.
(M) Opportunities for improvements under this Act.
(3) Statistical analyses and other studies.--The Secretary
may, either directly or by contract--
(A) make statistical and other studies, on a
nationwide, regional, State, or local basis, of any
aspect of the operation of this Act;
(B) develop and test methods of delivery of items
and services as the Secretary may consider necessary or
promising for the evaluation, or for the improvement,
of the operation of this Act; and
(C) develop methodological standards for
policymaking.
(c) Audits.--
(1) In general.--The Comptroller General of the United
States shall conduct an audit of the Department of Health and
Human Services every fifth fiscal year following the effective
date of this Act to determine the effectiveness of the program
in carrying out the duties under subsection (a).
(2) Reports.--The Comptroller General of the United States
shall submit a report to Congress concerning the results of
each audit conducted under this subsection.
SEC. 402. CONSULTATION.
The Secretary shall consult with Federal agencies, Indian tribes
and urban Indian health organizations, and private entities, such as
labor organizations representing health care workers, professional
societies, national associations, nationally recognized associations of
health care experts, medical schools and academic health centers,
consumer groups, and business organizations in the formulation of
guidelines, regulations, policy initiatives, and information gathering
to ensure the broadest and most informed input in the administration of
this Act. Nothing in this Act shall prevent the Secretary from adopting
guidelines, consistent with the provisions of section 203(c), developed
by such a private entity if, in the Secretary's judgment, such
guidelines are generally accepted as reasonable and prudent and
consistent with this Act.
SEC. 403. REGIONAL ADMINISTRATION.
(a) Coordination With Regional Offices.--The Secretary shall
establish and maintain regional offices for purposes of carrying out
the duties specified in subsection (c) and promoting adequate access
to, and efficient use of, tertiary care facilities, equipment, and
services by individuals enrolled under this Act. Wherever possible, the
Secretary shall incorporate regional offices of the Centers for
Medicare & Medicaid Services for this purpose.
(b) Appointment of Regional Directors.--In each such regional
office there shall be--
(1) one regional director appointed by the Secretary;
(2) one deputy director appointed by the regional director
to represent the Indian and Alaska Native tribes in the region,
if any; and
(3) one deputy direction appointed by the regional director
to oversee long-term services and supports.
(c) Regional Office Duties.--Each regional director shall--
(1) provide an annual health care needs assessment with
respect to the region under the director's jurisdiction to the
Secretary after a thorough examination of health needs and in
consultation with public health officials, clinicians,
patients, and patient advocates;
(2) recommend any changes in provider reimbursement or
payment for delivery of health services determined appropriate
by the regional director, subject to the provisions of title
VI; and
(3) establish a quality assurance mechanism in each such
region in order to minimize both underutilization and
overutilization of health care items and services and to ensure
that all providers meet quality standards established pursuant
to this Act.
SEC. 404. BENEFICIARY OMBUDSMAN.
(a) In General.--The Secretary shall appoint a Beneficiary
Ombudsman who shall have expertise and experience in the fields of
health care and education of, and assistance to, individuals enrolled
under this Act.
(b) Duties.--The Beneficiary Ombudsman shall--
(1) receive complaints, grievances, and requests for
information submitted by individuals enrolled under this Act or
eligible to enroll under this Act with respect to any aspect of
the Medicare for All Program;
(2) provide assistance with respect to complaints,
grievances, and requests referred to in paragraph (1),
including assistance in collecting relevant information for
such individuals, to seek an appeal of a decision or
determination made by a regional office or the Secretary; and
(3) submit annual reports to Congress and the Secretary
that describe the activities of the Ombudsman and that include
such recommendations for improvement in the administration of
this Act as the Ombudsman determines appropriate. The Ombudsman
shall not serve as an advocate for any increases in payments or
new coverage of services, but may identify issues and problems
in payment or coverage policies.
SEC. 405. CONDUCT OF RELATED HEALTH PROGRAMS.
In performing functions with respect to health personnel education
and training, health research, environmental health, disability
insurance, vocational rehabilitation, the regulation of food and drugs,
and all other matters pertaining to health, the Secretary shall direct
the activities of the Department of Health and Human Services toward
contributions to the health of the people complementary to this Act.
Subtitle B--Control Over Fraud and Abuse
SEC. 411. APPLICATION OF FEDERAL SANCTIONS TO ALL FRAUD AND ABUSE UNDER
THE MEDICARE FOR ALL PROGRAM.
The following sections of the Social Security Act shall apply to
this Act in the same manner as they apply to title XVIII or State plans
under title XIX of the Social Security Act:
(1) Section 1128 (relating to exclusion of individuals and
entities).
(2) Section 1128A (civil monetary penalties).
(3) Section 1128B (criminal penalties).
(4) Section 1124 (relating to disclosure of ownership and
related information).
(5) Section 1126 (relating to disclosure of certain
owners).
(6) Section 1877 (relating to physician referrals).
TITLE V--QUALITY ASSESSMENT
SEC. 501. QUALITY STANDARDS.
(a) In General.--All standards and quality measures under this Act
shall be implemented and evaluated by the Center for Clinical Standards
and Quality of the Centers for Medicare & Medicaid Services (referred
to in this title as the ``Center'') or such other agency determined
appropriate by the Secretary, in coordination with the Agency for
Healthcare Research and Quality and other offices of the Department of
Health and Human Services.
(b) Duties of the Center.--The Center shall perform the following
duties:
(1) Review and evaluate each practice guideline developed
under part B of title IX of the Public Health Service Act. In
so reviewing and evaluating, the Center shall determine whether
the guideline should be recognized as a national practice
guideline in accordance with and subject to the provisions of
section 203(c).
(2) Review and evaluate each standard of quality,
performance measure, and medical review criterion developed
under part B of title IX of the Public Health Service Act (42
U.S.C. 299 et seq.). In so reviewing and evaluating, the Center
shall determine whether the standard, measure, or criterion is
appropriate for use in assessing or reviewing the quality of
items and services provided by health care institutions or
health care professionals. The use of mechanisms that
discriminate against people with disabilities is prohibited for
use in any value or cost-effectiveness assessments. The Center
shall consider the evidentiary basis for the standard, and the
validity, reliability, and feasibility of measuring the
standard.
(3) Adoption of methodologies for profiling the patterns of
practice of health care professionals and for identifying and
notifying outliers.
(4) Development of minimum criteria for competence for
entities that can qualify to conduct ongoing and continuous
external quality reviews in the administrative regions. Such
criteria shall require such an entity to be administratively
independent of the individual or board that administers the
region and shall ensure that such entities do not provide
financial incentives to reviewers to favor one pattern of
practice over another. The Center shall ensure coordination and
reporting by such entities to ensure national consistency in
quality standards.
(5) Submission of a report to the Secretary annually
specifically on findings from outcomes research and development
of practice guidelines that may affect the Secretary's
determination of coverage of services under section
401(a)(1)(G).
SEC. 502. ADDRESSING HEALTH CARE DISPARITIES.
(a) Evaluating Data Collection Approaches.--The Center shall
evaluate approaches for the collection of data under this Act, to be
performed in conjunction with existing quality reporting requirements
and programs under this Act, that allow for the ongoing, accurate, and
timely collection of data on disparities in health care services and
performance on the basis of race, ethnicity, national origin, primary
language use, age, disability, sex (including gender identity and
sexual orientation), geography, or socioeconomic status. In conducting
such evaluation, the Center shall consider the following objectives:
(1) Protecting patient privacy.
(2) Minimizing the administrative burdens of data
collection and reporting on providers under this Act.
(3) Improving data on race, ethnicity, national origin,
primary language use, age, disability, sex (including gender
identity and sexual orientation), geography, and socioeconomic
status.
(b) Reports to Congress.--
(1) Report on evaluation.--Not later than 18 months after
the date on which benefits first become available as described
in section 106(a), the Center shall submit to Congress and the
Secretary a report on the evaluation conducted under subsection
(a). Such report shall, taking into consideration the results
of such evaluation--
(A) identify approaches (including defining
methodologies) for identifying and collecting and
evaluating data on health care disparities on the basis
of race, ethnicity, national origin, primary language
use, age, disability, sex (including gender identity
and sexual orientation), geography, or socioeconomic
status under the Medicare for All Program; and
(B) include recommendations on the most effective
strategies and approaches to reporting quality
measures, as appropriate, on the basis of race,
ethnicity, national origin, primary language use, age,
disability, sex (including gender identity and sexual
orientation), geography, or socioeconomic status.
(2) Report on data analyses.--Not later than 4 years after
the submission of the report under subsection (b)(1), and every
4 years thereafter, the Center shall submit to Congress and the
Secretary a report that includes recommendations for improving
the identification of health care disparities based on the
analyses of data collected under subsection (c).
(c) Implementing Effective Approaches.--Not later than 2 years
after the date on which benefits first become available as described in
section 106(a), the Secretary shall implement the approaches identified
in the report submitted under subsection (b)(1) for the ongoing,
accurate, and timely collection and evaluation of data on health care
disparities on the basis of race, ethnicity, national origin, primary
language use, age, disability, sex (including gender identity and
sexual orientation), geography, or socioeconomic status.
TITLE VI--HEALTH BUDGET; PAYMENTS; COST CONTAINMENT MEASURES
Subtitle A--Budgeting
SEC. 601. NATIONAL HEALTH BUDGET.
(a) National Health Budget.--
(1) In general.--By not later than September 1 of each
year, beginning with the year prior to the date on which
benefits first become available as described in section 106(a),
the Secretary shall establish a national health budget, which
specifies a budget for the total expenditures to be made for
covered health care items and services under this Act.
(2) Division of budget into components.--The national
health budget shall consist of the following components:
(A) An operating budget.
(B) A capital expenditures budget.
(C) A special projects budget.
(D) Quality assessment activities under title V.
(E) Health professional education expenditures.
(F) Administrative costs, including costs related
to the operation of regional offices.
(G) A reserve fund.
(H) Prevention and public health activities.
(3) Allocation among components.--The Secretary shall
allocate the funds received for purposes of carrying out this
Act among the components described in paragraph (2) in a manner
that ensures--
(A) that the operating budget allows for every
participating provider in the Medicare for All Program
to meet the needs of their respective patient
populations;
(B) that the special projects budget is sufficient
to meet the health care needs within areas described in
paragraph (2)(C) through the construction, renovation,
and staffing of health care facilities in a reasonable
timeframe;
(C) a fair allocation for quality assessment
activities; and
(D) that the health professional education
expenditure component is sufficient to provide for the
amount of health professional education expenditures
sufficient to meet the need for covered health care
services.
(4) Regional allocation.--The Secretary shall annually
provide each regional office with an allotment the Secretary
determines appropriate for purposes of carrying out this Act in
such region, including payments to providers in such region,
capital expenditures in such region, special projects in such
region, health professional education in such region,
administrative expenses in such region, and prevention and
public health activities in such region.
(5) Operating budget.--The operating budget described in
paragraph (2)(A) shall be used for--
(A) payments to institutional providers pursuant to
section 611; and
(B) payments to individual providers pursuant to
section 612.
(6) Capital expenditures budget.--The capital expenditures
budget described in paragraph (2)(B) shall be used for--
(A) the construction or renovation of health care
facilities, excluding congregate or segregated
facilities for individuals with disabilities who
receive long-term care services and support; and
(B) major equipment purchases.
(7) Special projects budget.--The special projects budget
described in paragraph (2)(C) shall be used for the purposes of
allocating funds for the construction of new facilities, major
equipment purchases, and staffing in rural or medically
underserved areas (as defined in section 330(b)(3) of the
Public Health Service Act (42 U.S.C. 254b(b)(3))), including
areas designated as health professional shortage areas (as
defined in section 332(a) of the Public Health Service Act (42
U.S.C. 254e(a))), and to address health disparities, including
racial, ethnic, national origin, primary language use, age,
disability, sex (including gender identity and sexual
orientation), geography, or socioeconomic health disparities.
(8) Temporary worker assistance.--
(A) In general.--For up to 5 years following the
date on which benefits first become available as
described in section 106(a), at least 1 percent of the
budget shall be allocated to programs providing
assistance to workers who perform functions in the
administration of the health insurance system, or
related functions within health care institutions or
organizations who may be affected by the implementation
of this Act and who may experience economic dislocation
as a result of the implementation of this Act.
(B) Clarification.--Assistance described in
subparagraph (A) shall include wage replacement,
retirement benefits, job training and placement,
preferential hiring, and education benefits.
(9) Reserve fund.--The reserve fund described in paragraph
(2)(G) shall be used to respond to the costs of an epidemic,
pandemic, natural disaster, or other such health emergency, or
market-shift adjustments related to patient volume.
(10) Supplemental indian health service allocation.--The
Secretary shall annually determine the need to provide an
allotment of supplemental funds to Indian Health Services,
including payments to providers, capital expenditures, special
projects, health professional education, administrative
expenses, and prevention and public health activities.
(b) Definitions.--In this section:
(1) Capital expenditures.--The term ``capital
expenditures'' means expenses for the purchase, lease,
construction, or renovation of capital facilities and for major
equipment.
(2) Health professional education expenditures.--The term
``health professional education expenditures'' means
expenditures in hospitals and other health care facilities to
cover costs associated with teaching and related research
activities, including the impact of workforce diversity on
patient outcomes.
Subtitle B--Payments to Providers
SEC. 611. PAYMENTS TO INSTITUTIONAL PROVIDERS BASED ON GLOBAL BUDGETS.
(a) In General.--Not later than the beginning of each fiscal
quarter during which an institutional provider of care (including
hospitals, skilled nursing facilities, Federally qualified health
centers, and independent dialysis facilities) is to furnish items and
services under this Act, the Secretary shall pay to such institutional
provider a lump sum in accordance with the succeeding provisions of
this subsection and consistent with the following:
(1) Payment in full.--Such payment shall be considered as
payment in full for all operating expenses for items and
services furnished under this Act, whether inpatient or
outpatient, by such provider for such quarter, including
outpatient or any other care provided by the institutional
provider or provided by any health care provider who provided
items and services pursuant to an agreement paid through the
global budget as described in paragraph (3).
(2) Quarterly review.--The regional director, on a
quarterly basis, shall review whether requirements of the
institutional provider's participation agreement and negotiated
global budget have been performed and shall determine whether
adjustments to such institutional provider's payment are
warranted. This review shall include consideration for
additional funding necessary for unanticipated items and
services for individuals with complex medical needs or market-
shift adjustments related to patient volume. The review shall
also include an assessment of any adjustments made to ensure
that accuracy and need for adjustment was appropriate.
(3) Agreements for salaried payments for certain
providers.--Certain group practices and other health care
providers, as determined by the Secretary, with agreements to
provide items and services at a specified institutional
provider paid a global budget under this subsection may elect
to be paid through such institutional provider's global budget
in lieu of payment under section 612 of this title. Any--
(A) individual health care professional of such
group practice or other provider receiving payment
through an institutional provider's global budget shall
be paid on a salaried basis that is equivalent to
salaries or other compensation rates negotiated for
individual health care professionals of such
institutional provider; and
(B) any group practice or other health care
provider that receives payment through an institutional
provider global budget under this paragraph shall be
subject to the same reporting and disclosure
requirements of the institutional provider.
(4) Interim adjustments.--The regional director shall
consider a petition for adjustment of any payment under this
section filed by an institutional provider at any time based on
the following:
(A) Factors that led to increased costs for the
institutional provider that can reasonably be
considered to be unanticipated and out of the control
of the institutional provider, such as--
(i) natural disasters;
(ii) outbreaks of epidemics or infectious
diseases;
(iii) unexpected facility or equipment
repairs or purchases;
(iv) significant and unexpected increases
in pharmaceutical or medical device prices; and
(v) unanticipated increases in complex or
high-cost patients or care needs.
(B) Changes in Federal or State law that result in
a change in costs.
(C) Reasonable increases in labor costs, including
salaries and benefits, and changes in collective
bargaining agreements, prevailing wage, or local law.
(b) Payment Amount.--
(1) In general.--The amount of each payment to a provider
described in subsection (a) shall be determined before the
start of each fiscal year through negotiations between the
provider and the regional director with jurisdiction over such
provider. Such amount shall be based on factors specified in
paragraph (2).
(2) Payment factors.--Payments negotiated pursuant to
paragraph (1) shall take into account, with respect to a
provider--
(A) the historical volume of services provided for
each item and services in the previous 3-year period;
(B) the actual expenditures of such provider in
such provider's most recent cost report under title
XVIII of the Social Security Act for each item and
service compared to--
(i) such expenditures for other
institutional providers in the director's
jurisdiction; and
(ii) normative payment rates established
under comparative payment rate systems,
including any adjustments, for such items and
services;
(C) projected changes in the volume and type of
items and services to be furnished;
(D) wages for employees, including any necessary
increases for mandatory minimum safe registered nurse-
to-patient ratios and optimal staffing levels for
physicians and other health care workers;
(E) the provider's maximum capacity to provide
items and services;
(F) education and prevention programs;
(G) permissible adjustment to the provider's
operating budget due to factors such as--
(i) an increase in primary or specialty
care access;
(ii) efforts to decrease health care
disparities in rural or medically underserved
areas;
(iii) a response to emergent epidemic
conditions;
(iv) an increase in complex or high-cost
patients or care needs; or
(v) proposed new and innovative patient
care programs at the institutional level;
(H) whether the provider is located in a high
social vulnerability index community, ZIP Code, or
census track, or is a minority-serving provider; and
(I) any other factor determined appropriate by the
Secretary.
(3) Limitation.--Payment amounts negotiated pursuant to
paragraph (1) may not--
(A) take into account capital expenditures of the
provider or any other expenditure not directly
associated with the provision of items and services by
the provider to an individual;
(B) be used by a provider for capital expenditures
or such other expenditures;
(C) exceed the provider's capacity to provide care
under this Act; or
(D) be used to pay or otherwise compensate any
board member, executive, or administrator of the
institutional provider who has any interest or
relationship prohibited under section 301(b)(2) of this
Act or disclosed under section 301 of this Act.
(4) Limitation on compensation.--Compensation costs for any
employee or any contractor or any subcontractor employee of an
institutional provider receiving global budgets under this
section shall meet the compensation cap established in section
702 of the Bipartisan Budget Act of 2013 (41 U.S.C.
4304(a)(16)) and implementing regulations.
(5) Regional negotiations permitted.--Subject to section
614, a regional director may negotiate changes to an
institutional provider's global budget, including any
adjustments to address unforeseen market-shifts related to
patient volume.
(c) Baseline Rates and Adjustments.--
(1) In general.--The Secretary shall use existing
prospective payment systems under title XVIII of the Social
Security Act to serve as the comparative payment rate system in
global budget negotiations described in subsection (b). The
Secretary shall update such comparative payment rate systems
annually.
(2) Specifications.--In developing the comparative payment
rate system, the Secretary shall use only the operating base
payment rates under each such prospective payment systems with
applicable adjustments.
(3) Limitation.--The comparative rate system established
under this subsection shall not include the value-based payment
adjustments and the capital expenses base payment rates that
may be included in such a prospective payment system.
(4) Initial year.--In the first year that global budget
payments under this Act are available to institutional
providers and for purposes of selecting a comparative payment
rate system used during initial global budget negotiations for
each institutional provider, the Secretary shall take into
account the appropriate prospective payment system from the
most recent year under title XVIII of the Social Security Act
to determine what operating base payment the institutional
provider would have been paid for covered items and services
furnished the preceding year with applicable adjustments,
excluding value-based payment adjustments, based on such
prospective payment system.
(d) Operating Expenses.--For purposes of this title, ``operating
expenses'' of a provider include the following:
(1) The cost of all items and services associated with the
provision of inpatient care and outpatient care, including the
following:
(A) Wages and salary costs for physicians, nurses,
and other health care practitioners employed by an
institutional provider, including mandatory minimum
safe registered nurse-to-patient staffing ratios and
optimal staffing levels for physicians and other
healthcare workers.
(B) Wages and salary costs for all ancillary staff
and services.
(C) Costs of all pharmaceutical products
administered by health care clinicians at the
institutional provider's facilities or through services
provided in accordance with State licensing laws or
regulations under which the institutional provider
operates.
(D) Costs for infectious disease response
preparedness, including maintenance of a 1-year or 365-
day stockpile of personal protective equipment,
occupational testing and surveillance, medical services
for occupational infectious disease exposure, and
contact tracing.
(E) Purchasing and maintenance of medical devices,
supplies, and other health care technologies, including
diagnostic testing equipment.
(F) Costs of all incidental services necessary for
safe patient care and handling.
(G) Costs of patient care, education, and
prevention programs, including occupational health and
safety programs, public health programs, and necessary
staff to implement such programs, for the continued
education and health and safety of clinicians and other
individuals employed by the institutional provider.
(2) Administrative costs for the institutional provider.
SEC. 612. PAYMENT TO INDIVIDUAL PROVIDERS THROUGH FEE-FOR-SERVICE.
(a) In General.--In the case of a provider not described in section
611(a) (including those in group practices who are not receiving
payment on a salaried basis described in section 611(a)(3) and
providers of home and community-based services), payment for items and
services furnished under this Act for which payment is not otherwise
made under section 611 shall be made by the Secretary in amounts
determined under the fee schedule established pursuant to subsection
(b). Such payment shall be considered to be payment in full for such
items and services, and a provider receiving such payment may not
charge the individual receiving such item or service in any amount.
(b) Fee Schedule.--
(1) Establishment.--Not later than 1 year after the date of
the enactment of this Act, and in consultation with providers
and regional office directors, the Secretary shall establish a
national fee schedule for items and services payable under this
Act. The Secretary shall evaluate the effectiveness of the fee-
for-service structure and update such fee schedule annually.
(2) Amounts.--In establishing payment amounts for items and
services under the fee schedule established under paragraph
(1), the Secretary shall take into account--
(A) the amounts payable for such items and services
under title XVIII of the Social Security Act; and
(B) the expertise of providers and value of items
and services furnished by such providers.
(c) Electronic Billing.--The Secretary shall establish a uniform
national system for electronic billing for purposes of making payments
under this subsection.
(d) Physician Practice Review Board.--Each director of a regional
office, in consultation with representatives of physicians practicing
in that region, shall establish and appoint a physician practice review
board to assure quality, cost effectiveness, and fair reimbursements
for physician-delivered items and services. The use of mechanisms that
discriminate against people with disabilities is prohibited for use in
any value or cost-effectiveness assessments.
SEC. 613. ENSURING ACCURATE VALUATION OF SERVICES UNDER THE MEDICARE
PHYSICIAN FEE SCHEDULE.
(a) Standardized and Documented Review Process.--Section 1848(c)(2)
of the Social Security Act (42 U.S.C. 1395w-4(c)(2)) is amended by
adding at the end the following new subparagraph:
``(P) Standardized and documented review process.--
``(i) In general.--Not later than one year
after the date of enactment of this
subparagraph, the Secretary shall establish,
document, and make publicly available, in
consultation with the Office of Primary Health
Care, a standardized process for reviewing the
relative values of physicians' services under
this paragraph.
``(ii) Minimum requirements.--The
standardized process shall include, at a
minimum, methods and criteria for identifying
services for review, prioritizing the review of
services, reviewing stakeholder
recommendations, and identifying additional
resources to be considered during the review
process.''.
(b) Planned and Documented Use of Funds.--Section 1848(c)(2)(M) of
the Social Security Act (42 U.S.C. 1395w-4(c)(2)(M)) is amended by
adding at the end the following new clause:
``(x) Planned and documented use of
funds.--For each fiscal year (beginning with
the first fiscal year beginning on or after the
date of enactment of this clause), the
Secretary shall provide to Congress a written
plan for using the funds provided under clause
(ix) to collect and use information on
physicians' services in the determination of
relative values under this subparagraph.''.
(c) Internal Tracking of Reviews.--
(1) In general.--Not later than 1 year after the date of
enactment of this Act, the Secretary shall submit to Congress a
proposed plan for systematically and internally tracking the
Secretary's review of the relative values of physicians'
services, such as by establishing an internal database, under
section 1848(c)(2) of the Social Security Act (42 U.S.C. 1395w-
4(c)(2)), as amended by this section.
(2) Minimum requirements.--The proposal shall include, at a
minimum, plans and a timeline for achieving the ability to
systematically and internally track the following:
(A) When, how, and by whom services are identified
for review.
(B) When services are reviewed or reviewed or when
new services are added.
(C) The resources, evidence, data, and
recommendations used in reviews.
(D) When relative values are adjusted.
(E) The rationale for final relative value
decisions.
(d) Frequency of Review.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)) is amended--
(1) in subparagraph (B)(i), by striking ``5'' and inserting
``4''; and
(2) in subparagraph (K)(i)(I), by striking ``periodically''
and inserting ``annually''.
(e) Consultation With Medicare Payment Advisory Commission.--
(1) In general.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)) is amended--
(A) in subparagraph (B)(i), by inserting ``in
consultation with the Medicare Payment Advisory
Commission,'' after ``The Secretary,''; and
(B) in subparagraph (K)(i)(I), as amended by
subsection (d)(2), by inserting ``, in coordination
with the Medicare Payment Advisory Commission,'' after
``annually''.
(2) Conforming amendments.--Section 1805 of the Social
Security Act (42 U.S.C. 1395b-6) is amended--
(A) in subsection (b)(1)(A), by inserting the
following before the semicolon at the end: ``and
including coordinating with the Secretary in accordance
with section 1848(c)(2) to systematically review the
relative values established for physicians' services,
identify potentially misvalued services, and propose
adjustments to the relative values for physicians'
services''; and
(B) in subsection (e)(1), in the second sentence,
by inserting ``or the Ranking Minority Member'' after
``the Chairman''.
(f) Periodic Audit by the Comptroller General.--Section 1848(c)(2)
of the Social Security Act (42 U.S.C. 1395w-4(c)(2)), as amended by
subsection (a), is amended by adding at the end the following new
subparagraph:
``(Q) Periodic audit by the comptroller general.--
``(i) In general.--The Comptroller General
of the United States (in this subsection
referred to as the `Comptroller General') shall
periodically audit the review by the Secretary
of relative values established under this
paragraph for physicians' services.
``(ii) Access to information.--The
Comptroller General shall have unrestricted
access to all deliberations, records, and data
related to the activities carried out under
this paragraph, in a timely manner, upon
request.''.
SEC. 614. PAYMENT PROHIBITIONS; CAPITAL EXPENDITURES; SPECIAL PROJECTS.
(a) Sense of Congress.--It is the sense of Congress that tens of
millions of people in the United States do not receive healthcare
services while billions of dollars that could be spent on providing
health care are diverted to profit. There is a moral imperative to
correct the massive deficiencies in our current health system and to
eliminate profit from the provision of health care.
(b) Prohibitions.--Payments to providers under this Act may not
take into account, include any process for the provision of funding
for, or be used by a provider for--
(1) marketing of the provider;
(2) the profit or net revenue of the provider, or
increasing the profit or net revenue of the provider;
(3) incentive payments, bonuses, or other compensation
based on patient utilization of items and services or any
financial measure applied with respect to the provider (or any
group practice, integrated health care delivery system, or
other provider with which the provider contracts or has a
pecuniary interest), including any value-based payment or
employment-based compensation;
(4) any agreement or arrangement described in section
203(a)(4) of the Labor-Management Reporting and Disclosure Act
of 1959 (29 U.S.C. 433(a)(4)); or
(5) political or contributions prohibited under section 317
of the Federal Elections Campaign Act of 1971 (52 U.S.C.
30119(a)(1)).
(c) Payments for Capital Expenditures.--
(1) In general.--The Secretary shall pay, from amounts made
available for capital expenditures pursuant to section
601(a)(2)(B), such sums determined appropriate by the Secretary
to providers who have submitted an application to the regional
director of the region or regions in which the provider
operates or seeks to operate in a time and manner specified by
the Secretary for purposes of funding capital expenditures of
such providers.
(2) Priority.--The Secretary shall prioritize allocation of
funding under paragraph (1) to projects that propose to use
such funds to improve service in a medically underserved area
(as defined in section 330(b)(3) of the Public Health Service
Act (42 U.S.C. 254b(b)(3))) or to address health disparities,
including racial, ethnic, national origin, primary language
use, age, disability, sex (including gender identity and sexual
orientation), geography, or socioeconomic health disparities.
(3) Limitation.--The Secretary shall not grant funding for
capital expenditures under this subsection for capital projects
that are financed directly or indirectly through the diversion
of private or other non-Medicare for All Program funding that
results in reductions in care to patients, including reductions
in registered nursing staffing patterns and changes in
emergency room or primary care services or availability.
(4) Capital assets not funded by the medicare for all
program.--Operating expenses and funds shall not be used by an
institutional provider receiving payment for capital
expenditures under this subsection for a capital asset that was
not funded by the Medicare for All program without the approval
of the regional director or directors of the region or regions
where the capital asset is located.
(d) Prohibition Against Co-Mingling Operating and Capital Funds.--
Providers that receive payment under this title shall be prohibited
from using, with respect to funds made available under this Act--
(1) funds designated for operating expenditures for capital
expenditures or for profit; or
(2) funds designated for capital expenditures for operating
expenditures.
(e) Payments for Special Projects.--
(1) In general.--The Secretary shall allocate to each
regional director, from amounts made available for special
projects pursuant to section 601(a)(2)(C), such sums determined
appropriate by the Secretary for purposes of funding projects
described in such section, including the construction,
renovation, or staffing of health care facilities, in rural,
underserved, or health professional or medical shortage areas
within such region and to address health disparities, including
racial, ethnic, national origin, primary language use, age,
disability, sex, including gender identity and sexual
orientation, geography, or socioeconomic health disparities.
Each regional director shall, prior to distributing such funds
in accordance with paragraph (2), present a budget describing
how such funds will be distributed to the Secretary.
(2) Distribution.--A regional director shall distribute
funds to providers operating in the region of such director's
jurisdiction in a manner determined appropriate by the
director.
(f) Prohibition on Financial Incentive Metrics in Payment
Determinations.--The Secretary may not utilize any quality metrics or
standards for the purposes of establishing provider payment
methodologies, programs, modifiers, or adjustments for provider
payments under this title.
SEC. 615. OFFICE OF HEALTH EQUITY.
Title XVII of the Public Health Service Act (42 U.S.C. 300u et
seq.) is amended by adding at the end the following:
``SEC. 1712. OFFICE OF HEALTH EQUITY.
``(a) In General.--There is established, in the Office of the
Secretary of Health and Human Services, an Office of Health Equity, to
be headed by a Director, to ensure coordination and collaboration
across the programs and activities of the Department of Health and
Human Services with respect to ensuring health equity.
``(b) Monitoring, Tracking, and Availability of Data.--
``(1) In general.--In carrying out subsection (a), the
Director of the Office of Health Equity shall monitor, track,
and make publicly available data on--
``(A) the disproportionate burden of disease and
death among people of color, disaggregated by race,
major ethnic group, Tribal affiliation, national
origin, primary language use, English proficiency
status, immigration status, length of stay in the
United States age, disability, sex (including gender
identity and sexual orientation), incarceration,
homelessness, geography, and socioeconomic status;
``(B) barriers to health, including such barriers
relating to income, education, housing, food insecurity
(including availability, access, utilization, and
stability), employment status, working conditions, and
conditions related to the physical environment
(including pollutants and population density);
``(C) barriers to health care access, including--
``(i) lack of trust and awareness;
``(ii) lack of transportation;
``(iii) geography;
``(iv) hospital and service closures;
``(v) lack of health care infrastructure
and facilities; and
``(vi) lack of health care professional
staffing and recruitment;
``(D) disparities in quality of care received,
including discrimination in health care settings and
the use of racially-biased practice guidelines and
algorithms; and
``(E) disparities in utilization of care.
``(2) Analysis of cross-sectional information.--The
Director of the Office of Health Equity shall ensure that the
data collection and reporting process under paragraph (1)
allows for the analysis of cross-sectional information on
people's identities.
``(c) Policies.--In carrying out subsection (a), the Director of
the Office of Health Equity shall develop, coordinate, and promote
policies that enhance health equity, including by--
``(1) providing recommendations on--
``(A) cultural competence, implicit bias, and
ethics training with respect to health care workers;
``(B) increasing diversity in the health care
workforce; and
``(C) ensuring sufficient health care professionals
and facilities; and
``(2) ensuring adequate public health funding at the local
and State levels to address health disparities.
``(d) Consultation.--In carrying out subsection (a), the Director
of the Office of Health Equity, in coordination with the Director of
the Indian Health Service, shall consult with Indian Tribes and with
Urban Indian organizations on data collection, reporting, and
implementation of policies.
``(e) Annual Report.--In carrying out subsection (a), the Director
of the Office of Health Equity shall develop and publish an annual
report on--
``(1) statistics collected by the Office;
``(2) proposed evidence-based solutions to mitigate health
inequities; and
``(3) health care professional staffing levels and access
to facilities.
``(f) Centralized Electronic Repository.--In carrying out
subsection (a), the Director of the Office of Health Equity shall--
``(1) establish and maintain a centralized electronic
repository to incorporate data collected across Federal
departments and agencies on race, ethnicity, Tribal
affiliation, national origin, primary language use, English
proficiency status, immigration status, length of stay in the
United States age, disability, sex (including gender identity
and sexual orientation), incarceration, homelessness,
geography, and socioeconomic status; and
``(2) make such data available for public use and analysis.
``(g) Privacy.--Notwithstanding any other Federal or State law, no
Federal or State official or employee or other entity shall disclose,
or use, for any law enforcement or immigration purpose, any personally
identifiable information (including with respect to an individual's
religious beliefs, practices, or affiliation, national origin,
ethnicity, or immigration status) that is collected or maintained
pursuant to this section.''.
SEC. 616. OFFICE OF PRIMARY CARE.
Title XVII of the Public Health Service Act (42 U.S.C. 300u et
seq.) is amended by adding at the end the following:
``SEC. 1713. OFFICE OF PRIMARY CARE.
``(a) In General.--There is established, in the Office of Health
Equity established under section 1712, an Office of Primary Health
Care, to be headed by a Director, to ensure coordination and
collaboration across the programs and activities of the Department of
Health and Human Services with respect to increasing access to high-
quality primary health care, particularly in underserved areas and for
underserved populations.
``(b) National Goals.--Not later than 1 year after the date of
enactment of this section, the Director of the Office of Primary Health
Care shall publish national goals--
``(1) to increase access to high-quality primary health
care, particularly in underserved areas and for underserved
populations; and
``(2) to address health disparities, including with respect
to race, ethnicity, national origin (disaggregated by major
ethnic group and Tribal affiliation), primary language use,
English proficiency status, immigration status, length of stay
in the United States, age, disability, sex (including gender
identity and sexual orientation), incarceration, homelessness,
geography, and socioeconomic status.
``(c) Other Responsibilities.--In carrying out subsections (a) and
(b), the Director of the Office of Primary Health Care shall--
``(1) coordinate, in consultation with the Secretary,
health professional education policies and goals to achieve the
national goals published pursuant to subsection (b);
``(2) develop and maintain a system to monitor the number
and specialties of individuals pursuing careers in, or
practicing, primary health care through their health
professional education, any postgraduate training, and
professional practice;
``(3) develop, coordinate, and promote policies that expand
the number of primary health care practitioners, registered
nurses, advance practice clinicians, and dentists;
``(4) recommend appropriate training, technical assistance,
and patient protection enhancements for primary care health
professionals, including registered nurses, to achieve uniform
high quality and patient safety;
``(5) provide recommendations on targeted programs and
resources for Federally qualified health centers, rural health
centers, community health centers, and other community-based
organizations;
``(6) provide recommendations for broader patient referral
to additional resources, not limited to health care, and
collaboration with other organizations and sectors that
influence health outcomes; and
``(7) consult with the Secretary on the allocation of the
special projects budget under section 601(a)(2)(C) of the
Medicare for All Act.
``(d) Rule of Construction.--Nothing in this section shall be
construed--
``(1) to preempt any provision of State law establishing
practice standards or guidelines for health care professionals,
including professional licensing or practice laws or
regulations; or
``(2) to require that any State impose additional
educational standards or guidelines for health care
professionals.''.
SEC. 617. PAYMENTS FOR PRESCRIPTION DRUGS AND APPROVED DEVICES AND
EQUIPMENT.
The prices to be paid for covered pharmaceuticals, medical
supplies, medical technologies, and medically necessary equipment
covered under this Act shall be negotiated annually by the Secretary.
(1) In general.--Notwithstanding any other provision of
law, the Secretary shall, for fiscal years beginning on or
after the date of the enactment of this subsection, negotiate
with pharmaceutical manufacturers the prices (including
discounts, rebates, and other price concessions) that may be
charged to the Medicare for All Program during a negotiated
price period (as specified by the Secretary) for covered drugs
for eligible individuals under the Medicare for All Program. In
negotiating such prices under this section, the Secretary shall
take into account the following factors:
(A) The comparative clinical effectiveness and cost
effectiveness, when available from an impartial source,
of such drug.
(B) The budgetary impact of providing coverage of
such drug.
(C) The number of similarly effective drugs or
alternative treatment regimens for each approved use of
such drug.
(D) The total revenues from global sales obtained
by the manufacturer for such drug and the associated
investment in research and development of such drug by
the manufacturer.
(2) Finalization of negotiated price.--The negotiated price
of each covered drug for a negotiated price period shall be
finalized not later than 30 days before the first fiscal year
in such negotiated price period.
(3) Competitive licensing authority.--
(A) In general.--Notwithstanding any exclusivity
under clause (iii) or (iv) of section 505(j)(5)(F) of
the Federal Food, Drug, and Cosmetic Act, clause (iii)
or (iv) of section 505(c)(3)(E) of such Act, section
351(k)(7)(A) of the Public Health Service Act, or
section 527(a) of the Federal Food, Drug, and Cosmetic
Act, or by an extension of such exclusivity under
section 505A of such Act or section 505E of such Act,
and any other provision of law that provides for market
exclusivity (or extension of market exclusivity) with
respect to a drug, in the case that the Secretary is
unable to successfully negotiate an appropriate price
for a covered drug for a negotiated price period, the
Secretary shall authorize the use of any patent,
clinical trial data, or other exclusivity granted by
the Federal Government with respect to such drug as the
Secretary determines appropriate for purposes of
manufacturing such drug for sale under Medicare for All
Program. Any entity making use of a competitive license
to use patent, clinical trial data, or other
exclusivity under this section shall provide to the
manufacturer holding such exclusivity reasonable
compensation, as determined by the Secretary based on
the following factors:
(i) The risk-adjusted value of any Federal
Government subsidies and investments in
research and development used to support the
development of such drug.
(ii) The risk-adjusted value of any
investment made by such manufacturer in the
research and development of such drug.
(iii) The impact of the price, including
license compensation payments, on meeting the
medical need of all patients at a reasonable
cost.
(iv) The relationship between the price of
such drug, including compensation payments, and
the health benefits of such drug.
(v) Other relevant factors determined
appropriate by the Secretary to provide
reasonable compensation.
(B) Reasonable compensation.--The manufacturer
described in subparagraph (A) may seek recovery against
the United States in the United States Court of Federal
Claims.
(C) Interim period.--Until 1 year after a drug
described in subparagraph (A) is approved under section
505(j) of the Federal Food, Drug, and Cosmetic Act or
section 351(k) of the Public Health Service Act and is
provided under license issued by the Secretary under
such subparagraph, the Medicare for All Program shall
not pay more for such drug than the average of the
prices available, during the most recent 12-month
period for which data is available prior to the
beginning of such negotiated price period, from the
manufacturer to any wholesaler, retailer, provider,
health maintenance organization, nonprofit entity, or
governmental entity in the ten OECD (Organization for
Economic Cooperation and Development) countries that
have the largest gross domestic product with a per
capita income that is not less than half the per capita
income of the United States.
(D) Authorization for secretary to procure drugs
directly.--The Secretary may procure a drug
manufactured pursuant to a competitive license under
subparagraph (A) for purposes of this Act.
(4) FDA review of licensed drug applications.--The
Secretary shall prioritize review of applications under section
505(j) of the Federal Food, Drug, and Cosmetic Act for drugs
licensed under paragraph (3)(A).
(5) Prohibition of anticompetitive behavior.--No drug
manufacturer may engage in anticompetitive behavior with
another manufacturer that may interfere with the issuance and
implementation of a competitive license or run contrary to
public policy.
(6) Required reporting.--The Secretary may require
pharmaceutical manufacturers to disclose to the Secretary such
information that the Secretary determines necessary for
purposes of carrying out this subsection.
TITLE VII--UNIVERSAL MEDICARE TRUST FUND
SEC. 701. UNIVERSAL MEDICARE TRUST FUND.
(a) In General.--There is hereby created on the books of the
Treasury of the United States a trust fund to be known as the Universal
Medicare Trust Fund (in this section referred to as the ``Trust
Fund''). The Trust Fund shall consist of such gifts and bequests as may
be made and such amounts as may be deposited in, or appropriated to,
such Trust Fund as provided in this Act.
(b) Appropriations Into Trust Fund.--
(1) Taxes.--There are appropriated to the Trust Fund for
each fiscal year beginning with the fiscal year which includes
the date on which benefits first become available as described
in section 106, out of any monies in the Treasury not otherwise
appropriated, amounts equivalent to 100 percent of the net
increase in revenues to the Treasury which is attributable to
the amendments made by sections 801 and 902. The amounts
appropriated by the preceding sentence shall be transferred
from time to time (but not less frequently than monthly) from
the general fund in the Treasury to the Trust Fund, such
amounts to be determined on the basis of estimates by the
Secretary of the Treasury of the taxes paid to or deposited
into the Treasury, and proper adjustments shall be made in
amounts subsequently transferred to the extent prior estimates
were in excess of or were less than the amounts that should
have been so transferred.
(2) Current program receipts.--
(A) Initial year.--Notwithstanding any other
provision of law, there is appropriated to the Trust
Fund for the fiscal year containing January 1 of the
first year following the date of the enactment of this
Act, an amount equal to the aggregate amount
appropriated for the preceding fiscal year for the
following (increased by the consumer price index for
all urban consumers for the fiscal year involved):
(i) The Medicare program under title XVIII
of the Social Security Act (other than amounts
attributable to any premiums under such title).
(ii) The Medicaid program under State plans
approved under title XIX of such Act.
(iii) The Federal Employees Health Benefits
program, under chapter 89 of title 5, United
States Code.
(iv) The purchased care component of the
TRICARE program, under chapter 55 of title 10,
United States Code (other than amounts
appropriated for the purchased care component
of the TRICARE Overseas Program).
(v) The maternal and child health program
(under title V of the Social Security Act),
vocational rehabilitation programs, programs
for drug abuse and mental health services under
the Public Health Service Act, programs
providing general hospital or medical
assistance, and any other Federal program
identified by the Secretary, in consultation
with the Secretary of the Treasury, to the
extent the programs provide for payment for
health services the payment of which may be
made under this Act.
(B) Subsequent years.--Notwithstanding any other
provision of law, there is appropriated to the trust
fund for the fiscal year containing January 1 of the
second year following the date of the enactment of this
Act, and for each fiscal year thereafter, an amount
equal to the amount appropriated to the Trust Fund for
the previous year, adjusted for reductions in costs
resulting from the implementation of this Act, changes
in the consumer price index for all urban consumers for
the fiscal year involved, and other factors determined
appropriate by the Secretary.
(3) Restrictions shall not apply.--Any other provision of
law in effect on the date of enactment of this Act restricting
the use of Federal funds for any reproductive health service
shall not apply to monies in the Trust Fund.
(c) Incorporation of Provisions.--The provisions of subsections (b)
through (i) of section 1817 of the Social Security Act (42 U.S.C.
1395i) shall apply to the Trust Fund under this section in the same
manner as such provisions applied to the Federal Hospital Insurance
Trust Fund under such section 1817, except that, for purposes of
applying such subsections to this section, the ``Board of Trustees of
the Trust Fund'' shall mean the ``Secretary''.
(d) Transfer of Funds.--Any amounts remaining in the Federal
Hospital Insurance Trust Fund under section 1817 of the Social Security
Act (42 U.S.C. 1395i) or the Federal Supplementary Medical Insurance
Trust Fund under section 1841 of such Act (42 U.S.C. 1395t) after the
payment of claims for items and services furnished under title XVIII of
such Act have been completed, shall be transferred into the Universal
Medicare Trust Fund under this section.
TITLE VIII--CONFORMING AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME
SECURITY ACT OF 1974
SEC. 801. PROHIBITION OF EMPLOYEE BENEFITS DUPLICATIVE OF BENEFITS
UNDER THE MEDICARE FOR ALL PROGRAM; COORDINATION IN CASE
OF WORKERS' COMPENSATION.
(a) In General.--Part 5 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.) is
amended by adding at the end the following new section:
``SEC. 522. PROHIBITION OF EMPLOYEE BENEFITS DUPLICATIVE OF UNIVERSAL
MEDICARE PROGRAM BENEFITS; COORDINATION IN CASE OF
WORKERS' COMPENSATION.
``(a) In General.--Subject to subsection (b), no employee benefit
plan may provide benefits that duplicate payment for any items or
services for which payment may be made under the Medicare for All Act.
``(b) Reimbursement.--Each workers compensation carrier that is
liable for payment for workers compensation services furnished in a
State shall reimburse the Medicare for All Program for the cost of such
services.
``(c) Definitions.--In this subsection--
``(1) the term `workers compensation carrier' means an
insurance company that underwrite workers compensation medical
benefits with respect to one or more employers and includes an
employer or fund that is financially at risk for the provision
of workers compensation medical benefits;
``(2) the term `workers compensation medical benefits'
means, with respect to an enrollee who is an employee subject
to the workers compensation laws of a State, the comprehensive
medical benefits for work-related injuries and illnesses
provided for under such laws with respect to such an employee;
and
``(3) the term `workers compensation services' means items
and services included in workers compensation medical benefits
and includes items and services (including rehabilitation
services and long-term care services) commonly used for
treatment of work-related injuries and illnesses.''.
(b) Conforming Amendment.--Section 4(b) of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1003(b)) is amended by adding at
the end the following: ``Paragraph (3) shall apply subject to section
522(b) (relating to reimbursement of the Medicare for All Program by
workers compensation carriers).''.
(c) Clerical Amendment.--The table of contents in section 1 of such
Act is amended by inserting after the item relating to section 521 the
following new item:
``Sec. 522. Prohibition of employee benefits duplicative of Universal
Medicare Program benefits; coordination in
case of workers' compensation.''.
SEC. 802. APPLICATION OF CONTINUATION COVERAGE REQUIREMENTS UNDER ERISA
AND CERTAIN OTHER REQUIREMENTS RELATING TO GROUP HEALTH
PLANS.
(a) In General.--Part 6 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1161 et seq.) shall
apply only with respect to any employee health benefit plan that does
not duplicate payments for any items or services for which payment may
be made under the this Act.
(b) Conforming Amendment.--Section 601 of part 6 of subtitle B of
title I of the Employee Retirement Income Security Act of 1974 (19
U.S.C. 1161) is amended by adding the following subsection at the end:
``(c) Subsection (a) shall apply to any group health plan that does
not duplicate payments for any items or services for which payment may
be made under the Medicare for All Act.''.
SEC. 803. EFFECTIVE DATE OF TITLE.
The provisions of and amendments made by this title shall take
effect on the date described in section 106(a).
TITLE IX--ADDITIONAL CONFORMING AMENDMENTS
SEC. 901. RELATIONSHIP TO EXISTING FEDERAL HEALTH PROGRAMS.
(a) Medicare, Medicaid, and State Children's Health Insurance
Program (SCHIP).--
(1) In general.--Notwithstanding any other provision of law
and with respect to an individual eligible to enroll under this
Act, subject to paragraphs (2) and (3)--
(A) no benefits shall be available under title
XVIII of the Social Security Act for any item or
service furnished beginning on the date that is 2 years
after the date of the enactment of this Act;
(B) no individual is entitled to medical assistance
under a State plan approved under title XIX of such Act
for any item or service furnished on or after such
date;
(C) no individual is entitled to medical assistance
under a State child health plan under title XXI of such
Act for any item or service furnished on or after such
date; and
(D) no payment shall be made to a State under
section 1903(a) or 2105(a) of such Act with respect to
medical assistance or child health assistance for any
item or service furnished on or after such date.
(2) Transition.--In the case of inpatient hospital services
and extended care services during a continuous period of stay
which began before the effective date of benefits under section
106, and which had not ended as of such date, for which
benefits are provided under title XVIII of the Social Security
Act, under a State plan under title XIX of such Act, or under a
State child health plan under title XXI of such Act, the
Secretary shall provide for continuation of benefits under such
title or plan until the end of the period of stay.
(3) School programs.--All school related health programs,
centers, initiatives, services, or other activities or work
provided under title XIX or title XXI of the Social Security
Act as of January 1, 2019, shall be continued and covered by
the Medicare for All Program.
(b) Federal Employees Health Benefits Program.--No benefits shall
be made available under chapter 89 of title 5, United States Code, with
respect to items and services furnished to any individual eligible to
enroll under this Act.
(c) TRICARE Program.--
(1) Direct care component.--Nothing in this Act shall
affect the eligibility of beneficiaries under chapter 55 of
title 10, United States Code, who are entitled to receive care
furnished at facilities of the uniformed services under the
TRICARE program for such care.
(2) Purchased care component.--
(A) In general.--Except as provided in subparagraph
(B), no benefits shall be made available under the
purchased care component of the TRICARE program for
items or services furnished to any individual eligible
to enroll under this Act.
(B) TRICARE overseas.--During any period in which
an individual is eligible for benefits under the
TRICARE Overseas Program and is located in a TRICARE
overseas region, the individual may receive benefits
for items or services furnished to the individual under
the purchased care component of such program during
such period.
(d) Treatment of Benefits for Veterans and Native Americans.--
(1) In general.--Nothing in this Act shall affect the
eligibility of veterans for the medical benefits and services
provided under title 38, United States Code, or of Indians for
the medical benefits and services provided by or through the
Indian Health Service.
(2) Reevaluation.--No reevaluation of the Indian Health
Service shall be undertaken without consultation with tribal
leaders and stakeholders.
SEC. 902. SUNSET OF PROVISIONS RELATED TO THE STATE EXCHANGES.
Effective on the date that is 2 years after the date of the
enactment of this Act, the Federal and State Exchanges established
pursuant to title I of the Patient Protection and Affordable Care Act
(Public Law 111-148) shall terminate, and any other provision of law
that relies upon participation in or enrollment through such an
Exchange, including such provisions of the Internal Revenue Code of
1986, shall cease to have force or effect.
SEC. 903. SUNSET OF PROVISIONS RELATED TO PAY FOR PERFORMANCE PROGRAMS.
(a) Effective on the date described in section 106(a), the Federal
programs related to pay for performance programs and value-based
purchasing shall terminate, and any other provision of law that relies
upon participation in or enrollment in such program shall cease to have
force or effect. Programs that shall terminate include--
(1) the Merit-based Incentive Payment System established
pursuant to subsection (q) of section 1848 of the Social
Security Act (42 U.S.C. 1395w-4(q));
(2) the incentives for meaningful use of certified EHR
technology established pursuant to subsection (a)(7) of section
1848 of the Social Security Act (42 U.S.C. 1395w-4(a)(7));
(3) the incentives for adoption and meaningful use of
certified EHR technology established pursuant to subsection (o)
of section 1848 of the Social Security Act (42 U.S.C. 1395w-
4(o));
(4) alternative payment models established under section
1833(z) of the Social Security Act (42 U.S.C. 1395(z)); and
(5) the following programs as established pursuant to the
following sections of the Patient Protection and Affordable
Care Act:
(A) Section 2701 (adult health quality measures).
(B) Section 2702 (payment adjustments for health
care acquired conditions).
(C) Section 2706 (Pediatric Accountable Care
Organization Demonstration Projects for the purposes of
receiving incentive payments).
(D) Section 3002(b) (42 U.S.C. 1395w-4(a)(8))
(incentive payments for quality reporting).
(E) Section 3001(a) (42 U.S.C. 1395ww(o)) (Hospital
Value-Based Purchasing).
(F) Section 3006 (value-based purchasing program
for skilled nursing facilities and home health
agencies).
(G) Section 3007 (42 U.S.C. 1395w-4(p)) (value
based payment modifier under physician fee schedule).
(H) Section 3008 (42 U.S.C. 1395ww(p)) (payment
adjustments for health care-acquired condition).
(I) Section 3022 (42 U.S.C. 1395jjj) (Medicare
shared savings programs).
(J) Section 3023 (42 U.S.C. 1395cc-4) (National
Pilot Program on Payment Bundling).
(K) Section 3024 (42 U.S.C. 1395cc-5) (Independence
at home demonstration program).
(L) Section 3025 (42 U.S.C. 1395ww(q)) (hospital
readmissions reduction program).
(M) Section 10301 (plans for value-based purchasing
program for ambulatory surgical centers).
TITLE X--TRANSITION
Subtitle A--Medicare for All Transition Over 2 Years and Transitional
Buy-In Option
SEC. 1001. MEDICARE FOR ALL TRANSITION OVER TWO YEARS.
Title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.) is
amended by adding at the end the following new section:
``SEC. 1899C. MEDICARE FOR ALL TRANSITION OVER 2 YEARS.
``(a) Transition.--
``(1) In general.--Every individual who meets the
requirements described in paragraph (3) shall be eligible to
enroll in the Medicare for All Program under this section
during the transition period starting one year after the date
of enactment of the Medicare for All Act.
``(2) Benefits.--An individual enrolled under this section
is entitled to the benefits established under title II of the
Medicare for All Act.
``(3) Requirements for eligibility.--The requirements
described in this paragraph are the following:
``(A) The individual meets the eligibility
requirements established by the Secretary under title I
of the Medicare for All Act.
``(B) The individual has attained the applicable
year of age, or is currently enrolled in Medicare at
the time of the transition to Medicare for All.
``(4) Applicable year of age defined.--For purposes of this
section, the term `applicable year of age' means one year after
the date of enactment of the Medicare for All Act, the age of
55 or older, the age 18 or younger.
``(b) Enrollment; Coverage.--The Secretary shall establish
enrollment periods and coverage under this section consistent with the
principles for establishment of enrollment periods and coverage for
individuals under other provisions of this title. The Secretary shall
establish such periods so that coverage under this section shall first
begin on January 1 of the year on which an individual first becomes
eligible to enroll under this section.
``(c) Satisfaction of Individual Mandate.--For purposes of applying
section 5000A of the Internal Revenue Code of 1986, the coverage
provided under this section constitutes minimum essential coverage
under subsection (f)(1)(A)(i) of such section 5000A.
``(d) Consultation.--In promulgating regulations to implement this
section, the Secretary shall consult with interested parties, including
groups representing beneficiaries, health care providers, employers,
and insurance companies.''.
SEC. 1002. ESTABLISHMENT OF THE MEDICARE TRANSITION BUY-IN.
(a) In General.--To carry out the purpose of this section, for the
year beginning one year after the date of enactment of this Act and
ending with the effective date described in section 106(a), the
Secretary, acting through the Administrator of the Centers for Medicare
& Medicaid (referred to in this section as the ``Administrator''),
shall establish, and provide for the offering through the Exchanges, an
option to buy in to the Medicare for All Program (in this Act referred
to as the ``Medicare Transition buy-in'').
(b) Administering the Medicare Transition Buy-In.--
(1) Administrator.--The Administrator shall administer the
Medicare Transition buy-in in accordance with this section.
(2) Application of aca requirements.--Consistent with this
section, the Medicare Transition buy-in shall comply with
requirements under title I of the Patient Protection and
Affordable Care Act (and the amendments made by that title) and
title XXVII of the Public Health Service Act (42 U.S.C. 300gg
et seq.) that are applicable to qualified health plans offered
through the Exchanges, subject to the limitation under
subsection (e)(2).
(3) Offering through exchanges.--The Medicare Transition
buy-in shall be made available only through the Exchanges, and
shall be available to individuals wishing to enroll and to
qualified employers (as defined in section 1312(f)(2) of the
Patient Protection and Affordable Care Act (42 U.S.C. 18032))
who wish to make such plan available to their employees.
(4) Eligibility to purchase.--Any United States resident
may enroll in the Medicare Transition buy-in.
(c) Benefits; Actuarial Value.--In carrying out this section, the
Administrator shall ensure that the Medicare Transition buy-in
provides--
(1) coverage for the benefits required to be covered under
title II of this Act; and
(2) coverage of benefits that are actuarially equivalent to
90 percent of the full actuarial value of the benefits provided
under the plan.
(d) Providers and Reimbursement Rates.--
(1) In general.--With respect to the reimbursement provided
to health care providers for covered benefits, as described in
section 201, provided under the Medicare Transition buy-in, the
Administrator shall reimburse such providers at rates
determined for equivalent items and services under the Medicare
for All fee-for-service schedule established in section 612(b)
of this Act.
(2) Prescription drugs.--Any payment rate under this
subsection for a prescription drug shall be at the prices
negotiated under section 616 of this Act.
(3) Participating providers.--
(A) In general.--A health care provider that is a
participating provider of services or supplier under
the Medicare program under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.) or under a State
Medicaid plan under title XIX of such Act (42 U.S.C.
1396 et seq.) on the date of enactment of this Act
shall be a participating provider in the Medicare
Transition buy-in.
(B) Additional providers.--The Administrator shall
establish a process to allow health care providers not
described in subparagraph (A) to become participating
providers in the Medicare Transition buy-in. Such
process shall be similar to the process applied to new
providers under the Medicare program.
(e) Premiums.--
(1) Determination.--The Administrator shall determine the
premium amount for enrolling in the Medicare Transition buy-in,
which--
(A) may vary according to family or individual
coverage, age, and tobacco status (consistent with
clauses (i), (iii), and (iv) of section 2701(a)(1)(A)
of the Public Health Service Act (42 U.S.C.
300gg(a)(1)(A))); and
(B) shall take into account the cost-sharing
reductions and premium tax credits which will be
available with respect to the plan under section 1402
of the Patient Protection and Affordable Care Act (42
U.S.C. 18071) and section 36B of the Internal Revenue
Code of 1986, as amended by subsection (g).
(2) Limitation.--Variation in premium rates of the Medicare
Transition buy-in by rating area, as described in clause (ii)
of section 2701(a)(1)(A)(iii) of the Public Health Service Act
(42 U.S.C. 300gg(a)(1)(A)) is not permitted.
(f) Termination.--This section shall cease to have force or effect
on the effective date described in section 106(a).
(g) Tax Credits and Cost-Sharing Subsidies.--
(1) Premium assistance tax credits.--
(A) Credits allowed to medicare transition buy-in
enrollees in non-expansion states.--Paragraph (1) of
section 36B(c) of the Internal Revenue Code of 1986 is
amended by redesignating subparagraphs (C) and (D) as
subparagraphs (D) and (E), respectively, and by
inserting after subparagraph (B) the following new
subparagraph:
``(C) Special rules for medicare transition buy-in
enrollees.--
``(i) In general.--In the case of a
taxpayer who is covered, or whose spouse or
dependent (as defined in section 152) is
covered, by the Medicare Transition buy-in
established under section 1002(a) of the
Medicare for All Act for all months in the
taxable year, subparagraph (A) shall be applied
without regard to `but does not exceed 400
percent'.
``(ii) Enrollees in medicaid nonexpansion
states.--In the case of a taxpayer residing in
a State which (as of the date of the enactment
of the Medicare for All Act) does not provide
for eligibility under clause (i)(VIII) or
(ii)(XX) of section 1902(a)(10)(A) of the
Social Security Act for medical assistance
under title XIX of such Act (or a waiver of the
State plan approved under section 1115) who is
covered, or whose spouse or dependent (as
defined in section 152) is covered, by the
Medicare Transition buy-in established under
section 1002(a) of the Medicare for All Act for
all months in the taxable year, subparagraphs
(A) and (B) shall be applied by substituting `0
percent' for `100 percent' each place it
appears.''.
(B) Premium assistance amounts for taxpayers
enrolled in medicare transition buy-in.--
(i) In general.--Subparagraph (A) of
section 36B(b)(3) of such Code is amended--(I)
by redesignating clause (ii) as clause (iii),
(II) by striking ``clause (ii)'' in clause (i)
and inserting ``clauses (ii) and (iii)'', and
(III) by inserting after clause (i) the
following new clause:
``(ii) Special rules for taxpayers enrolled
in medicare transition buy-in.--In the case of
a taxpayer who is covered, or whose spouse or
dependent (as defined in section 152) is
covered, by the Medicare Transition buy-in
established under section 1002(a) of the
Medicare for All Act for all months in the
taxable year, the applicable percentage for any
taxable year shall be determined in the same
manner as under clause (i), except that the
following table shall apply in lieu of the
table contained in such clause:
------------------------------------------------------------------------
``In the case of household income
(expressed as a percent of The initial The final
poverty line) within the premium premium
following income tier: percentage is-- percentage is--
------------------------------------------------------------------------
Up to 100 percent................. 2.00 2.00
100 percent up to 138 percent..... 2.04 2.04
138 percent up to 150 percent..... 3.06 4.08
150 percent and above............. 4.08 5.00.''.
------------------------------------------------------------------------
(ii) Conforming amendment.--Subclause (I)
of clause (iii) of section 36B(b)(3) of such
Code, as redesignated by subparagraph (A)(i),
is amended by inserting ``, and determined
after the application of clause (ii)'' after
``after application of this clause''.
(2) Cost-sharing subsidies.--Subsection (b) of section 1402
of the Patient Protection and Affordable Care Act (42 U.S.C.
18071(b)) is amended--
(A) by inserting ``, or in the Medicare Transition
buy-in established under section 1002(a) of the
Medicare for All Act,'' after ``coverage'' in paragraph
(1);
(B) by redesignating paragraphs (1) (as so amended)
and (2) as subparagraphs (A) and (B), respectively, and
by moving such subparagraphs 2 ems to the right;
(C) by striking ``Insured.--In this section'' and
inserting ``Insured.--
``(1) In general.--In this section'';
(D) by striking the flush language; and
(E) by adding at the end the following new
paragraph:
``(2) Special rules.--
``(A) Individuals lawfully present.--In the case of
an individual described in section 36B(c)(1)(B) of the
Internal Revenue Code of 1986, the individual shall be
treated as having household income equal to 100 percent
of the poverty line for a family of the size involved
for purposes of applying this section.
``(B) Medicare transition buy-in enrollees in
medicaid non-expansion states.--In the case of an
individual residing in a State which (as of the date of
the enactment of the Medicare for All Act) does not
provide for eligibility under clause (i)(VIII) or
(ii)(XX) of section 1902(a)(10)(A) of the Social
Security Act for medical assistance under title XIX of
such Act (or a waiver of the State plan approved under
section 1115) who enrolls in such Medicare Transition
buy-in, the preceding sentence, paragraph (1)(B), and
paragraphs (1)(A)(i) and (2)(A) of subsection (c) shall
each be applied by substituting `0 percent' for `100
percent' each place it appears.''.
(h) Conforming Amendments.--
(1) Treatment as a qualified health plan.--Section
1301(a)(2) of the Patient Protection and Affordable Care Act
(42 U.S.C. 18021(a)(2)) is amended--
(A) in the paragraph heading, by inserting ``The
medicare transition buy-in,'' before ``and''; and
(B) by inserting ``The Medicare Transition buy-
in,'' before ``and a multi-State plan''.
(2) Level playing field.--Section 1324(a) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18044(a)) is
amended by inserting ``the Medicare Transition buy-in,'' before
``or a multi-State qualified health plan''.
Subtitle B--Transitional Medicare Reforms
SEC. 1011. ELIMINATING THE 24-MONTH WAITING PERIOD FOR MEDICARE
COVERAGE FOR INDIVIDUALS WITH DISABILITIES.
(a) In General.--Section 226(b) of the Social Security Act (42
U.S.C. 426(b)) is amended--
(1) in paragraph (2)(A), by striking ``, and has for 24
calendar months been entitled to,'';
(2) in paragraph (2)(B), by striking ``, and has been for
not less than 24 months,'';
(3) in paragraph (2)(C)(ii), by striking ``, including the
requirement that he has been entitled to the specified benefits
for 24 months,'';
(4) in the first sentence, by striking ``for each month
beginning with the later of (I) July 1973 or (II) the twenty-
fifth month of his entitlement or status as a qualified
railroad retirement beneficiary described in paragraph (2),
and'' and inserting ``for each month for which the individual
meets the requirements of paragraph (2), beginning with the
month following the month in which the individual meets the
requirements of such paragraph, and''; and
(5) in the second sentence, by striking ``the `twenty-fifth
month of his entitlement''' and all that follows through
``paragraph (2)(C) and''.
(b) Conforming Amendments.--
(1) Section 226.--Section 226 of the Social Security Act
(42 U.S.C. 426) is amended by--
(A) striking subsections (e)(1)(B), (f), and (h);
and
(B) redesignating subsections (g) and (i) as
subsections (f) and (g), respectively.
(2) Medicare description.--Section 1811(2) of the Social
Security Act (42 U.S.C. 1395c(2)) is amended by striking ``have
been entitled for not less than 24 months'' and inserting ``are
entitled''.
(3) Medicare coverage.--Section 1837(g)(1) of the Social
Security Act (42 U.S.C. 1395p(g)(1)) is amended by striking
``25th month of'' and inserting ``month following the first
month of''.
(4) Railroad retirement system.--Section 7(d)(2)(ii) of the
Railroad Retirement Act of 1974 (45 U.S.C. 231f(d)(2)(ii)) is
amended--
(A) by striking ``has been entitled to an annuity''
and inserting ``is entitled to an annuity'';
(B) by striking ``, for not less than 24 months'';
and
(C) by striking ``could have been entitled for 24
calendar months, and''.
(c) Effective Date.--The amendments made by this section shall
apply to insurance benefits under title XVIII of the Social Security
Act with respect to items and services furnished in months beginning
after December 1 following the date of enactment of this Act, and
before the date that is 2 years after the date of the enactment of such
Act.
SEC. 1012. ENSURING CONTINUITY OF CARE.
(a) In General.--The Secretary shall ensure that all persons
enrolled or who seek to enroll in a health plan during the transition
period of the Medicare for All Program are protected from disruptions
in their care during the transition period, including continuity of
care with such persons' current health care provider teams.
(b) Continuity of Coverage and Care in General.--During the
transition period of the Medicare for All Act, group health plans and
health insurance issuers offering group or individual health insurance
coverage shall not end coverage for an enrollee during the transition
period described in the Act until all ages are eligible to enroll in
the Medicare for All Program except as expressly agreed upon under the
terms of the plan.
(c) Continuity of Coverage and Care for Persons With Complex
Medical Needs.--
(1) The Secretary shall ensure that persons' with
disabilities, complex medical needs, or chronic conditions are
protected from disruptions in their care during the transition
period, including continuity of care with such persons current
health care provider teams.
(2) During the transition period of the Medicare for All
Act group health plans and health insurance issuers offering
group or individual health insurance coverage shall not--
(A) end coverage for an enrollee who has a
disability, complex medical need, or chronic condition
during the transition period described in the Act until
all ages are eligible to enroll in the Medicare for All
Program; or
(B) impose any exclusion with respect to such plan
or coverage on the basis of a person's disability,
complex medical need, or chronic condition during the
transition period described under this Act until all
ages are eligible to enroll in the Medicare for All
Program.
(d) Public Consultation During Transition.--The Secretary shall
consult with communities and advocacy organizations of persons living
with disabilities as well as other patient advocacy organizations to
ensure that the transition buy-in takes into account the continuity of
care for persons with disabilities, complex medical needs, or chronic
conditions.
TITLE XI--MISCELLANEOUS
SEC. 1101. DEFINITIONS.
In this Act--
(1) the term ``global budget'' means the payment negotiated
between an institutional provider and as described in section
611(b);
(2) the term ``group practice'' has the meaning given such
term in section 1877(h)(4) of the Social Security Act (42
U.S.C. 1395nn(h)(4));
(3) the term ``individual provider'' means a supplier (as
defined in section 1861(d) of such Act (42 U.S.C. 1395x(d)));
(4) the term ``institutional provider'' means--
(A) providers of services described in section
1861(u) of such Act (42 U.S.C. 1395x(u));
(B) hospitals as defined in section 1861(e) of the
Social Security Act (42 U.S.C. 1395x(e)), and any
outpatient settings or clinics operating within a
hospital license or any setting or clinic that provides
outpatient hospital services;
(C) psychiatric hospitals (as defined in section
1861(e) of the Social Security Act (42 U.S.C.
1395x(f)));
(D) rehabilitation hospitals (as defined by the
Secretary of Health and Human Services under section
1886(d)(1)(B)(ii) of the Social Security Act (42 U.S.C.
1395ww(d)(1)(B)(ii)));
(E) long-term care hospitals as defined in section
1861 of the Social Security Act (42 U.S.C. 1395x(ccc));
and
(F) independent dialysis facilities and independent
end-stage renal disease facilities as described in 42
CFR 413.174(b);
(5) the term ``medically necessary or appropriate'' means
the health care items and services or supplies that are needed
or appropriate to prevent, diagnose, or treat an illness,
injury, condition, disease, or its symptoms for an individual
and are determined to be necessary or appropriate for such
individual by the physician or other health care professional
treating such individual, after such professional performs an
assessment of such individual's condition, in a manner that
meets--
(A) the scope of practice, licensing, and other law
of the State in which the individual receiving such
items and services is located; and
(B) appropriate standards established by the
Secretary for purposes of carrying out this Act;
(6) the term ``provider'' means an institutional provider
or a supplier (as defined in section 1861(d) of such Act (42
U.S.C. 1395x(d)) if the reference to ``this title'' were a
reference to the Medicare for All Program);
(7) the term ``Secretary'' means the Secretary of Health
and Human Services;
(8) the term ``State'' means a State, the District of
Columbia, or a territory of the United States;
(9) the term ``TRICARE Overseas Program'' means the element
of the TRICARE program administered by International SOS (or
such successor administrator) under which care and health
benefits are furnished to TRICARE beneficiaries located in a
TRICARE overseas region;
(10) the term ``TRICARE program'' has the meaning given
such term in section 1072 of title 10, United States Code;
(11) the term ``uniformed services'' has the meaning given
such term in section 101 of title 10, United States Code; and
(12) the term ``United States'' shall include the States,
the District of Columbia, and the territories of the United
States.
SEC. 1102. RULES OF CONSTRUCTION.
(a) In General.--A State or local government may set additional
standards or apply other State or local laws with respect to
eligibility, benefits, and minimum provider standards, only if such
State or local standards--
(1) provide equal or greater eligibility than is available
under this Act;
(2) provide equal or greater in-person access to benefits
under this Act;
(3) do not reduce access to benefits under this Act;
(4) allow for the effective exercise of the professional
judgment of physicians or other health care professionals; and
(5) are otherwise consistent with this Act.
(b) Relation to State Licensing Law.--Nothing in this Act shall be
construed to preempt State licensing, practice, or educational laws or
regulations with respect to health care professionals and health care
providers, for such professionals and providers who practice in that
State.
(c) Application to State and Federal Law on Workplace Rights.--
Nothing in this Act shall be construed to diminish or alter the rights,
privileges, remedies, or obligations of any employee or employer under
any Federal or State law or regulation or under any collective
bargaining agreement.
(d) Restrictions on Providers.--With respect to any individuals or
entities certified to provide items and services covered under section
201(a)(7), a State may not prohibit an individual or entity from
participating in the program under this Act for reasons other than the
ability of the individual or entity to provide such services.
SEC. 1103. NO USE OF RESOURCES FOR LAW ENFORCEMENT OF CERTAIN
REGISTRATION REQUIREMENTS.
Notwithstanding any provision of Federal or State law, no Federal
or State law enforcement official or employee shall use any funds,
facilities, property, equipment, or personnel made available pursuant
to this Act (or any amendment made thereby) to investigate, enforce, or
assist in the investigation or enforcement of any criminal, civil, or
administrative violation or warrant for a violation of any requirement
that individuals register with the Federal Government based on
religion, national origin, ethnicity, immigration status, or other
protected category.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Education and Workforce, Rules, Oversight and Government Reform, Armed Services, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Education and Workforce, Rules, Oversight and Government Reform, Armed Services, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Education and Workforce, Rules, Oversight and Government Reform, Armed Services, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Education and Workforce, Rules, Oversight and Government Reform, Armed Services, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Education and Workforce, Rules, Oversight and Government Reform, Armed Services, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
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Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Education and Workforce, Rules, Oversight and Government Reform, Armed Services, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Education and Workforce, Rules, Oversight and Government Reform, Armed Services, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.