I 

116TH CONGRESS 

1ST SESSION H. R. 5010 

To amend title I of the Patient Protection and Affordable Care Act to 

authorize the establishment of, and provide support for, State-based 

universal health care systems that provide comprehensive health benefits 

to State residents, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

NOVEMBER 8, 2019 

Mr. KHANNA (for himself, Ms. JAYAPAL, Mr. BLUMENAUER, Ms. BONAMICI, 

Mr. DEFAZIO, Mr. GARCI ́A of Illinois, Mr. GRIJALVA, Ms. LEE of California, Ms. OCASIO-CORTEZ, Ms. OMAR, Mr. POCAN, Ms. PRESSLEY, Mr. 

RASKIN, Ms. SCHAKOWSKY, Mr. SMITH of Washington, and Mrs. WATSON COLEMAN) introduced the following bill; which was referred to the 

Committee on Energy and Commerce, and in addition to the Committees 

on Ways and Means, Oversight and Reform, Armed Services, and Education and Labor, 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 amend title I of the Patient Protection and Affordable 

Care Act to authorize the establishment of, and provide 

support for, State-based universal health care systems 

that provide comprehensive health benefits to State residents, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE; PURPOSE. 

2 (a) SHORT TITLE.—This Act may be cited as the 

3 ‘‘State-Based Universal Health Care Act of 2019’’. 

4 (b) PURPOSE.—The purpose of this Act is to estab5 lish a flexible framework under which States can provide 

6 comprehensive universal health coverage to their residents. 

7 SEC. 2. WAIVER FOR STATE UNIVERSAL HEALTH CARE. 

8 (a) IN GENERAL.—Subtitle D of title I of the Patient 

9 Protection and Affordable Care Act (42 U.S.C. 18021 et 

10 seq.) is amended by inserting after section 1334 the fol11 lowing new section: 

12 ‘‘SEC. 1335. WAIVER FOR STATE UNIVERSAL HEALTH CARE. 

13 ‘‘(a) APPLICATION.— 

14 ‘‘(1) IN GENERAL.—Subject to paragraph (6), a 

15 State may apply to the Secretary (as defined in sub16 section (i)(3)) for the waiver of so much of the re17 quirements described in paragraph (2) with respect 

18 to health benefits coverage within the State for plan 

19 years beginning on or after January 1, 2020, as is 

20 necessary to implement a comprehensive State uni21 versal health care plan in the State under this sec22 tion. Such application shall— 

23 ‘‘(A) be filed at such time and in such 

24 manner as the Secretary may require; 

25 ‘‘(B) contain such information as the Sec26 retary may require, including— 


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1 ‘‘(i) a comprehensive description of 

2 the State legislation, or other State legal 

3 authority as applicable, and program to 

4 implement a plan meeting the require5 ments for a waiver under this section; 

6 ‘‘(ii) a plan for how the State will 

7 achieve in 5 years health coverage for at 

8 least 95 percent of residents of the State; 

9 and 

10 ‘‘(iii) a 10-fiscal-year budget plan for 

11 such plan that is budget neutral for the 

12 Federal Government; and 

13 ‘‘(C) provide an assurance that the State 

14 has legal authority to implement such plan or 

15 has enacted the law described in subsection 

16 (b)(2). 

17 ‘‘(2) REQUIREMENTS.—The requirements de18 scribed in this paragraph with respect to health ben19 efits coverage within the State for plan years begin20 ning on or after January 1, 2020, are as follows: 

21 ‘‘(A) Sections 1301 through 1324. 

22 ‘‘(B) Section 1402. 

23 ‘‘(C) Sections 36B and 4980H of the In24 ternal Revenue Code of 1986. 

25 ‘‘(D) Title XI of the Social Security Act. 


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1 ‘‘(E) Title XVIII of the Social Security 

2 Act. 

3 ‘‘(F) Title XIX of the Social Security Act. 

4 ‘‘(G) Title XXI of the Social Security Act. 

5 ‘‘(H) Chapter 89 of title 5, United States 

6 Code. 

7 ‘‘(I) Chapter 55 of title 10, United States 

8 Code, including coverage under the TRICARE 

9 program. 

10 ‘‘(J) Section 514 of the Employee Retire11 ment Income Security Act of 1974. 

12 ‘‘(3) PASSTHROUGH OF FUNDING.—With re13 spect to a State waiver under paragraph (1), under 

14 which the State assumes responsibility for health 

15 coverage under one or more of the specified Federal 

16 health programs, including under each of the Fed17 eral health care or subsidy programs specified in 

18 subparagraphs (A), (B), (C), (E), (F), (G), (H), and 

19 (I) of paragraph (2), the Secretary shall not spend 

20 Federal health or related administrative funds that 

21 would otherwise have been spent for such a pro22 gram, as applicable, for the time periods covered 

23 under the waiver and shall provide for an alternative 

24 means by which the aggregate amount of such funds 

25 (determined by the Secretary in coordination with 


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1 the State), including caseload growth, adjusted for 

2 inflation in health care costs within the State, shall 

3 be paid to the State for purposes of implementing 

4 the State plan under the waiver. Any savings in 

5 health care spending, including administrative sav6 ings, shall be available to the State for reinvestment 

7 in health care services under the State plan. Such 

8 amount shall be determined annually by the Sec9 retary, taking into account the amount that would 

10 otherwise have been spent under each such Federal 

11 health program, including for administrative activi12 ties and caseload growth, with respect to residents 

13 of such State, for those time periods covered under 

14 the waiver, adjusted for inflation in health care 

15 costs, if such waiver did not apply. Such amount 

16 shall include funds equal to the aggregate amount of 

17 premium tax credits, cost-sharing reductions, or 

18 small-business credits, to the extent applicable to an 

19 approved waiver, under sections 36B and 45R of the 

20 Internal Revenue Code of 1986 or under section 

21 1402 that would have been available to individuals 

22 and businesses in the State for those time periods 

23 covered under the waiver, including caseload growth, 

24 adjusted for inflation in health care costs, if such 

25 waiver did not apply. 


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1 ‘‘(4) WAIVER CONSIDERATION AND TRANS2 PARENCY.— 

3 ‘‘(A) IN GENERAL.—An application for a 

4 waiver under this section shall be considered by 

5 the Secretary, after taking into account rec6 ommendations of the Panel under subsection 

7 (g), in accordance with the regulations de8 scribed in subparagraph (B). 

9 ‘‘(B) REGULATIONS.—Not later than 180 

10 days after the date of the enactment of the 

11 State-Based Universal Health Care Act of 

12 2019, the Secretary shall promulgate regula13 tions relating to waivers under this section that 

14 provide— 

15 ‘‘(i) a process for public notice and 

16 comment in accordance with the public no17 tice and comment requirements applicable 

18 under regulations used for Medicaid waiv19 ers pursuant to section 1115 of the Social 

20 Security Act; 

21 ‘‘(ii) a process for the submission of 

22 an application that ensures the disclosure 

23 of— 

24 ‘‘(I) the provisions of law that 

25 the State involved seeks to waive; and 


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1 ‘‘(II) the specific plans of the 

2 State to ensure that the waiver will be 

3 in compliance with subsection (b); 

4 ‘‘(iii) a process for providing public 

5 notice and comment after the application is 

6 received by the Secretary that is sufficient 

7 to ensure a meaningful level of public 

8 input and that does not impose require9 ments that are in addition to, or duplica10 tive of, requirements imposed under chap11 ter 5 of title 5, United States Code (com12 monly referred to as the Administrative 

13 Procedure Act), or requirements that are 

14 unreasonable or unnecessarily burdensome 

15 with respect to State compliance; 

16 ‘‘(iv) a process for the submission to 

17 the Secretary of periodic reports by the 

18 State concerning the implementation of the 

19 program under the waiver; 

20 ‘‘(v) a process for the periodic evalua21 tion by the Secretary with respect to waiv22 ers granted under this section; and 

23 ‘‘(vi) a process for providing technical 

24 assistance on— 


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1 ‘‘(I) how to develop an applica2 tion to any State seeking to submit an 

3 application for a waiver relating to de4 veloping a program of providing 

5 health care for all residents for such 

6 State; and 

7 ‘‘(II) how to improve such a pro8 gram for purposes of a State seeking 

9 assistance pursuant to subsection 

10 (e)(2). 

11 ‘‘(C) REPORT.—The Secretary shall annu12 ally report to Congress concerning actions 

13 taken by the Secretary with respect to applica14 tions for waivers under this section and pro15 grams conducted pursuant to such waivers that 

16 are approved. 

17 ‘‘(5) REGIONAL WAIVER REQUEST AND PLAN.— 

18 Nothing in this section shall be construed to prevent 

19 two or more States in a region from submitting a 

20 single application under this section for a waiver 

21 that establishes a plan that is applicable to all of the 

22 States included in such application. In the case of 

23 such an application and plan, the requirements of 

24 this section shall continue to be applicable with re25 spect to each State included in such application. 


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1 ‘‘(6) COORDINATION WITH 1332 WAIVERS.—A 

2 State may not apply for a waiver under this section 

3 with respect to a plan year if such State has in ef4 fect, with respect to such plan year, a waiver under 

5 section 1332. 

6 ‘‘(7) AUTHORIZATION OF APPROPRIATIONS.— 

7 There is authorized to be appropriated such sums as 

8 may be necessary for providing funds to States with 

9 a waiver under this section for purposes of carrying 

10 out activities described in subsection (b)(1)(E). 

11 ‘‘(b) GRANTING OF WAIVERS.— 

12 ‘‘(1) IN GENERAL.—The Secretary shall grant a 

13 request for a waiver under subsection (a)(1) if the 

14 Secretary determines that the State plan— 

15 ‘‘(A) will provide, in accordance with sub16 paragraph (B), health benefits coverage to ap17 plicable State residents that is at least as com18 prehensive as the health benefits coverage that 

19 such residents would have received under one or 

20 more of the specified Federal health programs 

21 (as defined in subsection (i)(4)), as applicable, 

22 for which such residents would have been eligi23 ble, absent such waiver; 

24 ‘‘(B) will provide, in the case of such a 

25 waiver under subsection (a)(1) for the State to 


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1 waive any of the requirements described in sub2 section (a)(2)(F), as applicable, health benefits 

3 coverage to applicable State residents who 

4 would have otherwise received health benefits 

5 coverage in the form of medical assistance 

6 under the State Federal health program de7 scribed in subsection (i)(4)(B) (regardless of 

8 whether the State provides for such assistance 

9 through a State Medicaid plan under title XIX 

10 of the Social Security Act or a waiver of such 

11 State Medicaid plan) that includes at least the 

12 mandatory benefits under title XIX of the So13 cial Security Act that are required of a State 

14 without a waiver of a State Medicaid plan 

15 under such title, including benefits for early 

16 and periodic screening, diagnostic, and treat17 ment, benefits for non-emergency transpor18 tation, and retroactive coverage; 

19 ‘‘(C) will provide coverage and cost-sharing 

20 protections against excessive out-of-pocket 

21 spending to State residents that are at least as 

22 affordable as the coverage and cost-sharing pro23 tections under the specified Federal health pro24 gram (as defined in subsection (i)(4)) for which 


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1 such residents would have been eligible, absent 

2 such waiver; 

3 ‘‘(D) will provide coverage to all residents 

4 of the State, including those otherwise covered 

5 under one or more of the Federal health care 

6 or subsidy programs specified in subparagraphs 

7 (B), (C), (E), (F), (G), and (H) of subsection 

8 (a)(2), except individuals who are eligible for 

9 benefits through the Indian Health Service or 

10 for benefits and services under title 38, United 

11 States Code; 

12 ‘‘(E) will provide for public education ac13 tivities to raise awareness of the availability of 

14 qualified health plans and the facilitation of en15 rollment in such coverage in a manner similar 

16 to an entity that serves as a navigator under a 

17 grant under section 1311(i); 

18 ‘‘(F) will be publicly administered by an 

19 agency or multiple agencies of the State, or an 

20 independent public entity within the govern21 ment of the State; 

22 ‘‘(G) will not preclude the purchase of in23 surance that offers coverage for benefits that 

24 are not offered under the State plan; and 


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1 ‘‘(H) will provide systems for complaints, 

2 appeals, independent review, and other proce3 dures for accessing and maintaining benefits 

4 that are at least as accessible to applicable 

5 State residents as those of one or more of the 

6 specified Federal health programs (as defined 

7 in subsection (i)(4)) for which such residents 

8 would have otherwise been eligible without ap9 plication of such waiver under subsection 

10 (a)(1). 

11 Subparagraph (D) shall not be construed as limiting 

12 a State from contracting with one or more private 

13 entities to administer the State plan. 

14 ‘‘(2) REQUIREMENT TO ENACT A LAW.— 

15 ‘‘(A) IN GENERAL.—A law described in 

16 this paragraph is a State law (including an ex17 ecutive order by a State governor) that provides 

18 for State actions under a waiver under this sec19 tion, including the implementation of the State 

20 plan under subsection (a)(1)(B). 

21 ‘‘(B) TERMINATION OF OPT OUT.—A State 

22 may repeal a law described in subparagraph (A) 

23 and terminate the authority provided under the 

24 waiver with respect to the State. 

25 ‘‘(c) SCOPE OF WAIVER.— 


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1 ‘‘(1) IN GENERAL.—The Secretary shall deter2 mine the scope of a waiver of a requirement de3 scribed in subsection (a)(2) granted to a State under 

4 subsection (a)(1). 

5 ‘‘(2) LIMITATION.—Under this section, the Sec6 retary may not waive any Federal law or require7 ment that is not listed in subsection (a)(2). 

8 ‘‘(d) DETERMINATIONS BY SECRETARY.— 

9 ‘‘(1) TIME FOR DETERMINATION.—The Sec10 retary shall, with respect to an application from a 

11 State under this section and after taking into ac12 count recommendations of the Panel under sub13 section (g) for such application, make a determina14 tion under subsection (a)(1) not later than 90 days 

15 after the receipt of such recommendations. 

16 ‘‘(2) EFFECT OF DETERMINATION.— 

17 ‘‘(A) GRANTING OF WAIVERS.—If the Sec18 retary determines to grant a waiver under sub19 section (a)(1), the Secretary shall notify the 

20 State involved of such determination and the 

21 terms and effectiveness of such waiver. 

22 ‘‘(B) DENIAL OF WAIVER.—If the Sec23 retary determines a waiver should not be grant24 ed under subsection (a)(1), the Secretary shall 

25 notify the State involved and the appropriate 


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1 committees of Congress of such determination 

2 and the reasons therefor. 

3 ‘‘(e) REQUIRED REPORTS; 5-YEAR REVIEW.— 

4 ‘‘(1) IN GENERAL.—As a condition of receipt of 

5 a waiver under this section, after each 5-year period 

6 of such waiver, a State shall submit to the Secretary 

7 a report that is carried out by an independent, non8 partisan entity, with respect to such 5-year period 

9 and after a process for public notice and comment 

10 at the State level, including public hearings, suffi11 cient to ensure a meaningful level of public input, on 

12 the following: 

13 ‘‘(A) How waiver funds have been spent by 

14 the State. 

15 ‘‘(B) The number of residents of the State 

16 without health insurance and a description of 

17 how the State plans to provide health insurance 

18 coverage within the subsequent 5 years to resi19 dents of the State without health insurance. 

20 ‘‘(C) How affordability in the State for 

21 health care has changed over the period. 

22 ‘‘(D) Whether the State has achieved 

23 health coverage for at least 95 percent of the 

24 residents of the State. 


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1 ‘‘(E) Measurable changes in quality and 

2 access. 

3 ‘‘(F) Any additional information specified 

4 by the Secretary for purposes of determining 

5 the successes and challenges of the waiver. 

6 ‘‘(2) 5-YEAR REVIEW.—In the case a State, 

7 based on the report submitted under paragraph (1) 

8 for a 5-year period— 

9 ‘‘(A) has been determined by the Secretary 

10 to have not achieved health coverage for at least 

11 95 percent of the residents of the State— 

12 ‘‘(i) the State shall have access to 

13 technical assistance described in subsection 

14 (a)(4)(B)(vii) to improve the health insur15 ance program of the State implemented 

16 through the waiver under this section; 

17 ‘‘(ii) the State shall have a grace pe18 riod of 12 months after such determination 

19 to achieve health coverage for at least 95 

20 percent of residents of the State; and 

21 ‘‘(iii) if after such 12 months, the 

22 State has not achieved such health cov23 erage, the waiver under this section may be 

24 terminated at the discretion of the Sec25 retary; and 


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1 ‘‘(B) has been determined by the Secretary 

2 to have achieved health coverage for at least 95 

3 percent of residents of the State, the State, as 

4 a condition of continuing such waiver, shall sub5 mit to the Secretary a plan for achieving health 

6 coverage for the remainder of the residents of 

7 the State. 

8 ‘‘(f) ASSURING COORDINATION.— 

9 ‘‘(1) IN GENERAL.—Not later than 180 days 

10 after the date of the enactment of the State-Based 

11 Universal Health Care Act of 2019, the Secretary of 

12 Health and Human Services, the Secretary of the 

13 Treasury, the Secretary of Defense, the Secretary of 

14 Labor, and the Director of the Office of Personnel 

15 Management, shall, through the execution of an 

16 interagency memorandum of understanding among 

17 such Secretaries and Director— 

18 ‘‘(A) develop a process for coordinating 

19 and consolidating the State waiver processes 

20 applicable under the provisions of this section, 

21 and the existing waiver processes applicable 

22 under— 

23 ‘‘(i) titles XI, XVIII, XIX, and XXI 

24 of the Social Security Act; and 


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1 ‘‘(ii) any other Federal law relating to 

2 the provision of health care items or serv3 ices; and 

4 ‘‘(B) ensure that— 

5 ‘‘(i) regulations (including regulations 

6 required under subsection (a)(4)(B)), rul7 ings, and interpretations issued by such 

8 Secretaries and Director relating to the 

9 same matter over which two or more such 

10 Secretaries or Director have responsibility 

11 under this section are administered so as 

12 to have the same effect at all times; and 

13 ‘‘(ii) coordination of policies relating 

14 to the granting, implementation, and con15 tinuation of waivers through such Secre16 taries and Director in order to have a co17 ordinated strategy that avoids duplication 

18 of effort by the States or Secretaries and 

19 Director and ensures clarity about waiver 

20 application status and approval. 

21 ‘‘(2) SINGLE APPLICATION.—The process under 

22 paragraph (1)(A) shall permit a State to submit a 

23 single application for a waiver under all of the provi24 sions of this section and the provisions of law listed 

25 under clauses (i) and (ii) of such paragraph. 


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1 ‘‘(3) SUBMISSION OF CONFORMING AMEND2 MENTS.—The Secretary of Health and Human Serv3 ices, in coordination with the other Secretaries listed 

4 in paragraph (1) (including the Director of the Of5 fice of Personnel Management), shall submit to Con6 gress such recommendations for such technical and 

7 conforming amendments to law as may be appro8 priate to assist in the implementation of this section. 

9 ‘‘(g) INDEPENDENT ASSESSMENT PANEL FOR COM10 PREHENSIVE HEALTH CARE.— 

11 ‘‘(1) ESTABLISHMENT.—There is established a 

12 committee to be known as the ‘Independent Assess13 ment Panel for Comprehensive Health Care’ (in this 

14 section referred to as the ‘Panel’). 

15 ‘‘(2) CONSIDERATION OF SUBMISSIONS.—The 

16 Secretary shall forward a copy of each waiver appli17 cation submitted under this section to the Panel for 

18 consideration under this subsection. 

19 ‘‘(3) DUTIES.—The Panel shall— 

20 ‘‘(A) review any waiver application by a 

21 State forwarded under paragraph (2) and any 

22 report submitted under paragraph (1) of sub23 section (e) for purposes of the review under 

24 paragraph (2) of such subsection; 


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1 ‘‘(B) not later than 90 days after submis2 sion of such application (or report) by the 

3 State, provide to the State and to the Secretary 

4 the recommendations of the Panel regarding 

5 the approval or disapproval of such waiver ap6 plication (or regarding the status of the waiver 

7 for continuation pursuant to subsection (e)(2)) 

8 and, if applicable, possible improvements to 

9 such application (or for purposes of subsection 

10 (e)(2)); and 

11 ‘‘(C) submit to Congress an annual report 

12 on waiver applications (and waiver reports 

13 under subsection (e)) reviewed by the Panel 

14 during the applicable year, including the num15 ber of applications (and reports) received and 

16 the number of applications recommended for 

17 approval (and of reports with respect to which 

18 recommendations for continuation were pro19 vided). 

20 ‘‘(4) MEMBERSHIP.— 

21 ‘‘(A) NUMBER AND APPOINTMENT.—The 

22 Panel shall consist of 11 members appointed by 

23 the Secretary of Health and Human Services, 

24 of whom— 


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1 ‘‘(i) one shall be appointed on the rec2 ommendation of the Speaker of the House 

3 of Representatives; 

4 ‘‘(ii) one shall be appointed on the 

5 recommendation of the minority leader of 

6 the House of Representatives; 

7 ‘‘(iii) one shall be appointed on the 

8 recommendation of the majority leader of 

9 the Senate; 

10 ‘‘(iv) one shall be appointed on the 

11 recommendation of the minority leader of 

12 the Senate; 

13 ‘‘(v) one shall be appointed on the rec14 ommendation of the Republican Governors 

15 Association; 

16 ‘‘(vi) one shall be appointed on the 

17 recommendation of the Democratic Gov18 ernors Association; 

19 ‘‘(vii) one shall be a representative 

20 from the patient advocacy community; 

21 ‘‘(viii) two shall be representatives of 

22 a labor organization representing health 

23 care professionals who provide direct pa24 tient care, including at least one labor orVerDate Sep 11 2014 22:09 Nov 18, 2019 Jkt 099200 PO 00000 Frm 00020 Fmt 6652 Sfmt 6201 E:\BILLS\H5010.IH H5010

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1 ganization that primarily represents reg2 istered nurses; 

3 ‘‘(ix) one shall be a representative of 

4 primary care physicians; and 

5 ‘‘(x) one shall be a representative of 

6 health care professionals practicing in 

7 rural or underserved areas. 

8 ‘‘(B) TERM OF SERVICE.— 

9 ‘‘(i) IN GENERAL.—Each member of 

10 the Panel shall serve a three-year term. A 

11 member may serve after the expiration of 

12 that member’s term until a successor has 

13 been appointed pursuant to subparagraph 

14 (A). 

15 ‘‘(ii) VACANCY.—Any member ap16 pointed to fill a vacancy occurring before 

17 the expiration of the term for which the 

18 member’s predecessor was appointed shall 

19 be appointed only for the remainder of that 

20 term. A vacancy in the Commission shall 

21 be filled in the manner in which the origi22 nal appointment was made. 

23 ‘‘(C) PAY.—Members of the Panel shall 

24 serve without pay. 


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1 ‘‘(D) CHAIRPERSON; VICE CHAIR2 PERSON.— 

3 ‘‘(i) CHAIRPERSON.—The Secretary of 

4 Health and Human Services, or a designee 

5 of the Secretary, shall serve on the Panel 

6 as the Chairperson of the Panel. 

7 ‘‘(ii) VICE CHAIRPERSON.—The Ad8 ministrator of the Federal Emergency 

9 Management Agency, or a designee of the 

10 Administrator, shall serve on the Panel as 

11 the Vice Chairperson of the Panel. 

12 ‘‘(5) STAFF, EXPERTS, AND CONSULTANTS.— 

13 The Panel may— 

14 ‘‘(A) appoint such staff as the Panel con15 siders to be appropriate, without regard to the 

16 provisions of title 5, United States Code, gov17 erning appointments in the competitive service; 

18 ‘‘(B) fix the pay of such staff, without re19 gard to the provisions of chapter 51 and sub20 chapter III of chapter 53 of such title relating 

21 to classification and General Schedule pay 

22 rates; and 

23 ‘‘(C) procure the services of experts and 

24 consultants in accordance with the provisions of 

25 section 3109(b) of such title. 


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1 ‘‘(6) DETAIL OF FEDERAL PERSONNEL.—Upon 

2 request of the Panel, the head of any Federal agency 

3 may detail, on a reimbursable basis, any of the per4 sonnel of the agency to the Panel to assist it in car5 rying out the duties under paragraph (3). 

6 ‘‘(7) FEDERAL ADVISORY COMMITTEE ACT.— 

7 The Federal Advisory Committee Act (5 U.S.C. 

8 App.) shall apply to the Panel. 

9 ‘‘(8) AUTHORIZATION OF APPROPRIATIONS.— 

10 There is authorized to be appropriated such sums as 

11 may be necessary to the Panel for carrying out the 

12 duties of the panel for each of fiscal years 2020 

13 through 2025. 

14 ‘‘(h) GUIDANCE RELATING TO AMERICAN INDIANS

15 AND ALASKA NATIVES.— 

16 ‘‘(1) IN GENERAL.—The Secretary shall issue 

17 guidance with respect to applying the provisions of 

18 this section in a manner consistent with the fol19 lowing: 

20 ‘‘(A) To further the goal that Federal 

21 health services to maintain and improve the 

22 health of Indians are consonant with and re23 quired by the Federal Government’s historical 

24 and unique legal relationship with, and result25 ing responsibility to, Indians. 


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1 ‘‘(B) No enrollment fee, premium, or simi2 lar charge, and no deduction, copayment, cost 

3 sharing, or similar charge, is to be imposed 

4 against an Indian who is furnished an item or 

5 service through a waiver under this section. All 

6 costs incurred in waiving such charges shall be 

7 borne by the Federal Government in fulfillment 

8 of the trust responsibility. 

9 ‘‘(C) A State may not require the enroll10 ment of an individual who is an Indian in 

11 health insurance offered through a waiver under 

12 this section. 

13 ‘‘(D) Health insurance issuers offering cov14 erage pursuant to a waiver under this section 

15 must make good faith efforts to contract with 

16 Indian health care providers operating within 

17 the area served by the issuers. 

18 ‘‘(E) Health insurance issuers offering cov19 erage pursuant to a waiver under this section 

20 shall pay Indian health care providers, whether 

21 such providers are participating or nonpartici22 pating providers with respect to the coverage, 

23 for covered services provided to those Indian 

24 enrollees who are eligible to receive services 

25 from such providers at a rate equal to the rate 


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1 negotiated between such entity and the provider 

2 involved or, if such a rate has not been nego3 tiated, at a rate that is not less than the level 

4 and amount of payment which the entity would 

5 make for the services if the services were fur6 nished by a participating provider which is not 

7 an Indian health care provider. 

8 ‘‘(F) Health insurance issuers offering cov9 erage pursuant to a waiver under this section 

10 will include a standard contract addendum 

11 when contracting with Indian health care pro12 viders. The contract addendum will be devel13 oped in consultation with Tribes and in con14 ference with urban Indian health programs op15 erating within the service area of the State. 

16 ‘‘(G) The treatment of Indians under this 

17 section does not constitute invidious racial dis18 crimination in violation of the due process 

19 clause of the Fifth or Fourteenth Amendments, 

20 but is reasonable and rationally designed to fur21 ther the health of Indians. 

22 ‘‘(H) In the case of any State in which 1 

23 or more Indian health care programs furnishes 

24 health care services, the State will provide for 

25 a process under which the State seeks advice on 


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1 a regular, ongoing basis from designees of such 

2 Indian health care programs and urban Indian 

3 organizations on matters relating to the appli4 cation of a waiver under this section that are 

5 likely to have a direct effect on such Indian 

6 health programs and that— 

7 ‘‘(i) shall include solicitation of advice 

8 prior to submission of any plan amend9 ments, waiver requests, and proposals for 

10 demonstration projects likely to have a di11 rect effect on Indians or Indian health care 

12 programs; and 

13 ‘‘(ii) may include appointment of an 

14 advisory committee and of a designee of 

15 such Indian health care programs to the 

16 medical care advisory committee advising 

17 the State on its waiver under this section. 

18 ‘‘(2) DEFINITIONS.—For purposes of this sub19 section: 

20 ‘‘(A) The term ‘Indian’ has the meaning 

21 given such term in section 447.50 of title 42, 

22 Code of Federal Regulations (as in effect on 

23 July 1, 2010). 

24 ‘‘(B) The term ‘Indian health care pro25 vider’ has the meaning given such term in secVerDate Sep 11 2014 22:09 Nov 18, 2019 Jkt 099200 PO 00000 Frm 00026 Fmt 6652 Sfmt 6201 E:\BILLS\H5010.IH H5010

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1 tion 438.14(a) of title 42, Code of Federal Reg2 ulations. 

3 ‘‘(i) DEFINITIONS.—In this section: 

4 ‘‘(1) HEALTH BENEFITS COVERAGE.—The term 

5 ‘health benefits coverage’— 

6 ‘‘(A) means— 

7 ‘‘(i) health insurance coverage, as 

8 such term is defined in section 2791(b) of 

9 the Public Health Service Act (42 U.S.C. 

10 300gg–(b)); and 

11 ‘‘(ii) coverage under a group health 

12 plan, as such term is defined in section 

13 2791(a) of the Public Health Service Act 

14 (42 U.S.C. 300gg–(a)); and 

15 ‘‘(B) includes any medical coverage or 

16 health benefits provided under one or more of 

17 the specified Federal health program described 

18 in subparagraphs (A) through (E) of paragraph 

19 (4), as applicable to a waiver under subsection 

20 (a)(1). 

21 ‘‘(2) RESIDENT.—With respect to a State, the 

22 term ‘resident’ means an individual— 

23 ‘‘(A) who is— 

24 ‘‘(i) a citizen or national of the United 

25 States; or 


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1 ‘‘(ii) an alien lawfully residing in the 

2 State (including an alien who is granted 

3 deferred action or who is otherwise author4 ized to remain in the United States); and 

5 ‘‘(B) whose primary residence (as defined 

6 by the State) is located in the State. 

7 ‘‘(3) SECRETARY.—The term ‘Secretary’ 

8 means— 

9 ‘‘(A) the Secretary of Health and Human 

10 Services with respect to waivers relating to the 

11 provisions described in subparagraphs (A), (B), 

12 and (D) through (G) of paragraph (2) of sub13 section (a); 

14 ‘‘(B) the Secretary of the Treasury with 

15 respect to waivers relating to the provisions de16 scribed in subparagraph (C) of such paragraph; 

17 ‘‘(C) the Director of the Office of Per18 sonnel Management with respect to waivers re19 lating to the provisions described in subpara20 graph (H) of such paragraph; 

21 ‘‘(D) the Secretary of Defense with respect 

22 to waivers relating to the provisions described 

23 in subparagraph (I) of such paragraph; and 


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1 ‘‘(E) the Secretary of Labor with respect 

2 to waivers relating to the provisions described 

3 in subparagraph (J) of such paragraph. 

4 ‘‘(4) SPECIFIED FEDERAL HEALTH PROGRAM.— 

5 The term ‘specified Federal health program’ means 

6 one or more of the following programs, as applicable 

7 to a waiver under subsection (a)(1): 

8 ‘‘(A) The Medicare program under title 

9 XVIII of the Social Security Act. 

10 ‘‘(B) The Medicaid program under title 

11 XIX of the Social Security Act. 

12 ‘‘(C) The Children’s Health Insurance Pro13 gram under title XXI of the Social Security 

14 Act. 

15 ‘‘(D) The Federal Employees Health Bene16 fits Plan under chapter 89 of title 5, United 

17 States Code. 

18 ‘‘(E) Medical coverage under chapter 55 of 

19 title 10, United States Code, including coverage 

20 under the TRICARE program. 

21 ‘‘(F) An Exchange established under this 

22 subtitle. 

23 ‘‘(G) Subsidies under section 1402. 

24 ‘‘(H) Tax credits under sections 36B and 

25 45R of the Internal Revenue Code of 1986.’’. 


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1 (b) CLERICAL AMENDMENT.—The table of contents 

2 in section 1(b) of the Patient Protection and Affordable 

3 Care Act (42 U.S.C. 18001 note) is amended by inserting 

4 after the item relating to section 1334 the following new 

5 item: 

‘‘1335. Waiver for State universal health care.’’. 

Æ 


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