I 

118TH CONGRESS 

2D SESSION H. R. 10526 

To amend the Social Security Act to establish a Medicare for America health 

program to provide for comprehensive health coverage for all Americans. 

IN THE HOUSE OF REPRESENTATIVES 

DECEMBER 19, 2024 

Ms. DELAURO (for herself and Ms. SCHAKOWSKY) introduced the following 

bill; which was referred to the Committee on Ways and Means, and in 

addition to the Committees on Energy and Commerce, the Judiciary, 

Natural Resources, Education and the Workforce, and House Administration, 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 the Social Security Act to establish a Medicare 

for America health program to provide for comprehensive 

health coverage for all Americans. 

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

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘Medicare for America Act of 2024’’. 

6 (b) TABLE OF CONTENTS.—The table of contents of 

7 this Act is as follows: 


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Sec. 1. Short title; table of contents. 

TITLE I—TRANSITIONING TO AND ESTABLISHING MEDICARE FOR 

AMERICA 

Subtitle A—Transitional Public Health Option 

Sec. 101. Establishment. 

Sec. 102. Eligibility. 

Sec. 103. Benefits. 

Sec. 104. Premiums. 

Sec. 105. Providers and reimbursement rates. 

Sec. 106. Account; funding. 

Subtitle B—Medicare for America 

Sec. 111. Establishment and administration of Medicare for America. 

Sec. 112. Modifications to and coordination with existing Federal health programs. 

Subtitle C—Targeted Reforms 

Sec. 121. Limitation on removal of Medicare Advantage providers by MA organizations. 

Sec. 122. Network adequacy. 

Sec. 123. Eliminating the 24-month waiting period for Medicare coverage for 

individuals with disabilities. 

Sec. 124. Eliminating the waiting period for individuals on State Medicaid 

waiting lists. 

Sec. 125. Employer health plan options. 

Sec. 127. Medicare outpatient observation services. 

Sec. 128. Abortion coverage. 

Sec. 129. Applicability of mental health parity. 

Sec. 130. Student loan forgiveness for health care providers participating in 

Medicare for America. 

Sec. 131. Clarification of the definition of pediatric medical necessity in qualifying group coverage. 

Sec. 132. Safe staffing requirements. 

Sec. 133. Enhancements for reduced cost-sharing. 

Sec. 134. Repeal of bonus payments for Medicare Advantage plans. 

TITLE II—TAX PROVISIONS 

Sec. 201. Sunset of Public Law 115–97. 

Sec. 202. Surtax. 

Sec. 203. Basis of property acquired from a decedent. 

Sec. 204. Medicare payroll tax. 

Sec. 205. Net investment income tax. 

Sec. 206. Termination of deduction for contributions to health savings accounts. 

Sec. 207. Increase in excise tax on small cigars and cigarettes and other tobacco products. 

Sec. 208. Excise tax on alcohol. 

Sec. 209. Tax on sugared drinks. 

Sec. 210. Repeal of excise tax on high-cost employer-sponsored health coverage. 

TITLE III—DRUG-RELATED PROVISIONS 


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Sec. 301. Establishment of the Prescription Drug and Medical Device review 

Board. 

Sec. 302. Membership; staff. 

Sec. 303. Prohibition against excessive price. 

Sec. 304. Enforcement provisions. 

Sec. 305. Authority. 

Sec. 306. Regulations. 

Sec. 307. Report to Federal agencies. 

Sec. 308. Definitions. 

Sec. 309. Moratorium on direct-to-consumer drug advertising. 

Sec. 310. Reporting on justification for drug price increases. 

TITLE IV—OUTCOMES AND REPORTING 

Sec. 401. Sense of Congress. 

Sec. 402. Evaluation of bill’s outcome. 

1 TITLE I—TRANSITIONING TO 

2 AND ESTABLISHING MEDI3 CARE FOR AMERICA 

4 Subtitle A—Transitional Public 

5 Health Option 

6 SEC. 101. ESTABLISHMENT. 

7 The Secretary of Health and Human Services (in this 

8 subtitle referred to as the ‘‘Secretary’’) shall establish a 

9 public health plan option that is offered in the individual 

10 market through the Federal and State Exchanges under 

11 title I of the Patient Protection and Affordable Care Act 

12 to eligible individuals for plan years 2025 and 2026 in 

13 accordance with this subtitle. 

14 SEC. 102. ELIGIBILITY. 

15 Subject to subsection (b), an individual is eligible to 

16 enroll in such public health plan option if the individual 

17 is otherwise eligible to purchase individual health insur18 ance coverage through an Exchange and the individual reVerDate Sep 11 2014 16:53 Feb 03, 2025 Jkt 059200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H10526.IH H10526

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1 sides in a rating area in which the Secretary makes the 

2 public health plan option available. 

3 SEC. 103. BENEFITS. 

4 (a) IN GENERAL.—The public health plan option 

5 shall be a qualified health plan within the meaning of sec6 tion 1301(a) of the Patient Protection and Affordable 

7 Care Act (42 U.S.C. 18021(a)) that— 

8 (1) meets all requirements applicable to quali9 fied health plans under subtitle D of title I of the 

10 Patient Protection and Affordable Care Act (other 

11 than the requirement under section 

12 1301(a)(1)(C)(ii) of such Act (42 U.S.C. 

13 18021(a)(1)(C)(ii))) and title XXVII of the Public 

14 Health Service Act; 

15 (2) provides coverage of the essential health 

16 benefits described in section 1302(b) of the Patient 

17 Protection and Affordable Care Act (42 U.S.C. 

18 18022(b)); 

19 (3) provides silver and gold-level coverage de20 scribed in section 1302(d)(1)(C) of the Patient Pro21 tection and Affordable Care Act (42 U.S.C. 

22 18022(d)(1)(C)); and 

23 (4) provides coverage of comprehensive repro24 ductive health services, including abortion. 


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1 (b) PREEMPTION.—Notwithstanding section 

2 1303(a)(1) of the Patient Protection and Affordable Care 

3 Act (42 U.S.C. 18023(a)(1))— 

4 (1) a State may not prohibit the public health 

5 plan option from offering the coverage described in 

6 subsection (a)(4); and 

7 (2) no State law that would prohibit such a 

8 plan from offering such coverage shall apply to such 

9 plan. 

10 SEC. 104. PREMIUMS. 

11 (a) IN GENERAL.—The Secretary shall establish pre12 mium rates for the public health plan option that— 

13 (1) are adjusted based on the applicable rating 

14 area; 

15 (2) are at a level sufficient to fully finance— 

16 (A) the costs of health benefits provided by 

17 such plans; and 

18 (B) administrative costs related to oper19 ating the plans; 

20 (3) comply with the requirements under section 

21 2701 of the Public Health Service Act (42 U.S.C. 

22 300gg); and 

23 (4) ensure that no individual or household will 

24 pay more than 8 percent of adjusted gross monthly 

25 income toward the monthly premium. 


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1 (b) FEDERAL SUBSIDIES.—Federal subsidies shall be 

2 provided to ensure that the premium shall be— 

3 (1) zero in the case of an individual whose an4 nual household income is below 200 percent of the 

5 poverty line; 

6 (2) determined by a linear sliding scale, in the 

7 case of an individual whose household income is at 

8 least 200 percent of the poverty line, but not more 

9 than 600 percent of the poverty line; and 

10 (3) no individual or household above 600 per11 cent of poverty level will pay more than 8 percent 

12 of adjusted gross monthly income toward such 

13 monthly premium. 

14 SEC. 105. PROVIDERS AND REIMBURSEMENT RATES. 

15 (a) IN GENERAL.—The Secretary shall establish a 

16 rate schedule for reimbursing types of health care pro17 viders furnishing items and services under the public 

18 health insurance plan option at rates based on rates ap19 plied for such items and services under title XVIII of the 

20 Social Security Act, as of the date of the enactment of 

21 this Act, that are necessary to maintain network ade22 quacy. The Secretary shall establish a rate schedule for 

23 items and services not currently covered under title XVIII 

24 of the Social Security Act, such as dental, vision, and 


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1 hearing benefits, well child visits, and reproductive health 

2 services, at a level to ensure adequate access to providers. 

3 (b) PARTICIPATING PROVIDERS.— 

4 (1) IN GENERAL.—A health care provider that 

5 is a participating provider of services or supplier 

6 under the Medicare program under title XVIII of 

7 the Social Security Act or under the Medicaid pro8 gram under title XIX of such Act on the date of en9 actment of this title shall be a participating provider 

10 for the public health insurance plan option. 

11 (2) ADDITIONAL PROVIDERS.—The Secretary 

12 shall establish a process to allow health care pro13 viders not described in paragraph (1) to become par14 ticipating providers for the public health insurance 

15 plan option. 

16 (3) CLARIFICATION.—Notwithstanding any 

17 other provision of law, health care providers may not 

18 be prohibited from participating in the public health 

19 insurance option for reasons other than their ability 

20 to provide covered services. Health care providers 

21 and institutions are prohibited from denying covered 

22 individuals access to any covered benefits and serv23 ices because of their religious objections. 

24 (c) PRESCRIPTION DRUGS.—The Secretary shall 

25 apply the provisions of section 1860D–11(i) of the Social 


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1 Security Act (42 U.S.C. 1395w–111(i)) to prescription 

2 drugs under the public health plan option in the same 

3 manner as such provisions apply with respect to applicable 

4 covered part D drugs under such section. 

5 SEC. 106. ACCOUNT; FUNDING. 

6 (a) ESTABLISHMENT.—There is established in the 

7 Treasury of the United States an account for the receipts 

8 and disbursements attributable to the operation of the 

9 public health plan option. 

10 (b) APPROPRIATION.—There is appropriated to the 

11 account established under subsection (a), out of any funds 

12 in the Treasury not otherwise obligated, such sums as may 

13 be necessary to be used by the Secretary for purposes of 

14 carrying out this part. 

15 (c) PROHIBITION OF STATE IMPOSITION OF

16 TAXES.—Section 1854(g) of the Social Security Act (42 

17 U.S.C. 1395w–24(g)) shall apply to receipts and disburse18 ments described in subsection (a) in the same manner as 

19 such section applies to payments or premiums described 

20 in such section. 

21 (d) CLARIFICATION.—Any provision of law restricting 

22 the use of Federal funds with respect to any reproductive 

23 health service shall not apply to funds appropriated under 

24 subsection (b) or with respect to the account under sub25 section (a). 


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1 Subtitle B—Medicare for America 

2 SEC. 111. ESTABLISHMENT AND ADMINISTRATION OF MEDI3 CARE FOR AMERICA. 

4 The Social Security Act is amended by adding at the 

5 end the following new title: 

6 ‘‘TITLE XXII—MEDICARE FOR 

7 AMERICA 

8 ‘‘PART A—COMPREHENSIVE HEALTH COVERAGE 

9 ‘‘SEC. 2201. ESTABLISHMENT. 

10 ‘‘The Secretary shall establish a public health insur11 ance program, to be known as ‘Medicare for America’, 

12 which shall for calendar year 2026 and each subsequent 

13 calendar year provide comprehensive health benefits in ac14 cordance with this part to individuals enrolled for coverage 

15 under this title. 

16 ‘‘SEC. 2202. ELIGIBILITY; AUTOMATIC ENROLLMENT. 

17 ‘‘(a) ELIGIBLE INDIVIDUALS.—For purposes of this 

18 title, every individual who is— 

19 ‘‘(1) a resident of the United States or a terri20 tory of the United States; 

21 ‘‘(2) an individual who is lawfully present, as 

22 defined in section 152.2 of title 45 of the Code of 

23 Federal Regulations; or 

24 ‘‘(3) an individual who would be eligible for cov25 erage under a State Medicaid plan pursuant to secVerDate Sep 11 2014 16:53 Feb 03, 2025 Jkt 059200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H10526.IH H10526

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1 tion 1903(v) (as such section was in effect as of the 

2 date of the enactment of this title), is entitled to 

3 benefits for health care services under this title. The 

4 Secretary shall promulgate a rule that provides cri5 teria for applying this subsection, including deter6 mining residency for eligibility purposes under this 

7 title. Nothing in this title shall preclude a State 

8 from using State funds to provide for an individual’s 

9 health coverage who is not eligible under this sub10 section. 

11 ‘‘(b) ENROLLMENTS.—Subject to subsection (c): 

12 ‘‘(1) IN GENERAL.—Beginning in 2027, the 

13 Secretary shall provide a mechanism for the enroll14 ment of individuals entitled to benefits under this 

15 title and, in conjunction with such enrollment, the 

16 issuance of a Medicare for America card which may 

17 be used for purposes of identification and processing 

18 of claims for benefits under this title. The card shall 

19 not use the individual’s social security number as an 

20 identifier. As a condition of participation in the pro21 gram, participating providers shall facilitate enroll22 ment as specified by the Secretary. The State enti23 ties responsible for enrolling individuals in the Med24 icaid program under title XIX and the Children’s 

25 Health Insurance Program under title XXI shall 


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1 serve as the enrolling entity for Medicare for Amer2 ica within each State. 

3 ‘‘(2) AUTOMATIC ENROLLMENTS.—The mecha4 nism provided under paragraph (1) shall, subject to 

5 paragraph (4), provide, for plan years, for the fol6 lowing automatic enrollments under Medicare for 

7 America: 

8 ‘‘(A) ENROLLMENT AT BIRTH.—For plan 

9 years (beginning with plan year 2027), a proc10 ess, established by the Secretary in consultation 

11 with the Commissioner of Social Security, for 

12 the automatic enrollment of eligible individuals 

13 born during such plan year. 

14 ‘‘(B) CURRENT MEDICARE BENE15 FICIARIES.— 

16 ‘‘(i) CURRENT MEDICARE BENE17 FICIARIES.—For plan years (beginning 

18 with plan year 2027), a process established 

19 by the Secretary for the automatic enroll20 ment of all individuals who are enrolled for 

21 benefits under part A or B of title XVIII 

22 (other than individuals who are enrolled 

23 for such benefits and receiving benefits 

24 under title XIX). 


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1 ‘‘(ii) CONTINUING POPULATION.—For 

2 plan years (beginning with plan year 

3 2027), a process established by the Sec4 retary for the automatic enrollment of eli5 gible individuals who attain the age of 65 

6 during such plan year. 

7 ‘‘(iii) DUALS.—For plan years (begin8 ning with plan year 2029), a process estab9 lished by the Secretary for the automatic 

10 enrollment of eligible individuals who are 

11 enrolled for benefits under part A or B of 

12 title XVIII and receiving benefits under 

13 title XIX. 

14 ‘‘(C) OTHER INDIVIDUALS WITHOUT

15 QUALIFIED HEALTH COVERAGE.—For plan 

16 years (beginning with plan year 2027), a proc17 ess established by the Secretary for the auto18 matic enrollment of eligible individuals who are 

19 not enrolled in other qualified health coverage 

20 (as defined in paragraph (4)(B)) for such plan 

21 year. 

22 ‘‘(3) OTHER ENROLLMENTS.—The mechanism 

23 provided under paragraph (1) shall provide for the 

24 following: 


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1 ‘‘(A) IN GENERAL.—Enrollment periods 

2 and processes for each plan year (beginning 

3 with plan year 2027) for enrollment under 

4 Medicare for America of any eligible individual 

5 not otherwise described in paragraph (2). 

6 ‘‘(B) SMALL EMPLOYERS.— 

7 ‘‘(i) IN GENERAL.—For plan years 

8 (beginning with plan year 2027), a process 

9 and methodology under which a small em10 ployer, as defined in section 126(d)(3) of 

11 the Medicare for America Act, may provide 

12 for the enrollment of the employees of such 

13 employer under Medicare for America. For 

14 purposes of this subparagraph, the term 

15 ‘small employer’ means any employer for 

16 any calendar year if the annual payroll of 

17 such employer for the preceding calendar 

18 year does not exceed $2,000,000 or has 

19 fewer than 100 employees. 

20 ‘‘(ii) REQUIREMENT.—Small employ21 ers shall either provide coverage as defined 

22 within the meaning of section 2791(d)(8) 

23 of the Public Health Service Act or facili24 tate the enrollment of their employees into 

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1 cilitating enrollment into Medicare for 

2 America will not be subject to a mandatory 

3 employer contribution. 

4 ‘‘(iii) AUTHORITY.—The Secretary 

5 may set standards for determining whether 

6 employers are undertaking any actions to 

7 affect the risk pool within Medicare for 

8 America by inducing individuals to decline 

9 coverage under a qualifying employer-spon10 sored plan and instead to enroll in Medi11 care for America. An employer violating 

12 such standards shall be treated as not 

13 meeting the requirements of qualified 

14 health coverage. 

15 ‘‘(C) LARGE EMPLOYERS.—For plan years 

16 (beginning with plan year 2030), the Secretary 

17 shall provide for a process and methodology 

18 under which a large employer may provide for 

19 the enrollment of the employees of such em20 ployer under Medicare for America. For pur21 poses of the preceding sentence, the term ‘large 

22 employer’ means an employer with at least 100 

23 employees or whose annual payroll exceeds 

24 $2,000,000. 


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1 ‘‘(D) MEMBERS OF CONGRESS AND THEIR

2 STAFF.—Beginning for plan year 2027, Mem3 bers of Congress and their staff, subject to 

4 paragraph (4), shall be enrolled in Medicare for 

5 America. 

6 ‘‘(4) OPT-OUT FOR INDIVIDUALS ENROLLED

7 UNDER QUALIFIED HEALTH COVERAGE.— 

8 ‘‘(A) IN GENERAL.—The mechanism pro9 vided under paragraph (1) shall provide, with 

10 respect to a plan year, for a process that en11 ables individuals who are enrolled in qualified 

12 health coverage for such plan year to opt-out of 

13 coverage under Medicare for America for such 

14 year. 

15 ‘‘(B) QUALIFIED HEALTH COVERAGE DE16 FINED.—For purposes of this section, the term 

17 ‘qualified health coverage’ means coverage 

18 under any of the following: 

19 ‘‘(i) For plan years 2027 and 2028: 

20 ‘‘(I) Qualified employer coverage, 

21 as defined in section 126 of the Medi22 care for America Act. 

23 ‘‘(II) Medical coverage under 

24 chapter 55 of title 10, United States 


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1 Code, including coverage under the 

2 TRICARE program. 

3 ‘‘(III) A health care program 

4 under chapter 17 or 18 of title 38, 

5 United States Code, as determined by 

6 the Secretary of Veterans Affairs, in 

7 coordination with the Secretary of 

8 Health and Human Services and the 

9 Secretary. 

10 ‘‘(IV) The health benefit program 

11 under chapter 89 of title 5, United 

12 States Code. 

13 ‘‘(V) Medical benefits and serv14 ices provided by or through the Indian 

15 Health Service. 

16 ‘‘(VI) The Medicaid program 

17 under title XIX of the Social Security 

18 Act. 

19 ‘‘(VII) The CHIP program under 

20 title XXI of the Social Security Act. 

21 ‘‘(ii) For plan years 2029 and 2030: 

22 ‘‘(I) Coverage described in sub23 clause (I), (II), (III), (IV), or (V) of 

24 clause (i). 


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1 ‘‘(II) Coverage described in sub2 clause (VI) of clause (i), but only with 

3 respect to coverage that is not for in4 dividuals described in subclause (VIII) 

5 of section 1902(a)(10)(A)(i) or who 

6 are also enrolled for benefits under 

7 title XVIII. 

8 ‘‘(iii) For each subsequent plan year, 

9 coverage described in subclause (I), (II), 

10 (III), (IV), or (V) of clause (i). 

11 ‘‘(c) WAIVER.—The Secretary shall establish a proc12 ess under which the Secretary may grant waivers to States 

13 for additional time before populations described in a pre14 vious subsection of this section of such State are automati15 cally enrolled under Medicare for America so long as the 

16 State can demonstrate substantial progress has been made 

17 in transitioning these populations. 

18 ‘‘SEC. 2203. BENEFITS. 

19 ‘‘(a) IN GENERAL.—Medicare for America shall, in 

20 accordance with this section, provide coverage for all the 

21 benefits, as determined to be medically necessary, as cov22 ered and defined under parts A and B of title XVIII and 

23 title XIX as of the date of the enactment of this title, 

24 including the following: 

25 ‘‘(1) Ambulatory patient services. 


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1 ‘‘(2) Emergency care and urgent care services. 

2 ‘‘(3) Hospitalization. 

3 ‘‘(4) Maternity and newborn care. 

4 ‘‘(5) Behavioral health services, including men5 tal health, substance use disorder services, and in6 tensive home- and community-based services. 

7 ‘‘(6) Prescription drugs approved by the Food 

8 and Drug Administration. 

9 ‘‘(7) Rehabilitative and habilitative services and 

10 devices, including the following: 

11 ‘‘(A) Physical therapy. 

12 ‘‘(B) Speech therapy. 

13 ‘‘(C) Occupational therapy. 

14 ‘‘(8) Laboratory services. 

15 ‘‘(9) Preventive and wellness services and 

16 chronic disease management. 

17 ‘‘(10) Pediatric services, all services that would 

18 otherwise be coverable under early and periodic 

19 screening, diagnostic, and treatment under the Med20 icaid program under title XIX and services otherwise 

21 included under the maternal, infant, and early child22 hood home visiting program under section 511, as of 

23 the date of the enactment of this title. 

24 ‘‘(11) Dental care, at a minimum the services 

25 necessary to prevent disease and promote oral 


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1 health, restore oral structures to health and func2 tion, and treat emergency conditions, nightguards, 

3 mouthguards, and dentures. 

4 ‘‘(12) Hearing health services including aids 

5 and exams. 

6 ‘‘(13) Vision services. 

7 ‘‘(14) Home- and community-based long-term 

8 services and supports. 

9 ‘‘(15) Chiropractic services. 

10 ‘‘(16) Durable medical equipment (as defined 

11 for purposes of title XIX), including the following: 

12 ‘‘(A) Wheelchairs and accessories. 

13 ‘‘(B) Walking aides such as walkers, canes, 

14 and crutches. 

15 ‘‘(C) Bathroom equipment such as com16 modes and safety equipment. 

17 ‘‘(D) Inhalation therapy equipment such as 

18 nebulizers. 

19 ‘‘(E) Hospital beds and accessories. 

20 ‘‘(F) Other devices such as Continuous 

21 Positive Airway Pressure (CPAP) machines, 

22 apnea monitors, and ventilators. 

23 ‘‘(G) Insulin pumps and glucometers. 

24 ‘‘(H) Breast pumps. 


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1 ‘‘(I) Lymphedema compression treatment 

2 items. 

3 ‘‘(J) Wigs for medical conditions. 

4 ‘‘(K) Augmentative and alternative com5 munication devices, including dual-use devices. 

6 ‘‘(L) Oxygen. 

7 ‘‘(M) Orthotic and prosthetic devices. 

8 ‘‘(N) Disposable medical supplies. 

9 ‘‘(17) Family planning, including the following: 

10 ‘‘(A) Reproductive health exams. 

11 ‘‘(B) Patient counseling and education re12 lated to family planning. 

13 ‘‘(C) Abortion. 

14 ‘‘(D) Screening, testing, treatment, and 

15 pre- and post-test counseling for sexually trans16 mitted diseases and HIV. 

17 ‘‘(E) Contraceptives including pill, patch, 

18 medication, condom, implant, or other devices 

19 used to prevent pregnancy. 

20 ‘‘(F) Voluntary sterilization for bene21 ficiaries over the age of 21. 

22 ‘‘(G) Infertility treatment. 

23 ‘‘(18) Gender-confirming medical procedures 

24 and treatment. 


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1 ‘‘(19) Screening, testing, treatment, and pre2 and post-test counseling for sexually transmitted dis3 eases and HIV. 

4 ‘‘(20) Dietary and nutrition counseling. 

5 ‘‘(21) Medically necessary food and vitamins for 

6 digestive and inherited metabolic disorders. 

7 ‘‘(22) Nursing facilities. 

8 ‘‘(23) Acupuncture. 

9 ‘‘(24) Digital health therapeutics, as approved 

10 by the Center for Healthcare and the Center for 

11 Medicare and Medicaid Innovation. 

12 ‘‘(25) Telehealth. 

13 ‘‘(26) Non-emergency medical transportation. 

14 ‘‘(27) Care coordination, including services de15 fined in section 440.169 of title 42, Code of Federal 

16 Regulations. 

17 ‘‘(28) Palliative care. 

18 ‘‘(29) Any additional benefit or service not in19 cluded in this section that is coverable by any State 

20 plan (or waiver of such State plan) under title XIX 

21 on the date of the enactment of this title. 

22 ‘‘(b) UPDATES.—Benefits coverable under Medicare 

23 for America shall be updated in accordance with the Na24 tional Coverage Determination process that had, as of the 


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1 date before the date of the enactment of this title, applied 

2 with respect to benefits covered under title XVIII. 

3 ‘‘(c) IMPLEMENTING POLICIES.—The Secretary shall 

4 establish payment models, quality measures, and other im5 plementing policies that provide further access to the cov6 erage under this title. For purposes of the previous sen7 tence, the Secretary shall consult with stakeholders, in8 cluding those covering pediatrics, disabilities, and seniors. 

9 ‘‘(d) PROHIBITION AGAINST DUPLICATING COV10 ERAGE.— 

11 ‘‘(1) IN GENERAL.—It is unlawful for a private 

12 health insurer (other than an insurer with respect to 

13 a Medicare Advantage for America plan under part 

14 C of this title or qualified employer-based coverage) 

15 to sell health insurance coverage that duplicates the 

16 benefits provided under Medicare for America under 

17 this part. 

18 ‘‘(2) CONSTRUCTION.—Nothing in paragraph 

19 (1) shall be construed as prohibiting the sale of 

20 health insurance coverage for any additional benefits 

21 not covered by this part, insofar as the coverage sat22 isfies the conditions of paragraphs (3) and (4). 

23 Nothing shall preclude employers meeting the re24 quirements under section 126 of the Medicare for 


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1 America Act from providing supplemental coverage 

2 under this section to their employees. 

3 ‘‘(3) APPLICATION OF PROTECTIONS.—For pur4 poses of paragraph (2), health insurance coverage 

5 for any additional benefits must satisfy the following 

6 conditions: 

7 ‘‘(A) The provisions of section 2718 of the 

8 Public Health Service Act, relating to a medical 

9 loss ratio. 

10 ‘‘(B) The provisions of section 2702 of the 

11 Public Health Service Act, relating to guaran12 teed issue. 

13 ‘‘(C) The provisions of section 2701 of the 

14 Public Health Service Act, relating to commu15 nity rating. 

16 ‘‘(D) The provisions of section 2704 of the 

17 Public Health Service Act, relating to the ban 

18 on pre-existing conditions exclusions. 

19 ‘‘(4) NO FEES TO BROKERS.—For purposes of 

20 paragraph (2), the condition described in this para21 graph is that health insurance coverage described in 

22 such paragraph does not pay fees to insurance bro23 kers. 

24 ‘‘(e) STATES MAY PROVIDE ADDITIONAL BENE25 FITS.—Individual States may provide additional benefits 


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1 for the residents of such States at the expense of the 

2 State. 

3 ‘‘(f) PROHIBITION AGAINST STEP THERAPY AND

4 PRIOR AUTHORIZATION.—Items and services covered 

5 under Medicare for America shall be covered without any 

6 need for any prior authorization determination and with7 out any limitation applied through the use of step therapy 

8 protocols. 

9 ‘‘SEC. 2204. PREMIUMS. 

10 ‘‘(a) IN GENERAL.— 

11 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

12 each individual enrolled for benefits under this title 

13 for a year shall pay monthly community-rated pre14 miums for such year in an amount determined by 

15 the Secretary in accordance with subsection (b). 

16 ‘‘(2) GRANDFATHERED MEDICARE BENE17 FICIARIES.—In the case of an individual enrolled 

18 under part B of title XVIII as of the date of the en19 actment of this part, the premium applied under this 

20 section for such individual for benefits under this 

21 title shall be the lesser of— 

22 ‘‘(A) the premium otherwise applicable to 

23 such individual under such title XVIII if this 

24 title had not been enacted; or 


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1 ‘‘(B) the premium that would be applied to 

2 such individual under this title without the ap3 plication of this paragraph. 

4 ‘‘(b) PREMIUM CONTRIBUTION BASED ON INCOME.— 

5 The amount of a monthly premium, with respect to a plan 

6 year (beginning with 2027), under this section shall be 

7 established by the Secretary in accordance with the fol8 lowing: 

9 ‘‘(1) Such premium shall be determined such 

10 that the collective premiums for the plan year are 

11 with respect to the costs of health benefits provided 

12 under this title for such year and related administra13 tive costs. 

14 ‘‘(2) Premiums shall vary by family composition 

15 only. 

16 ‘‘(3) Federal subsidies shall be provided to en17 sure that the premium shall be— 

18 ‘‘(A) zero in the case of an individual 

19 whose annual household income is below 200 

20 percent of the poverty line; 

21 ‘‘(B) determined by a linear sliding scale, 

22 in the case of an individual whose household in23 come is at least 200 percent of the poverty line, 

24 but not more than 600 percent of the poverty 

25 line; and 


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1 ‘‘(C) no individual or household will pay 

2 more than 8 percent of adjusted gross monthly 

3 income toward such premium. 

4 ‘‘(4) For an individual whose employer will be 

5 making a firm-wide contribution under this title in 

6 lieu of offering employer-sponsored insurance (as 

7 specified in section 126(b)(1)(B) of the Medicare for 

8 America Act), such individual shall pay a premium 

9 in accordance with this subsection. 

10 ‘‘(5) For an individual who has opted out of 

11 their employer-sponsored insurance in order to enroll 

12 in Medicare for America as specified in section 

13 126(c) of such Act, the individual shall pay the less14 er of— 

15 ‘‘(A) the premium described in this sub16 section; or 

17 ‘‘(B) the amount owed after the amount of 

18 employer contribution (as specified in section 

19 126(b)(1)(B) of the Medicare for America Act) 

20 is subtracted from the premium established by 

21 the Secretary of Health and Human Services as 

22 described in paragraph (1), whichever is less. 

23 ‘‘(c) DEPOSITS.—Amounts paid under this section for 

24 coverage under this title shall be deposited in the Treasury 


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1 to the credit of the Trust Fund established under section 

2 2206. 

3 ‘‘(d) APPEALS FOR CERTAIN MEDICARE GRAND4 FATHERED POPULATION.—In calculating premiums for 

5 purposes of subsection (a)(2): 

6 ‘‘(1) Any individual that was subject to a late 

7 enrollment penalty under part B of title XVIII shall 

8 have the right to appeal the assessment of the pen9 alty for good faith enrollment mistakes. 

10 ‘‘(2) The Secretary, in consultation with the 

11 Commissioner of Social Security, shall develop and 

12 publish a formal application for requesting an action 

13 of the Secretary under paragraph (1) to correct or 

14 eliminate the effects of an error, misrepresentation, 

15 or inaction described in such paragraph and deter16 mine and publish specific timelines for timely resolu17 tion of such a request. 

18 ‘‘(3) The Secretary shall also require that all 

19 such determinations with respect to such requests 

20 shall be reached within 15 business days of the sub21 mission of such application. All determinations shall 

22 be in writing through a standard decision notice 

23 which shall include an explanation of the reasons for 

24 the determination. 


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1 ‘‘(4) The Commissioner of Social Security shall 

2 enter into contracts with independent review organi3 zations in accordance with this subsection for the 

4 purpose of reviewing and determining individual ap5 peals of determinations under paragraph (3) with re6 spect to an application relating to enrollment under 

7 part A or part B. 

8 ‘‘(5) An individual who receives an adverse de9 termination under paragraph (3) may appeal to an 

10 independent review organization designated by the 

11 Commission. Any such appeal must be sent to the 

12 independent review organization within 90 days of 

13 the date the individual received the determination to 

14 be eligible for review. The independent review orga15 nization shall review and reach a determination of 

16 the review in writing within 45 days of the receipt 

17 of any such appeal. 

18 ‘‘(6) The Secretary of the Treasury may not 

19 enter into a contract under paragraph (4) with an 

20 independent review organization— 

21 ‘‘(A) unless the organization has staff that 

22 has the appropriate knowledge of, and experi23 ence with, the eligibility and coordination of 

24 benefits rules and regulations under this title; 

25 and 


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1 ‘‘(B) to the extent the organization is a fis2 cal intermediary under section 1816, a carrier 

3 under section 1842, or a Medicare administra4 tive contractor under section 1874A. 

5 ‘‘(7) The Secretary shall provide for access by 

6 independent review organizations conducting appeal 

7 determinations under this subsection, to the data8 base of the Coordination of Benefits Contractor of 

9 the Centers for Medicare & Medicaid Services as 

10 necessary in order to conduct the duties of such or11 ganizations to determine appeals pursuant to this 

12 subsection. 

13 ‘‘SEC. 2205. PAYMENT OF BENEFITS; COST-SHARING; OUT14 OF-POCKET LIMITS. 

15 ‘‘(a) PAYMENT OF BENEFITS; COST-SHARING.— 

16 There shall be paid, in the case of each individual who 

17 is enrolled under Medicare for America and incurs ex18 penses for items and services with respect to which bene19 fits are payable under this part, subject to subsection (c), 

20 80 percent of the reimbursement rates established pursu21 ant to section 2206 for such items and services, except 

22 that for the following services, the amounts paid under 

23 this section shall be equal to 100 percent of the reimburse24 ment rates established pursuant to section 2206 for such 

25 items and services: 


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1 ‘‘(1) USPTF recommended preventive and 

2 chronic disease services. 

3 ‘‘(2) Long-term services and supports. 

4 ‘‘(3) Generic drugs, and prescription drugs if 

5 medically necessary. 

6 ‘‘(4) All services for individuals who are medi7 cally frail or otherwise have special medical needs, 

8 (including children with serious emotional disturb9 ance and adults with serious mental illness), individ10 uals with chronic substance use disorders, or individ11 uals with serious and complex medical conditions 

12 (such as epilepsy and HIV), individuals with a phys13 ical, intellectual or developmental disability that sig14 nificantly impairs their ability to perform one or 

15 more activities of daily living. 

16 ‘‘(5) Pregnancy-related services. 

17 ‘‘(6) Emergency services. 

18 ‘‘(7) Services for children under age 21. 

19 The Secretary shall establish a default monthly payment 

20 plan under the Medicare for America benefits package to 

21 ensure the payment owed by the individual enrolled under 

22 Medicare for America is spread-out evenly throughout the 

23 year. 

24 ‘‘(b) DEDUCTIBLE.—There shall be no deductible 

25 under Medicare for America. 


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1 ‘‘(c) MAXIMUM OUT-OF-POCKET LIMIT.— 

2 ‘‘(1) IN GENERAL.—The coverage under Medi3 care shall provide benefits, after the eligible indi4 vidual has incurred out-of-pocket expenses for items 

5 and services with respect to which benefits are pay6 able under this part in a year equal to the annual 

7 out-of-pocket threshold specified in paragraph (2), 

8 with cost-sharing that is equal to $0. 

9 ‘‘(2) ANNUAL OUT-OF-POCKET THRESHOLD.— 

10 ‘‘(A) IN GENERAL.—For purposes of para11 graph (1), subject to subparagraphs (B) and 

12 (C), the annual out-of-pocket threshold speci13 fied in this paragraph is a threshold that shall 

14 be determined on a linear sliding scale for 

15 household income that is at least 200 percent of 

16 the poverty line, but not more than 600 percent 

17 of the poverty line, and that shall not exceed— 

18 ‘‘(i) with respect to an individual, 

19 $3,500; or 

20 ‘‘(ii) with respect to a household, 

21 $5,000. Individuals or households with in22 come above 600 percent of the Federal 

23 poverty line shall have their annual out-of24 pocket threshold capped at $3,500 and 

25 $5,000, respectively. 


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1 ‘‘(B) INDEXING.—In the case of plan years 

2 beginning after 2026, the threshold described in 

3 subparagraph (A) (as in effect for the preceding 

4 plan year after application of this subpara5 graph) shall be increased by the percentage in6 crease over the previous year in the medical 

7 care expenditure category of the Consumer 

8 Price Index for All Urban Consumers (United 

9 States city average), published by the Bureau 

10 of Labor Statistics. 

11 ‘‘(C) EXCEPTION.—For purposes of para12 graph (1), the annual out-of-pocket threshold 

13 for individuals and households with annual in14 come below 200 percent of the Federal poverty 

15 line is $0. 

16 ‘‘(d) NO LIFETIME OR ANNUAL LIMITS.—There shall 

17 be no lifetime or annual limits for any services or benefits 

18 coverable under Medicare for America. 

19 ‘‘(e) NO BALANCE BILLING.—No provider may im20 pose a charge to an enrolled individual for coverable serv21 ices for which benefits are provided under this part in an 

22 amount higher than the reimbursement rate for such serv23 ices under section 2206 and may not impose a charge to 

24 such individual for such service other than with respect 

25 to the other cost-sharing described in this section. 


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1 ‘‘(f) NO PRIVATE CONTRACTING.—A health care pro2 vider or health care institution are prohibited from enter3 ing into a private contract with an individual enrolled 

4 under Medicare for America for any item or service 

5 coverable under Medicare for America. 

6 ‘‘(g) LIMITATIONS ON THE USE OF FLEXIBLE SAV7 INGS ACCOUNTS.—Flexible Savings Accounts shall only be 

8 used for benefits and services not covered by Medicare for 

9 America. 

10 ‘‘SEC. 2206. PROVIDERS NETWORK AND REIMBURSEMENT 

11 RATES. 

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

13 rate schedule for reimbursing types of health care pro14 viders furnishing items and services under Medicare for 

15 America at rates that are consistent with subsection (b) 

16 and are necessary to maintain network adequacy. 

17 ‘‘(b) RATES.— 

18 ‘‘(1) IN GENERAL.—Except as provided in para19 graphs (2) and (3), the Secretary shall establish 

20 rates for benefits and services to be provided to 

21 health care providers and suppliers furnishing under 

22 Medicare for America based on rates that would be 

23 applied (including as computed, updated, and ad24 justed) under title XVIII or title XIX, whichever is 

25 higher, for such type of health care providers and 


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1 suppliers and item and service if such title remained 

2 in effect and, in the case of a type of provider and 

3 supplier or item or service coverable under Medicare 

4 for America but not otherwise coverable under title 

5 XVIII or title XIX, shall provide for rates that en6 sure adequate access to care. 

7 ‘‘(2) EXCEPTIONS.—For purposes of this sec8 tion, in applying paragraph (1) the Secretary shall 

9 ensure that rates to hospitals for inpatient services 

10 or outpatient services furnished under Medicare for 

11 America are at least 110 percent of such rates on 

12 average or in the aggregate for furnishing such inpa13 tient or outpatient services otherwise applied under 

14 title XVIII or title XIX, whichever is higher, except 

15 that for hospitals serving underserved areas as speci16 fied by the Secretary, such rates are increased as 

17 necessary to ensure adequate access to care. 

18 ‘‘(3) APPLICATION.—In applying rates under 

19 title XVIII and title XIX, as applicable, for purposes 

20 of this part, the following shall apply: 

21 ‘‘(A) The Secretary shall provide for site22 neutral payments for items and services fur23 nished in an outpatient hospital and physician 

24 office, the rate of payment for such service shall 

25 be the same. 


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1 ‘‘(B) The Secretary shall provide for a 

2 mechanism to provide payments for direct and 

3 indirect costs of graduate medical education 

4 programs without any cap on the number of 

5 residency positions for which payment may be 

6 made, including payments to hospitals for such 

7 programs and to eligible facilities for programs 

8 for population health-based residencies and for 

9 nurse practitioner post-licensure clinical train10 ing, residency, and fellowship programs. 

11 ‘‘(C) The Secretary shall increase the aver12 age relative value of primary care and other 

13 mental and behavioral health and cognitive 

14 services by not less than 30 percent in order to 

15 ensure adequate access to inpatient and out16 patient care. 

17 ‘‘(D) As a condition of participation in the 

18 program, participating providers shall accept 

19 Medicare for America rates paid by employer20 sponsored insurance plans and Medicare Advan21 tage for America plans. 

22 ‘‘(E) The Secretary shall semiannually re23 view if the rates paid by Medicare for America 

24 are creating barriers to care. The Secretary 


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1 shall have the authority to raise rates as nec2 essary to ensure adequate access to care. 

3 ‘‘(4) INCREASED FEDERAL MATCH FOR MED4 ICAID AND THE CHILDREN’S HEALTH INSURANCE

5 PROGRAM FOR YEARS 2027 THROUGH 2031.—The 

6 Secretary of Health and Human Services shall pay 

7 the difference between the Medicare for America 

8 rates and the Medicaid and CHIP rates during the 

9 period beginning on January 1, 2026, and ending on 

10 December 31, 2031. 

11 ‘‘(c) PARTICIPATING PROVIDERS.— 

12 ‘‘(1) IN GENERAL.—A health care provider that 

13 is a participating provider of services or supplier 

14 under the Medicare program under title XVIII or 

15 the Medicaid program under title XIX on the date 

16 of enactment of this title shall remain a partici17 pating provider for Medicare for America. 

18 ‘‘(2) ADDITIONAL PROVIDERS.—The Secretary 

19 shall establish a process to allow health care pro20 viders not described in paragraph (1) to become par21 ticipating providers for Medicare for America. 

22 ‘‘(d) PRESCRIPTION DRUGS.— 

23 ‘‘(1) IN GENERAL.—Notwithstanding any other 

24 provision of law, the Secretary shall, for plan years 

25 beginning on or after the date of the enactment of 


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1 this title, negotiate with pharmaceutical manufactur2 ers the prices (including discounts, rebates, and 

3 other price concessions) that may be charged to 

4 Medicare for America and MA for America organiza5 tions during a negotiated price period (as specified 

6 by the Secretary) for covered drugs for Medicare for 

7 America enrollees. In negotiating such prices under 

8 this section, the Secretary shall take into account 

9 the following factors: 

10 ‘‘(A) The comparative clinical effectiveness 

11 and cost effectiveness, when available from an 

12 impartial source, of such drug. 

13 ‘‘(B) The budgetary impact of providing 

14 coverage of such drug. 

15 ‘‘(C) The number of similarly effective 

16 drugs or alternative treatment regimens for 

17 each approved use of such drug. 

18 ‘‘(D) The associated financial burden on 

19 patients that utilize such drug. 

20 ‘‘(E) The associated unmet patient need 

21 for such drug. 

22 ‘‘(F) The total revenues from global sales 

23 obtained by the manufacturer for such drug 

24 and the associated investment in research and 

25 development of such drug by the manufacturer. 


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1 ‘‘(2) FINALIZATION OF NEGOTIATED PRICE.— 

2 The negotiated price of each covered drug for a ne3 gotiated price period shall be finalized not later than 

4 30 days before the first plan year in such negotiated 

5 price period. 

6 ‘‘(3) COMPETITIVE LICENSING AUTHORITY.— 

7 ‘‘(A) IN GENERAL.—Notwithstanding any 

8 exclusivity under clause (iii) or (iv) of section 

9 505(j)(5)(F) of the Federal Food, Drug, and 

10 Cosmetic Act, clause (iii) or (iv) of section 

11 505(c)(3)(E) of such Act, section 351(k)(7)(A) 

12 of the Public Health Service Act, or section 

13 527(a) of the Federal Food, Drug, and Cos14 metic Act, or by an extension of such exclusivity 

15 under section 505A of such Act or section 505E 

16 of such Act, and any other provision of law that 

17 provides for market exclusivity (or extension of 

18 market exclusivity) with respect to a drug, in 

19 the case that the Secretary is unable to success20 fully negotiate an appropriate price for a cov21 ered drug for a negotiated price period, the Sec22 retary shall authorize the use of any patent, 

23 clinical trial data, or other exclusivity granted 

24 by the Federal Government with respect to such 

25 drug as the Secretary determines appropriate 


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1 for purposes of manufacturing such drug for 

2 sale under Medicare for America. Any entity 

3 making use of a competitive license to use pat4 ent, clinical trial data, or other exclusivity 

5 under this section shall provide to the manufac6 turer holding such exclusivity reasonable com7 pensation, as determined by the Secretary 

8 based on the following factors: 

9 ‘‘(i) The risk-adjusted value of any 

10 Federal Government subsidies and invest11 ments in research and development used to 

12 support the development of such drug. 

13 ‘‘(ii) The risk-adjusted value of any 

14 investment made by such manufacturer in 

15 the research and development of such 

16 drug. 

17 ‘‘(iii) The impact of the price, includ18 ing license compensation payments, on 

19 meeting the medical need of all patients. 

20 ‘‘(iv) The relationship between the 

21 price of such drug, including compensation 

22 payments, and the health benefits of such 

23 drug. 


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1 ‘‘(v) Other relevant factors determined 

2 appropriate by the Secretary to provide 

3 reasonable compensation. 

4 ‘‘(B) REASONABLE COMPENSATION.—The 

5 manufacturer described in subparagraph (A) 

6 may seek recovery against the United States in 

7 the United States Court of Federal Claims. 

8 ‘‘(C) INTERIM PERIOD.— 

9 ‘‘(i) IN GENERAL.—Until 1 year after 

10 a drug described in subparagraph (A) is 

11 approved under section 505(j) of the Fed12 eral Food, Drug, and Cosmetic Act or sec13 tion 351(k) of the Public Health Service 

14 Act and is provided under license issued by 

15 the Secretary under such subparagraph, 

16 Medicare for America shall not pay more 

17 for such drug than the average of the 

18 prices available, during the most recent 12- 

19 month period for which data is available 

20 prior to the beginning of such negotiated 

21 price period, from the manufacturer to any 

22 wholesaler, retailer, provider, health main23 tenance organization, nonprofit entity, or 

24 governmental entity in the ten OECD (Or25 ganization for Economic Cooperation and 


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1 Development) countries that have the larg2 est gross domestic product with a per cap3 ita income that is not less than half the 

4 per capita income of the United States or 

5 the price established by the Prescription 

6 Drug and Medical Device Review Board 

7 established under title III of the Medicare 

8 for America Act of 2019. 

9 ‘‘(ii) FEDERAL PROGRAM LICENS10 ING.—If such drug is not made available 

11 at the price determined, the Secretary shall 

12 authorize such entities to use any patent, 

13 clinical trial data, or other exclusivity 

14 granted by the Federal Government with 

15 respect to such drug as the Secretary de16 termines appropriate for purposes of man17 ufacturing such drug for sale under any 

18 Federal program, including those provided 

19 by Medicare for America, Veterans Affairs, 

20 the Department of Defense, and the Coast 

21 Guard. 

22 ‘‘(D) AUTHORIZATION FOR SECRETARY TO

23 PROCURE DRUGS DIRECTLY.— 

24 ‘‘(i) IN GENERAL.—The Secretary 

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1 ant to a competitive license under subpara2 graph (A) for purposes of this part or pur3 suant to a Federal program license under 

4 subparagraph (C)(ii) for purposes of a 

5 Federal program directly from the entity 

6 manufacturing the drug pursuant to such 

7 a license. 

8 ‘‘(ii) CLARIFICATION REGARDING AP9 PLICATION OF BUY AMERICAN ACT.—In 

10 the case where the Secretary procures a 

11 drug under this subparagraph, the provi12 sions of chapter 83 of title 41, United 

13 States Code (commonly referred to as the 

14 ‘Buy American Act’), shall apply. 

15 ‘‘(E) PRIORITY FOR U.S. MANUFACTURERS

16 IN AUTHORIZING COMPETITIVE LICENSES.—In 

17 authorizing a competitive license under this 

18 paragraph, the Secretary— 

19 ‘‘(i) shall give preference to entities 

20 that the Secretary determines have the 

21 highest safety and security standards; and 

22 ‘‘(ii) may give priority to entities that 

23 will manufacture such drug in the United 

24 States. 


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1 ‘‘(4) FDA REVIEW OF LICENSED DRUG APPLICA2 TIONS.—The Secretary shall prioritize review of ap3 plications under section 505(j) of the Federal Food, 

4 Drug, and Cosmetic Act for drugs licensed under 

5 paragraph (3)(A). 

6 ‘‘(5) PROHIBITION OF ANTICOMPETITIVE BE7 HAVIOR.—No drug manufacturer may engage in 

8 anticompetitive behavior with another manufacturer 

9 that may interfere with the issuance and implemen10 tation of a competitive license or run contrary to 

11 public policy. 

12 ‘‘(6) REQUIRED REPORTING.—The Secretary 

13 may require pharmaceutical manufacturers to dis14 close to the Secretary such information that the Sec15 retary determines necessary for purposes of carrying 

16 out this subsection. 

17 ‘‘(7) CLARIFICATION.—Nothing in this sub18 section shall be construed as preventing Medicare for 

19 America obtaining a discount or reduction of the 

20 price for a covered drug below the price negotiated 

21 by the Secretary. 

22 ‘‘(8) VALUE OR COST-EFFECTIVENESS ASSESS23 MENTS.—The use of Quality-Adjusted Life Years, 

24 Disability-Adjusted Life Years, or other similar 

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1 fectiveness assessments for purposes of this sub2 section. 

3 ‘‘(9) CLARIFICATION.—There shall be no for4 mulary under Medicare for America. 

5 ‘‘SEC. 2207. TRUST FUND; FUNDING. 

6 ‘‘(a) TRUST FUND.—There shall be established a uni7 fied Medicare Trust Fund in which funds provided under 

8 this title are deposited and from which expenditures under 

9 this title are made. The Trust Fund shall consist of such 

10 gifts and bequests as may be made and such amounts as 

11 may be deposited in, or appropriated to, such Trust Fund 

12 as provided in this Act. 

13 ‘‘(b) FUNDING.— 

14 ‘‘(1) TAXES.—There are hereby appropriated to 

15 the Trust Fund for each fiscal year beginning with 

16 fiscal year 2027, out of any moneys in the Treasury 

17 not otherwise appropriated, amounts equivalent to 

18 100 percent of the net increase in revenues to the 

19 Treasury which is attributable to the amendments 

20 made by title II of the Medicare for America Act 

21 and premiums collected under this title. The 

22 amounts appropriated by the preceding sentence 

23 shall be transferred from time to time (but not less 

24 frequently than monthly) from the general fund in 

25 the Treasury to the Trust Fund, such amounts to be 


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1 determined on the basis of estimates by the Sec2 retary of the Treasury of the taxes paid to or depos3 ited into the Treasury; and proper adjustments shall 

4 be made in amounts subsequently transferred to the 

5 extent prior estimates were in excess of or were less 

6 than the amounts that should have been so trans7 ferred. 

8 ‘‘(2) CURRENT PROGRAM RECEIPTS.—Notwith9 standing any other provision of law, there are hereby 

10 appropriated to the Trust Fund for each fiscal year, 

11 beginning with fiscal year 2026, the amounts that 

12 would otherwise have been appropriated to carry out 

13 the following programs: 

14 ‘‘(A) The Medicare program under title 

15 XVIII. 

16 ‘‘(B) The Medicaid program under title 

17 XIX, beginning as of 2031. 

18 ‘‘(3) ADDITIONAL APPROPRIATIONS.—Addi19 tional sums are authorized to be appropriated annu20 ally as needed to maintain maximum quality, effi21 ciency, and access under this part. 

22 ‘‘(4) MEDICAID MAINTENANCE OF EFFORT PAY23 MENTS.—There shall be transferred to the Trust 

24 Fund the maintenance of effort payments made 

25 under section 2209. 


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1 ‘‘(c) RESTRICTIONS SHALL NOT APPLY.—Any other 

2 provision of law in effect on the date of enactment of this 

3 title restricting the use of Federal funds for any reproduc4 tive health service, including abortion, shall not apply to 

5 monies in the Trust Fund. 

6 ‘‘(d) INCORPORATION OF PROVISIONS.—The provi7 sions of subsections (b) through (i) of section 1817 shall 

8 apply to the Trust Fund under this section in the same 

9 manner as such provisions applied to the Federal Hospital 

10 Insurance Trust Fund under such section 1817, except 

11 that, for purposes of applying such subsections to this sec12 tion, the ‘Board of Trustees of the Trust Fund’ shall mean 

13 the ‘Secretary’. 

14 ‘‘(e) TRANSFER OF FUNDS.—Any amounts remain15 ing in the Federal Hospital Insurance Trust Fund under 

16 section 1817 or the Federal Supplementary Medical Insur17 ance Trust Fund under section 1841 after the payment 

18 of claims for items and services furnished under title 

19 XVIII have been completed, shall be transferred into the 

20 Trust Fund under this section. 

21 ‘‘SEC. 2208. ADMINISTRATIVE PROVISIONS. 

22 ‘‘(a) CENTER FOR HEALTH CARE.—Beginning 2027, 

23 the Centers for Medicare & Medicaid Services shall be re24 named the Center for Health Care and all references in 

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1 erence to such Center. All powers, duties, and responsibil2 ities of the Centers for Medicare & Medicaid Services shall 

3 be transferred to the Center for Health Care. 

4 ‘‘(b) AUTHORITY.—The Secretary shall have the au5 thority to issue interim final rules with respect to any pro6 vision in this part. 

7 ‘‘(c) ADMINISTRATIVE LAW JUDGES.— 

8 ‘‘(1) IN GENERAL.—The Center for Health 

9 Care is not authorized to appoint administrative law 

10 judges, in accordance with pages 11420 through 

11 11499 of title 70 of the Federal Register (March 8, 

12 2005). 

13 ‘‘(2) TIMING.—Under this title, administrative 

14 law judges must issue a decision within 90 days of 

15 receipt of a hearing request, as specified in sub16 sections (a) and (c) of section 405.1016 of title 2, 

17 Code of Federal Regulations. 

18 ‘‘(d) COVERAGE DETERMINATIONS APPEALS.— 

19 ‘‘(1) Individuals may appeal a coverage deter20 mination under this title before the individual ob21 tains the service or item that is the subject of the 

22 appeal. Individuals shall continue to receive the serv23 ice or item if an appeal is filed before the provision 

24 of the service or item is terminated. 


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1 ‘‘(2) The Secretary shall eliminate the redeter2 mination by a Medicare administrative contractor 

3 from the appeals process under the Medicare pro4 gram for beneficiaries. 

5 ‘‘(e) PRIVATE RIGHT OF ACTION.— 

6 ‘‘(1) IN GENERAL.—An applicant or recipient 

7 denied a right conferred by this title may bring a 

8 civil action seeking any remedy available in law or 

9 equity to remedy that violation. State courts and 

10 district courts of the United States shall have con11 current jurisdiction of such actions. 

12 ‘‘(2) RIGHT DEFINED.—Rights are created by 

13 any provision of this title that— 

14 ‘‘(A) prescribes, establishes, or confers a 

15 benefit or protection in favor of the individual 

16 or individuals seeking to enforce the provision; 

17 or 

18 ‘‘(B) prescribes, establishes, or imposes a 

19 duty or obligation on a person or entity to act 

20 or conduct operations in a manner that benefits 

21 the individual or individuals seeking to enforce 

22 the provision. 

23 ‘‘(3) REASONABLE ATTORNEY FEES.—In any 

24 action or proceeding to enforce this title, the court 

25 may award reasonable attorneys’ fees and litigation 


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1 costs (including expert fees) reasonably incurred 

2 against the defendant or defendants. 

3 ‘‘(4) APPEAL.—Any civil action brought under 

4 this section shall be subject to appeal as provided in 

5 sections 1291 and 1292 of title 28 of the United 

6 States Code. 

7 ‘‘(5) CONTINUED APPLICATION OF OTHER

8 LAWS.—Nothing in this title (or an amendment 

9 made by this title) shall be construed to invalidate 

10 or limit the rights, remedies, procedures, or legal 

11 standards available to individuals aggrieved under 

12 section 1979 of the Revised Statutes (42 U.S.C. 

13 1983), or to supersede State laws causes of action. 

14 ‘‘(f) NON-DISCRIMINATION.— 

15 ‘‘(1) IN GENERAL.—Except as otherwise pro16 vided for in this title, an individual shall not, on the 

17 ground prohibited under title VI of the Civil Rights 

18 Act of 1964 (42 U.S.C. 2000d et seq.), title IX of 

19 the Education Amendments of 1972 (20 U.S.C. 

20 1681 et seq.), the Age Discrimination Act of 1975 

21 (42 U.S.C. 6101 et seq.), section 504 of the Reha22 bilitation Act of 1973 (29 U.S.C. 794), or section 

23 1557 of the Affordable Care Act (42 U.S.C. 18116), 

24 be excluded from participation in, be denied the ben25 efits of, or be subjected to discrimination under, any 


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1 health program or activity, any part of which is re2 ceiving Federal financial assistance, including cred3 its, subsidies, or contracts of insurance, or under 

4 any program or activity that is administered by an 

5 Executive Agency or any entity established under 

6 this title (or amendments) or any employer-spon7 sored insurance. The enforcement mechanisms pro8 vided for and available under such title VI, title IX, 

9 section 794, Age Discrimination Act, or such section 

10 1557 shall apply for purposes of violations of this 

11 subsection. 

12 ‘‘(2) CONTINUED APPLICATION OF LAWS.— 

13 Nothing in this title (or an amendment made by this 

14 title) shall be construed to invalidate or limit the 

15 rights, remedies, procedures, or legal standards 

16 available to individuals aggrieved under title VI of 

17 the Civil Rights Act of 1964 (42 U.S.C. 2000d et 

18 seq.), title VII of the Civil Rights Act of 1964 (42 

19 U.S.C. 2000e et seq.), title IX of the Education 

20 Amendments of 1972 (20 U.S.C. 1681 et seq.), sec21 tion 504 of the Rehabilitation Act of 1973 (29 

22 U.S.C. 794), the Age Discrimination Act of 1975 

23 (42 U.S.C. 611 et seq.), or section 1557 of the Af24 fordable Care Act (42 U.S.C. 18116) or to super25 sede State laws that provide additional protections 


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1 against discrimination on any basis described in 

2 paragraph (1). 

3 ‘‘(3) HEALTH CARE PROVIDERS.—Health care 

4 providers may not be prohibited from participating 

5 in the Medicare for America for reasons other than 

6 their ability to provide covered services. Health care 

7 providers and institutions are prohibited from deny8 ing covered individuals access to covered benefits 

9 and services because of their religious objections. 

10 This subsection supercedes any provision of law that 

11 allows for conscience protection. 

12 ‘‘(4) REGULATIONS.—The Secretary may pro13 mulgate regulations to implement this subsection. 

14 ‘‘SEC. 2209. MAINTENANCE OF EFFORT REQUIREMENT. 

15 ‘‘(a) IN GENERAL.—A State is not eligible for pay16 ment under any program specified in subsection (c) for 

17 a calendar quarter in a plan year beginning after 2036 

18 unless the State makes to the Secretary for transfer to 

19 the unified Medicare Trust Fund under section 2207 the 

20 maintenance of effort payment applicable to such State 

21 and plan year under subsection (b). The Secretary shall 

22 extend such a waiver (including the availability of Federal 

23 financial participation under such waiver) for such period 

24 as may be required for a State to meet the requirement 

25 of the previous sentence. 


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1 ‘‘(b) MAINTENANCE OF EFFORT PAYMENTS.—For 

2 purposes of this section, a maintenance of effort payment 

3 with respect to a State and plan year is— 

4 ‘‘(1) for plan year 2037 and a State, a payment 

5 in an amount equal to the total amount of expendi6 tures of the State for medical assistance under title 

7 XIX and child health assistance under title XXI in8 cluding administrative costs for the plan year before 

9 the date of the enactment of this title; 

10 ‘‘(2) for plan year 2038 and each subsequent 

11 plan year before plan year 2041— 

12 ‘‘(A) in the case of a State that is a 

13 PPACA expansion State, the payment amount 

14 applied under this subsection for the previous 

15 plan year, increased by growth in GDP per cap16 ita plus 0.4 percent; and 

17 ‘‘(B) in the case of a State that is not a 

18 PPACA expansion State, the payment amount 

19 applied under this subsection for the previous 

20 plan year, increased by growth in GDP per cap21 ita plus 0.7 percent; and 

22 ‘‘(3) beginning in 2041, for each subsequent 

23 plan year, with respect to any State, the payment 

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1 vious year, increased by growth in GDP per capita 

2 plus 0.7 percent. 

3 ‘‘(c) PROGRAMS SPECIFIED.—For purposes of this 

4 section, the programs specified in this subsection are each 

5 of the following: 

6 ‘‘(1) Block grants for community mental health 

7 services under subpart I of part B of title XIX of 

8 the Public Health Service Act. 

9 ‘‘(2) Block grants and programs for social serv10 ices and elder justice under title XX. 

11 ‘‘(3) Maternal and child health services block 

12 grants under title V. 

13 ‘‘(4) Block grants for prevention and treatment 

14 of substance abuse under subpart II of part B of 

15 title XIX of the Public Health Service Act. 

16 ‘‘(5) State Targeted Response to Opioid Crisis 

17 Grant Community Services Block Grant. 

18 ‘‘(6) Grants under section 330 of the Public 

19 Health Service Act. 

20 ‘‘(7) Ryan White HIV/AIDS Program grants 

21 under title XXVI of the Public Health Service Act. 

22 ‘‘SEC. 2210. APPLICATION OF TITLE XVIII PROVISIONS. 

23 ‘‘Except as specified otherwise in this title, in imple24 menting Medicare for America, the Secretary shall to the 

25 greatest extent practicable apply the following provisions 


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1 of title XVIII to the program under this title, benefits cov2 ered under this title, individuals entitled to benefits under 

3 this title, and providers of services and suppliers partici4 pating under the program under this title in a similar 

5 manner as such provisions applied to the program under 

6 title XVIII, benefits covered under such title, individuals 

7 entitled to benefits or enrolled under such title, and pro8 viders of services and suppliers participating under the 

9 program under such title: 

10 ‘‘(1) Section 1801. 

11 ‘‘(2) Section 1805. 

12 ‘‘(3) Section 1806. 

13 ‘‘(4) Section 1807. 

14 ‘‘(5) Section 1809. 

15 ‘‘(6) Section 1814. 

16 ‘‘(7) Section 1815. 

17 ‘‘(8) Section 1816. 

18 ‘‘(9) Section 1818. 

19 ‘‘(10) Section 1818A. 

20 ‘‘(11) Section 1819. 

21 ‘‘(12) Section 1820. 

22 ‘‘(13) Section 1834. 

23 ‘‘(14) Section 1834A. 

24 ‘‘(15) Section 1843. 

25 ‘‘(16) Section 1846. 


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1 ‘‘(17) Section 1847. 

2 ‘‘(18) Section 1851. 

3 ‘‘(19) Section 1852. 

4 ‘‘(20) Section 1855. 

5 ‘‘(21) Section 1856. 

6 ‘‘(22) Section 1857. 

7 ‘‘(23) Section 1858. 

8 ‘‘(24) Section 1861. 

9 ‘‘(25) Section 1863. 

10 ‘‘(26) Section 1864. 

11 ‘‘(27) Section 1866B. 

12 ‘‘(28) Section 1866C. 

13 ‘‘(29) Section 1866E. 

14 ‘‘(30) Section 1867. 

15 ‘‘(31) Section 1868. 

16 ‘‘(32) Section 1869. 

17 ‘‘(33) Section 1871. 

18 ‘‘(34) Section 1874A. 

19 ‘‘(35) Section 1880. 

20 ‘‘(36) Section 1881. 

21 ‘‘(37) Section 1881A. 

22 ‘‘(38) Section 1891. 

23 ‘‘(39) Section 1894. 

24 ‘‘(40) Section 1895. 

25 ‘‘(41) Section 1896. 


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1 ‘‘PART B—HOME- AND COMMUNITY-BASED LONG2 TERM SERVICES AND SUPPORTS 

3 ‘‘SEC. 2231. HOME- AND COMMUNITY-BASED LONG-TERM 

4 SERVICES AND SUPPORTS BENEFIT. 

5 ‘‘All individuals enrolled under Medicare for America 

6 under this title shall have coverage for home- and commu7 nity-based long-term services and supports benefits. Noth8 ing in this part shall be construed to limit an enrollee’s 

9 entitlement to any other benefit that is covered pursuant 

10 to section 2203, including nursing facility benefits. 

11 ‘‘SEC. 2232. ELIGIBILITY. 

12 ‘‘(a) ELIGIBLE INDIVIDUALS.—An individual who is 

13 eligible for home- and community-based long-term services 

14 and supports benefits under this part is an individual who 

15 satisfies each of the following: 

16 ‘‘(1) The individual is eligible for Medicare for 

17 America. 

18 ‘‘(2) The individual is determined by a licensed 

19 health care practitioner to be unable to perform, 

20 without substantial assistance, at least one Activity 

21 of Daily Living as described in section 

22 7702B(c)(2)(B) of the Internal Revenue Code of 

23 1986, or to require substantial assistance with one 

24 or more of the following areas: 

25 ‘‘(A) Communication. 

26 ‘‘(B) Social interaction. 


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1 ‘‘(C) Learning. 

2 ‘‘(D) Self-care. 

3 ‘‘(E) Self-management. 

4 ‘‘(F) Impairments that affect the person’s 

5 capacity for social or economic participation. 

6 ‘‘(b) CLARIFICATION.—Under this part, in the case 

7 of an individual described in subsection (a) who experi8 ences periods in which their functional capacity changes 

9 or improves, such individual shall continue to have access 

10 to benefits under this part as needed. If such an individ11 ual’s functional capacity improves to a point in which the 

12 individual no longer requires home- and community-based 

13 long-term services and supports, or requires fewer serv14 ices, the individual shall be able to immediately and 

15 seamlessly resume receiving all needed services if and 

16 when their functional needs recur. Eligibility for services 

17 shall be maintained if, without the services, the individual 

18 would have reduced functional capacity. When assessing 

19 functional impairment, the individual will be assessed 

20 without regard to any current services or the ameliorative 

21 effects of other mitigating measures described in section 

22 3(4)(E)(i)(I) of the Americans With Disabilities Act of 

23 1990. 

24 ‘‘(c) BENEFITS.— 


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1 ‘‘(1) DEFINITION.—For purposes of this title, 

2 the term ‘home- and community-based long-term 

3 services and supports benefit’ means the daily living 

4 supports needed by eligible individuals in order to 

5 live, work, and participate in their communities, and 

6 includes all home- and community-based services 

7 and supports coverable as of the date of the enact8 ment of this title, under any State plan or waiver 

9 under title XIX, including— 

10 ‘‘(A) home health aides and homemakers; 

11 ‘‘(B) direct support professionals and per12 sonal attendant care services; 

13 ‘‘(C) hospice; 

14 ‘‘(D) nursing care; 

15 ‘‘(E) medical social services; 

16 ‘‘(F) care coordination, including case 

17 management, fiscal intermediary, and support 

18 brokerage services; 

19 ‘‘(G) short-term inpatient care, including 

20 respite care and care for pain control; 

21 ‘‘(H) behavioral health home- and commu22 nity-based long-term services and supports, in23 cluding assertive community treatment; peer 

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1 cluding case management; supported employ2 ment; and supported housing wraparound; 

3 ‘‘(I) private-duty nursing; 

4 ‘‘(J) respite services provided in the indi5 vidual’s home or broader community; and 

6 ‘‘(K) transitional services to support an in7 dividual’s transition from an institutional set8 ting to the community. 

9 ‘‘(2) NON-APPLICATION.—The provisions of sec10 tions 424.22(a)(1)(i) and 424.22(a)(1)(ii) of title 42 

11 of the Code of Federal Regulations does not apply 

12 in the case of the benefit described in paragraph 

13 (1)(A). 

14 ‘‘(d) HOME- AND COMMUNITY-BASED LONG-TERM

15 SERVICES AND SUPPORTS WORKFORCE DEVELOP16 MENT.— 

17 ‘‘(1) IN GENERAL.—The Secretary shall ensure 

18 that the number of individuals in the home- and 

19 community-based long-term services and supports 

20 workforce is adequate to ensure community integra21 tion for all beneficiaries under Medicare for Amer22 ica. In so doing, the Secretary may consider a wide 

23 range of factors, including payment rates for direct 

24 care workers, career pipelines and credentialing, 


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1 worker rights, and the impact of national labor poli2 cies. 

3 ‘‘(2) SELF-DIRECTED MODEL.—All eligible indi4 viduals shall be defaulted into a self-directed care 

5 option (as defined by the Secretary). The Secretary 

6 must consult with eligible individuals, caregivers, 

7 workers and their representatives, including unions, 

8 and state entities responsible for administering the 

9 LTSS benefit to establish this model. 

10 ‘‘(3) COMMUNITY FIRST.—The benefit under 

11 this part shall be arranged for and provided with a 

12 community first presumption and eligible individuals 

13 shall be provided home- and community-based long14 term services and support available under this sec15 tion, regardless of type or level of disability or serv16 ice need. No eligible individual may be referred to an 

17 institution without first being offered and, if chosen, 

18 provided home- and community-based long-term 

19 services and supports. Individuals in an institution 

20 on the effective date of the bill, and at least annually 

21 or upon any change in condition thereafter, shall be 

22 informed of, and if chosen, provided with home- and 

23 community-based long-term services and supports. 

24 ‘‘(e) ADMINISTRATION OF SERVICES AND SUP25 PORTS.—State entities responsible for administering 


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1 home- and community-based long-term services and sup2 port benefits under any State plan or waiver under title 

3 XIX as of the date of the enactment of this title shall 

4 continue to administer the benefits and services coverable 

5 under this section. 

6 ‘‘(f) COORDINATION WITH OTHER FEDERAL BENE7 FITS.— 

8 ‘‘(1) RULE OF CONSTRUCTION.—Nothing in 

9 this part shall be construed as prohibiting benefits 

10 paid under this part from being used to compensate 

11 a caregiver who provides community living assistance 

12 services and supports to a dependent relative for 

13 providing community living assistance services and 

14 supports to an eligible individual under this part. 

15 ‘‘(2) DEPENDENT RELATIVE DEFINED.—The 

16 term ‘dependent relative’ means a child, grandchild, 

17 niece, nephew, parent, grandparent, sibling, aunt, or 

18 uncle (of such caregiver or his or her spouse or do19 mestic partner); such caregiver’s spouse or domestic 

20 partner, if such child, grandchild, niece, nephew, 

21 parent, grandparent, sibling, aunt, uncle, spouse, or 

22 domestic partner is an eligible individual. 

23 ‘‘(3) SUPPLEMENT NOT SUPPLANT.—Benefits 

24 received under this part by a caregiver shall supple25 ment, but not supplant, other benefits for which the 


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1 individual is eligible under any other federally fund2 ed program that provides benefits or assistance. 

3 ‘‘(4) DISREGARD.—The benefit paid under this 

4 part shall be disregarded for purposes of deter5 mining or continuing the eligibility of the individual 

6 or the spouse of the individual for receipt of benefits 

7 under any other Federal, State, or locally funded as8 sistance program, including benefits paid under title 

9 II or XVI, under the laws administered by the Sec10 retary of Veterans Affairs, under low-income hous11 ing assistance programs, under the supplemental nu12 trition assistance program established under the 

13 Food and Nutrition Act of 2008, or under programs 

14 administered by State vocational rehabilitation agen15 cies. 

16 ‘‘(5) REGULATIONS.—Not later than one year 

17 after the date of the enactment of this section, the 

18 Secretary shall promulgate such regulations as are 

19 necessary to carry out this part and to prevent fraud 

20 and abuse with respect to the benefits under this 

21 part. 

22 ‘‘PART C—MEDICARE ADVANTAGE FOR AMERICA 

23 ‘‘SEC. 2221. ALL PRIVATE PLANS. 

24 ‘‘(a) IN GENERAL.—For plan years beginning with 

25 plan year 2029, a health insurance issuer may offer health 


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1 insurance coverage in the individual market only if such 

2 issuer has entered into a contract with the Secretary 

3 under subsection (b) to offer such coverage. 

4 ‘‘(b) AGREEMENTS.—The Secretary shall enter into 

5 an agreement with an MA for America sponsor to offer 

6 MA for America plans under this part for the coverage 

7 of individuals enrolled under Medicare for America who 

8 elect to receive benefits under part A through such a plan. 

9 ‘‘(c) MA FOR AMERICA PLAN; MA FOR AMERICA

10 SPONSOR.—For purposes of this part: 

11 ‘‘(1) MA FOR AMERICA PLAN.—An MA for 

12 America plan is a Medicare Advantage plan under 

13 part C of title XVIII, except such plan shall provide 

14 coverage for individuals enrolled under Medicare for 

15 America under part A of this title, with respect to 

16 at least the benefits covered under such part A. 

17 ‘‘(2) MA FOR AMERICA SPONSOR.—An MA for 

18 America sponsor is a sponsor of an MA for America 

19 plan. 

20 ‘‘SEC. 2222. APPLICATION OF MEDICARE ADVANTAGE PRO21 VISIONS. 

22 ‘‘For purposes of applying this part, except as other23 wise specified under this part, the provisions of part C 

24 of title XVIII, as in effect as of the date of the enactment 

25 of this title shall apply with respect to an MA for America 


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1 sponsor, MA for America plan, individuals eligible for cov2 erage under this part, individuals enrolled under such 

3 plan, and benefits covered under part A in a similar man4 ner and to a similar extent as such provisions applied to 

5 an MA organization, MA plan, individuals eligible for 

6 under part C of such title, individuals enrolled under an 

7 MA plan, and benefits covered under fee-for-service Medi8 care as of such date. 

9 ‘‘SEC. 2223. MEDICARE ADVANTAGE FOR AMERICA PAY10 MENT RATES. 

11 ‘‘The rates for Medicare Advantage for America 

12 plans shall be equal to the rates paid by Medicare for 

13 America. The Administrator of the Center for Healthcare 

14 shall pay Medicare Advantage for America plans 95 per15 cent of average Medicare for America costs in each county. 

16 ‘‘SEC. 2224. SEPARATE PREMIUM FOR MEDICARE ADVAN17 TAGE FOR AMERICA PLANS FURNISHING 

18 SUPPLEMENTAL BENEFITS. 

19 ‘‘Nothing in this part shall preclude an individual 

20 from choosing a Medicare Advantage for America plan 

21 which requires the individual to pay an additional, sepa22 rate amount because of supplemental benefits or because 

23 it is a more expensive plan. In such case the individual 

24 enrolled under such plan would be responsible for a sepa25 rate monthly premium. 


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1 ‘‘SEC. 2225. PRESCRIPTION DRUG PRICING UNDER MEDI2 CARE ADVANTAGE FOR AMERICA PLANS. 

3 ‘‘Medicare Advantage for America plans, for prescrip4 tion drugs, shall pay no more than the price negotiated 

5 under Medicare for America. 

6 ‘‘SEC. 2226. BAN ON PAYING BROKERS’ FEES. 

7 ‘‘Medicare Advantage for America plans may not pay 

8 fees to insurance brokers. 

9 ‘‘SEC. 2227. CLARIFICATION ON MEDICARE ADVANTAGE EM10 PLOYER GROUP WAIVER PLANS AND THE 

11 MEDICARE SECONDARY PAYER REQUIRE12 MENT. 

13 ‘‘Such plans shall be exempt from the MSP Require14 ment, and nothing in this section shall be construed as 

15 prohibiting such plans from contributing to the payment 

16 of premiums and cost-sharing. 

17 ‘‘SEC. 2228. REFERENCES. 

18 ‘‘Beginning in 2029, all references in law and regula19 tion to Medicare Advantage shall be deemed a reference 

20 to Medicare Advantage for America.′′’’. 

21 SEC. 112. MODIFICATIONS TO AND COORDINATION WITH 

22 EXISTING FEDERAL HEALTH PROGRAMS. 

23 (a) MEDICARE, MEDICAID, AND STATE CHILDREN’S

24 HEALTH INSURANCE PROGRAM (SCHIP).— 

25 (1) IN GENERAL.—Notwithstanding any other 

26 provision of law, subject to paragraphs (2) and (3) 


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1 and section 2202(c) of the Social Security Act, as 

2 added by section 111— 

3 (A) no benefits shall be available under 

4 title XVIII of the Social Security Act for any 

5 item or service furnished— 

6 (i) beginning on or after January 1, 

7 2029 (except in the case of an individual 

8 enrolled under such title and title XIX of 

9 such Act); and 

10 (ii) beginning on or after January 1, 

11 2031, with respect to all individuals, in12 cluding individuals enrolled under such 

13 title and title XIX of such Act; 

14 (B) no individual is entitled to medical as15 sistance under a State plan approved under 

16 title XIX of such Act— 

17 (i) for any item or service furnished 

18 on or after January 1, 2031, in the case 

19 of an individual enrolled under such title 

20 and title XVIII of the Social Security Act 

21 or an individual described in subclause 

22 (VIII) of section 1902(a)(10)(A)(i); and 

23 (ii) for any item or service furnished 

24 on or after January 1, 2033; 


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1 (C) no individual is entitled to medical as2 sistance under a State child health plan under 

3 title XXI of such Act for any item or service 

4 furnished on or after January 1, 2031; and 

5 (D) no payment shall be made to a State 

6 under section 1903(a) or 2105(a) of such Act 

7 with respect to medical assistance or child 

8 health assistance— 

9 (i) for any item or service furnished 

10 on or after January 1, 2031, in the case 

11 of an individual enrolled under such title 

12 and title XVIII of the Social Security Act 

13 or an individual described in subclause 

14 (VIII) of section 1902(a)(10)(A)(i); and 

15 (ii) for any item or service furnished 

16 on or after January 1, 2033. 

17 (2) TRANSITION.—In the case of inpatient hos18 pital services and extended care services during a 

19 continuous period of stay which began before Janu20 ary 1, 2031, for Medicare and 2033 for Medicaid or 

21 CHIP, and which had not ended as of such date, for 

22 which benefits are provided under title XVIII of the 

23 Social Security Act, under a State plan under title 

24 XIX of such Act, or under a State child health plan 

25 under title XXI such Act, the Secretary of Health 


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1 and Human Services shall provide for continuation 

2 of benefits under such title or plan until the end of 

3 the period of stay. 

4 (b) OTHER FEDERAL HEALTH PROGRAMS.— 

5 (1) FEDERAL EMPLOYEES HEALTH BENEFITS

6 PROGRAM.—Nothing in this Act, or the amendments 

7 made by this Act, shall affect benefits made avail8 able under chapter 89 of title 5, United States Code. 

9 (2) TRICARE.—Nothing in this Act, or the 

10 amendments made by this Act, shall affect benefits 

11 made available under sections 1079 and 1086 of 

12 title 10, United States Code. 

13 (3) TREATMENT OF BENEFITS FOR VETERANS

14 AND NATIVE AMERICANS.— 

15 (A) IN GENERAL.—Nothing in this Act, or 

16 the amendments made by this Act, shall affect 

17 the eligibility of veterans for the medical bene18 fits and services provided under title 38, United 

19 States Code, or of Indians for the medical bene20 fits and services provided by or through the In21 dian Health Service. 

22 (B) REEVALUATION.—No reevaluation of 

23 the Indian Health Service shall be undertaken 

24 without consultation with tribal leaders and 

25 stakeholders. 


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1 (C) SUPPLEMENTAL INDIAN HEALTH

2 SERVICES ALLOCATION.—The Secretary shall 

3 annually determine the need to provide an allot4 ment of supplemental funds to Indian Health 

5 Services, including payments to providers, 

6 health professional education, administrative ex7 penses, and prevention and public health activi8 ties. 

9 (4) ENROLLEE CHOICE.—Nothing in this Act 

10 shall preclude individuals enrolled in the Federal 

11 Employees Health Benefits Program or TRICARE 

12 or individuals receiving benefits provided under title, 

13 38, United States Code or the Indian Health Service 

14 from enrolling in Medicare for America. Enrollees 

15 shall be entitled to the employer contribution as es16 tablished under section 126(c) of such Act. 

17 (c) SUNSET OF PROVISIONS RELATED TO THE STATE

18 EXCHANGES.—Effective January 1, 2031, the Federal 

19 and State Exchanges established pursuant to title I of the 

20 Patient Protection and Affordable Care Act (Public Law 

21 111–148) shall terminate, and any other provision of law 

22 that relies upon participation in or enrollment through 

23 such an Exchange, including such provisions of the Inter24 nal Revenue Code of 1986, shall cease to have force or 

25 effect. 


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1 (d) SEVERABILITY.—Every provision in this Act and 

2 every application of the provisions in this Act are severable 

3 from each other as a matter of Federal law. If any applica4 tion of any provision in this Act to any person or group 

5 of persons or circumstances is found by a court to be in6 valid, the remainder of this Act and the application of the 

7 Act’s provisions to all other persons and circumstances 

8 may not be affected. 

9 Subtitle C—Targeted Reforms 

10 SEC. 121. LIMITATION ON REMOVAL OF MEDICARE ADVAN11 TAGE PROVIDERS BY MA ORGANIZATIONS. 

12 (a) LIMITATION.—Section 1852(d) of the Social Se13 curity Act (42 U.S.C. 1395w–22(d)) is amended by adding 

14 at the end the following: 

15 ‘‘(7) LIMITATION ON REMOVAL OF PROVIDERS

16 FROM MA PLANS BY MA ORGANIZATIONS.— 

17 ‘‘(A) REMOVAL OF PROVIDERS WITH

18 CAUSE.—Beginning with plan year 2026, except 

19 as provided in subparagraph (C), an MA orga20 nization offering an MA plan may only remove 

21 a provider of services or a supplier from a net22 work of such plan if the organization has cause 

23 to remove such provider or supplier. 

24 ‘‘(B) CAUSE TO REMOVE PROVIDERS.— 


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1 ‘‘(i) IN GENERAL.—An MA organiza2 tion offering an MA plan has cause to re3 move a provider of services or a supplier 

4 from a network of such plan if the Sec5 retary determines that the provider or sup6 plier is— 

7 ‘‘(I) medically negligent; 

8 ‘‘(II) in violation of any legal or 

9 contractual requirement applicable to 

10 the provider or supplier acting within 

11 the lawful scope of practice, including 

12 any participation or other requirement 

13 applicable to such provider or supplier 

14 under this title or under any contrac15 tual term for such plan; or 

16 ‘‘(III) otherwise unfit to furnish 

17 items and services in accordance with 

18 requirements of this title. 

19 ‘‘(ii) CONSIDERATION OF COST TO MA

20 ORGANIZATIONS.—For purposes of sub21 paragraph (A), cost to an MA organization 

22 offering an MA plan due to the participa23 tion of a provider of services or supplier in 

24 a network of such plan does not constitute 

25 cause for the MA organization to remove 


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1 such provider or supplier from the network 

2 mid-year, and such cost may not be consid3 ered as a factor in favor of a determination 

4 that such organization has cause to remove 

5 the provider. 

6 ‘‘(C) EXCEPTION.—With respect to each 

7 upcoming plan year, beginning with plan year 

8 2026, an MA organization offering an MA plan 

9 may only remove a provider of services or sup10 plier from a network of such plan for reasons 

11 not specified in subparagraph (B)(i) before the 

12 date that is 60 days before the first day of the 

13 annual coordinated election period for such plan 

14 year under section 1851(e)(3). 

15 ‘‘(D) NOTICE AND APPEAL PROCESS.— 

16 ‘‘(i) IN GENERAL.—Any removal of a 

17 provider of services or supplier from a net18 work of an MA plan may occur only after 

19 the completion of a fair notice and appeal 

20 process that the Secretary shall establish 

21 by regulation. Such process shall require 

22 the MA organization to provide to such 

23 provider or supplier and to the Secretary 

24 an explanation of the reason or reasons for 


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1 the removal. The Secretary shall make this 

2 information publicly available. 

3 ‘‘(ii) APPLICATION.— 

4 ‘‘(I) APPLICATION OF NEW PROC5 ESS.—In the case of a removal of a 

6 provider of services or supplier from a 

7 network of an MA plan occurring on 

8 or after the effective date published in 

9 a final rule for such fair notice and 

10 appeal process, such process shall 

11 apply in lieu of the process for the 

12 termination or suspension of a pro13 vider contract under section 

14 422.202(a) of title 42, Code of Fed15 eral Regulations. 

16 ‘‘(II) CONTINUATION OF OLD

17 PROCESS.—In the case of a removal of 

18 a provider of services or supplier from 

19 a network of an MA plan occurring 

20 before such effective date, the process 

21 for the termination or suspension of a 

22 provider contract under section 

23 422.202(a) of title 42, Code of Fed24 eral Regulations, shall apply. 


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1 ‘‘(E) PARTICIPANT NOTICE AND PROTEC2 TION.— 

3 ‘‘(i) NOTICE TO PARTICIPANTS OF

4 PROVIDER REMOVAL.—Not less than 60 

5 days before the date on which a provider 

6 of services or supplier is removed from a 

7 network of an MA plan, the MA organiza8 tion offering such plan shall provide writ9 ten notification of the removal to each in10 dividual enrolled in such plan receiving 

11 items or services from the provider or sup12 plier during the plan year in effect on the 

13 date of removal or during the previous 

14 plan year. Such notification shall include 

15 at the minimum— 

16 ‘‘(I) the names and telephone 

17 numbers of available in-network pro18 viders of services and suppliers offer19 ing items and services that are the 

20 same or similar to the items and serv21 ices offered by the removed provider 

22 or supplier; 

23 ‘‘(II) information regarding the 

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1 tinuation of medical treatment or 

2 therapy with the removed provider or 

3 supplier; and 

4 ‘‘(III) one or more customer serv5 ice telephone numbers that an indi6 vidual enrolled in such plan may ac7 cess to obtain information regarding 

8 changes to the network of the plan. 

9 ‘‘(ii) ANNUAL NOTICE OF CHANGE.— 

10 In addition to providing the notification of 

11 removal as required under clause (i), the 

12 MA organization offering such MA plan 

13 shall include such notification in the an14 nual notice of change for the MA plan for 

15 the upcoming plan year. 

16 ‘‘(iii) CONTINUITY OF CARE.—In any 

17 case in which a provider of services or sup18 plier is removed from a network of an MA 

19 plan, such plan shall ensure that the re20 moval satisfies the continuity of care re21 quirements under paragraph (1)(A) with 

22 respect to each individual enrolled in such 

23 plan receiving items or services from the 

24 provider or supplier during the plan year 


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1 in effect on the date of removal or during 

2 the previous plan year. 

3 ‘‘(F) RULE OF CONSTRUCTION.—Nothing 

4 in this paragraph shall be construed as affect5 ing the ability of a provider of services or sup6 plier to decline to participate in a network of an 

7 MA plan. 

8 ‘‘(8) TRANSPARENCY IN MEASURES USED BY

9 MA ORGANIZATIONS TO ESTABLISH OR MODIFY PRO10 VIDER NETWORKS.— 

11 ‘‘(A) IN GENERAL.—Beginning with plan 

12 year 2026, an MA organization offering an MA 

13 plan shall publish and make accessible the in14 formation described in subparagraph (B)— 

15 ‘‘(i) in the annual bid information 

16 submitted by the MA organization with re17 spect to the MA plan under section 1854; 

18 and 

19 ‘‘(ii) on the Internet Web Site for the 

20 MA plan. 

21 ‘‘(B) INFORMATION DESCRIBED.—The in22 formation described in this subparagraph is the 

23 following: 

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1 lish or modify the provider network of the 

2 MA plan, including measures of the quality 

3 and efficiency of providers. Such informa4 tion shall include the specifications, meth5 odology, and sample size of such measures. 

6 ‘‘(ii) Other information related to the 

7 establishment or modification of such pro8 vider network that the Secretary deter9 mines appropriate. 

10 ‘‘(C) LIMITATION.—The information de11 scribed in subparagraph (B) shall not include 

12 any individually identifiable information of any 

13 provider or supplier of services.’’. 

14 (b) ENFORCEMENT.— 

15 (1) SANCTIONS FOR NONCOMPLIANCE.—Section 

16 1857(g)(1) of the Social Security Act (42 U.S.C. 

17 1395w–27(g)(1)) is amended— 

18 (A) in subparagraph (J), by striking ‘‘or’’; 

19 (B) by redesignating subparagraph (K) as 

20 subparagraph (L); 

21 (C) by inserting after subparagraph (J) 

22 the following new subparagraph: 

23 ‘‘(K) fails to comply with section 

24 1852(d)(7) or 1852(d)(8); or’’; and 


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1 (D) in subparagraph (L) (as so redesig2 nated), by striking ‘‘through (J)’’ and inserting 

3 ‘‘through (K)’’. 

4 (2) SANCTIONS NOT APPLICABLE TO PART D.— 

5 Title XVIII of the Social Security Act is amended— 

6 (A) in section 1860D–12(b)(3)(E) (42 

7 U.S.C. 1395w— 

8 (B) in section 1894(e)(6)(B) (42 U.S.C. 

9 1395eee(e)(6)(B)), by inserting ‘‘(other than 

10 paragraph (1)(K) of such section)’’ after 

11 ‘‘1857(g)(1)’’. 

12 (c) MEDICARE ADVANTAGE PLAN COMPARE TOOL.— 

13 Not later than one year after the date of enactment of 

14 this Act, the Secretary of Health and Human Services 

15 shall take such measures as are necessary to ensure that 

16 the Medicare Advantage Compare Tool takes into account 

17 the preferences and utilization needs of such individuals. 

18 SEC. 122. NETWORK ADEQUACY. 

19 (a) IN GENERAL.—Section 1852(d) of the Social Se20 curity Act (42 U.S.C. 1395w–22(d)) is amended by adding 

21 at the end the following: 

22 ‘‘(9) NETWORK ADEQUACY REQUIREMENTS.— 

23 Beginning in plan year 2024, notwithstanding any 

24 other provision of law, the following shall apply: 


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1 ‘‘(A) PROVIDER AVAILABILITY.—When es2 tablishing a plan network, a Medicare Advan3 tage organization offering an MA plan shall, 

4 among other factors determined by the Sec5 retary, consider the following: 

6 ‘‘(i) The anticipated enrollment in the 

7 plan. 

8 ‘‘(ii) The expected types of services 

9 provided and utilization of services by en10 rollees under the plan. 

11 ‘‘(iii) The number and types of pro12 viders needed to provide such services. 

13 ‘‘(iv) The number of network pro14 viders who are not accepting new patients. 

15 ‘‘(v) The location of providers and en16 rollees, taking into account geographic dis17 bursement. 

18 ‘‘(vi) The full-time equivalent avail19 ability of a provider to provide such serv20 ices. 

21 ‘‘(B) PROVISION OF CARE IN A TIMELY

22 MANNER.—A Medicare Advantage organization 

23 offering an MA plan shall ensure that providers 

24 are able to provide services in a timely manner, 

25 as defined by the Secretary, under the plan. 


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1 ‘‘(C) APPLICATION OF NETWORK ACCESS

2 ADEQUACY STANDARDS.—In applying the net3 work access adequacy standards pursuant to 

4 paragraph (1), the Secretary shall seek input 

5 from patient advocacy groups, providers of serv6 ices and suppliers, and MA plans under this 

7 part. 

8 ‘‘(D) CERTIFICATION.—Each plan year, a 

9 Medicare Advantage organization shall certify 

10 to the Secretary, with respect to each MA plan 

11 offered by the organization, that the providers, 

12 including specialists and subspecialists, in the 

13 plan network are able to provide the services re14 quired under the organization’s contract with 

15 the Secretary under section 1857 with respect 

16 to the offering of such plan and to meet the 

17 needs of the enrollees within the plan service 

18 area during the year. 

19 ‘‘(E) ANNUAL REPORTING.—Each plan 

20 year, a Medicare Advantage organization shall 

21 report to the Secretary, and make public the 

22 following with respect to each MA plan offered 

23 by the organization: 


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1 ‘‘(i) AVERAGE WAIT TIME.—The aver2 age wait time for primary and specialty 

3 care for enrollees under the plan. 

4 ‘‘(ii) UTILIZATION OF OUT-OF-NET5 WORK PROVIDERS.—The utilization of out6 of-network providers under the plan. 

7 ‘‘(iii) AVERAGE COST PER PATIENT.— 

8 The average annual spending per patient 

9 for primary and specialty care for enrollees 

10 under the plan. 

11 ‘‘(F) CERTIFICATION.—In advance of the 

12 annual, coordinated election period under sec13 tion 1851(e)(3), a Medicare Advantage organi14 zation shall certify to the Secretary the accu15 racy of provider directories for each plan of16 fered by the organization. 

17 ‘‘(G) NETWORK REVIEW.—The Secretary 

18 shall ensure that the network of each MA plan 

19 offered by a Medicare Advantage organization 

20 meets the network adequacy guidelines estab21 lished under this paragraph and under section 

22 422.112(a)(4) of title 42, Code of Federal Reg23 ulations (or any successor regulation to such 

24 section) at least once every 3 years or when a 

25 material change in network occurs. 


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1 ‘‘(H) AUTHORITY.—The Secretary shall 

2 have the authority to stop any further enroll3 ment in a Medicare Advantage plan if there is 

4 a pattern of excessive violations of this para5 graph.’’. 

6 (b) ENFORCEMENT.—Section 1857(g)(1)(K) of the 

7 Social Security Act (42 U.S.C. 1395w–27(g)(1)(K)), as 

8 added by section 2(b), is amended by striking ‘‘or 

9 1852(d)(8)’’ and inserting ‘‘, 1852(d)(8), or 1852(d)(9)’’. 

10 SEC. 123. ELIMINATING THE 24-MONTH WAITING PERIOD 

11 FOR MEDICARE COVERAGE FOR INDIVID12 UALS WITH DISABILITIES. 

13 (a) IN GENERAL.—Section 226(b) of the Social Secu14 rity Act (42 U.S.C. 426(b)) is amended— 

15 (1) in paragraph (2)(A), by striking ‘‘, and has 

16 for 24 calendar months been entitled to,’’; 

17 (2) in paragraph (2)(B), by striking ‘‘, and has 

18 been for not less than 24 months,’’; 

19 (3) in paragraph (2)(C)(ii), by striking ‘‘, in20 cluding the requirement that he has been entitled to 

21 the specified benefits for 24 months,’’; 

22 (4) in the first sentence, by striking ‘‘for each 

23 month beginning with the later of (I) July 1973 or 

24 (II) the twenty-fifth month of his entitlement or sta25 tus as a qualified railroad retirement beneficiary deVerDate Sep 11 2014 16:53 Feb 03, 2025 Jkt 059200 PO 00000 Frm 00082 Fmt 6652 Sfmt 6201 E:\BILLS\H10526.IH H10526

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1 scribed in paragraph (2), and’’ and inserting ‘‘for 

2 each month for which the individual meets the re3 quirements of paragraph (2), beginning with the 

4 month following the month in which the individual 

5 meets the requirements of such paragraph, and’’; 

6 and 

7 (5) in the second sentence, by striking ‘‘the’’ 

8 twenty-fifth month of his entitlement‘‘’’ and all that 

9 follows through ‘‘paragraph (2)(C) and’’. 

10 (b) CONFORMING AMENDMENTS.— 

11 (1) SECTION 226.—Section 226 of the Social 

12 Security Act (42 U.S.C. 426) is amended by— 

13 (A) striking subsections (e)(1)(B), (f), and 

14 (h); and 

15 (B) redesignating subsections (g) and (i) 

16 as subsections (f) and (g), respectively. 

17 (2) MEDICARE DESCRIPTION.—Section 1811(2) 

18 of the Social Security Act (42 U.S.C. 1395c(2)) is 

19 amended by striking ‘‘have been entitled for not less 

20 than 24 months’’ and inserting ‘‘are entitled’’. 

21 (3) MEDICARE COVERAGE.—Section 1837(g)(1) 

22 of the Social Security Act (42 U.S.C. 1395p(g)(1)) 

23 is amended by striking ‘‘25th month of’’ and insert24 ing ‘‘month following the first month of’’. 


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1 (4) RAILROAD RETIREMENT SYSTEM.—Section 

2 7(d)(2)(ii) of the Railroad Retirement Act of 1974 

3 (45 U.S.C. 231f(d)(2)(ii)) is amended— 

4 (A) by striking ‘‘has been entitled to an 

5 annuity’’ and inserting ‘‘is entitled to an annu6 ity’’; 

7 (B) by striking ‘‘, for not less than 24 

8 months’’; and 

9 (C) by striking ‘‘could have been entitled 

10 for 24 calendar months, and’’. 

11 (c) EFFECTIVE DATE.—The amendments made by 

12 this section shall apply to insurance benefits under title 

13 XVIII of the Social Security Act with respect to items and 

14 services furnished in months beginning after the date of 

15 enactment of this Act. 

16 SEC. 124. ELIMINATING THE WAITING PERIOD FOR INDI17 VIDUALS ON STATE MEDICAID WAITING 

18 LISTS. 

19 The Secretary of Health and Human Services is ap20 propriated such sums as are necessary to facilitate enroll21 ment, not later than 90 days after the date of the enact22 ment of this Act, all eligible individuals who, as of the 

23 date of the enactment of this Act, are on State Medicaid 

24 waiting lists or State Medicaid waiver waiting lists. 


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1 SEC. 125. EMPLOYER HEALTH PLAN OPTIONS. 

2 (a) DEFINITION.—A qualifying employer-sponsored 

3 plan is— 

4 (1) a governmental plan (within the meaning of 

5 section 2791(d)(8) of the Public Health Service 

6 Act); or 

7 (2) any other plan or coverage that meets the 

8 criteria under subsection (b), includes vision, dental, 

9 and hearing benefits, and provides health coverage 

10 that is equivalent to an actuarial value of at least 80 

11 percent of the coverage provided under title XXII of 

12 the Social Security Act and makes a premium con13 tribution of at least 70 percent. 

14 Such plan shall require a premium contribution from the 

15 employer of at least 70 percent regardless of whether cov16 erage is for single, spousal, or dependent care. 

17 (b) OBLIGATION.—Large employers shall, with re18 spect to any full-time employee of such employer— 

19 (1) offer a qualifying employer-sponsored plan 

20 to such employee, in accordance with subsection (a); 

21 or 

22 (2) make a contribution of 8 percent of their 

23 annual payroll to the Medicare Trust Fund under 

24 title XXII of the Social Security Act. 

25 (c) EMPLOYEE CHOICE.—An employee may opt-out 

26 of a qualifying employer-sponsored plan as satisfied by 


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1 subsection (b)(1) in order to enroll in Medicare for Amer2 ica. The employer shall make a contribution equal to the 

3 contribution it shall make in order to meet the require4 ments established by subsection (a)(1) or (a)(2). The Sec5 retary of Health and Human Services shall have authority 

6 to set standards for determining whether employers or in7 surers are undertaking any actions to affect the risk pool 

8 within Medicare for America by inducing individuals to de9 cline coverage under a qualifying employer-sponsored plan 

10 and instead to enroll in Medicare for America. An em11 ployer violating such standards shall be treated as not 

12 meeting the requirements of subsection (a). 

13 (d) EMPLOYEE EDUCATION ON HEALTH COVERAGE

14 OPTIONS.—Large employers shall disseminate to employ15 ees such publicly available information on coverage options 

16 under Medicare for America as the Secretary deems ap17 propriate, including contact information for assistance. 

18 (e) SPECIAL RULES.— 

19 (1) ANNUAL PAYROLL.—For purposes of this 

20 paragraph, the term ‘‘annual payroll’’ means, with 

21 respect to any employer for any calendar year, the 

22 aggregate wages paid by the employer during such 

23 calendar year. 


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1 (2) AGGREGATION RULES.—Related employers 

2 and predecessors shall be treated as a single em3 ployer for purposes of this subsection. 

4 (3) REDUCTION FOR PART-TIME EMPLOYEES.— 

5 In the case of a part-time employee, the employer 

6 contribution requirements of paragraph (1) shall be 

7 treated as satisfied if the employer contribution with 

8 respect to such employee is not less than the part9 time employment ratio of the contribution required 

10 under paragraph (1). 

11 (4) RULES RELATED TO PART-TIME EMPLOY12 MENT.—For purposes of this subsection— 

13 (A) PART-TIME EMPLOYEE.—The term 

14 ‘‘part-time employee’’ means, with respect to 

15 any month, an employee who works on average 

16 fewer than 30 hours per week. 

17 (B) PART-TIME EMPLOYMENT RATIO.— 

18 The term ‘‘part-time employment ratio’’ means, 

19 with respect to a part-time employee of an em20 ployer in a month, a fraction— 

21 (i) the numerator of which is the 

22 number of hours in the employee’s normal 

23 work week; and 

24 (ii) the denominator of which is 30 

25 hours. 


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1 (C) SPECIAL RULES.—Under rules pre2 scribed by the Secretary of Health and Human 

3 Services, in consultation with the Secretary of 

4 the Treasury, in the case of an employee for an 

5 employer whose defined work week for full-time 

6 employees is less than 30 hours, any reference 

7 in this subsection to 30 hours is deemed a ref8 erence to the number of hours in the work week 

9 so defined. 

10 (D) CONVERSION TO HOURS OF EMPLOY11 MENT.—The Secretary of Health and Human 

12 Services, in consultation with the Secretary of 

13 the Treasury, shall establish rules for the con14 version of compensation to hours of employ15 ment, for purposes of this subsection in the 

16 case of employees that receive compensation on 

17 a salaried basis, or on the basis of a commis18 sion, or other contingent or bonus basis, rather 

19 than based on an hourly wage. 

20 (f) TIMING AND MANNER.—Each employer that 

21 makes a financial contribution under subsection (b)(2) 

22 and (c) under this section (other than with respect to cov23 erage under a group health plan) shall pay such contribu24 tion in a form and manner, specified by the Secretary of 

25 the Treasury, based upon the form and manner in which 


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1 employer excise taxes are required to be paid under section 

2 3111 of the Internal Revenue Code of 1986. 

3 (g) NON-DISCRIMINATION.— 

4 (1) IN GENERAL.—Except as otherwise pro5 vided for in this title (or an amendment made by 

6 this title), an individual shall not, on the ground 

7 prohibited under title VI of the Civil Rights Act of 

8 1964 (42 U.S.C. 2000d et seq.), title IX of the Edu9 cation Amendments of 1972 (20 U.S.C. 1681 et 

10 seq.), the Age Discrimination Act of 1975 (42 

11 U.S.C. 6101 et seq.), or section 504 of the Rehabili12 tation Act of 1973 (29 U.S.C. 794), be excluded 

13 from participation in, be denied the benefits of, or 

14 be subjected to discrimination under, any health pro15 gram or activity, any part of which is receiving Fed16 eral financial assistance, including credits, subsidies, 

17 or contracts of insurance, or under any program or 

18 activity that is administered by an Executive Agency 

19 or any entity established under this title (or amend20 ments) or any employer-sponsored insurance. 

21 (2) CONTINUED APPLICATION OF LAWS.—Noth22 ing in this title (or an amendment made by this 

23 title) shall be construed to invalidate or limit the 

24 rights, remedies, procedures, or legal standards 

25 available to individuals aggrieved under title VI of 


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1 the Civil Rights Act of 1964 (42 U.S.C. 2000d et 

2 seq.), title VII of the Civil Rights Act of 1964 (42 

3 U.S.C. 2000e et seq.), title IX of the Education 

4 Amendments of 1972 (20 U.S.C. 1681 et seq.), sec5 tion 504 of the Rehabilitation Act of 1973 (29 

6 U.S.C. 794), or the Age Discrimination Act of 1975 

7 (42 U.S.C. 611 et seq.), or to supersede State laws 

8 that provide additional protections against discrimi9 nation on any basis described in paragraph (1). 

10 (3) LIMITATION.—A group health plan may not 

11 establish rules relating to the health insurance cov12 erage eligibility (including continued eligibility) or 

13 contribution requirements of any full-time employee 

14 under the terms of the plan that have the effect of 

15 discriminating in favor of higher-wage employees. 

16 (4) REGULATIONS.—The Secretary of Health 

17 and Human Services, in conjunction with the Sec18 retary of Labor, may promulgate regulations to im19 plement this subsection. 

20 SEC. 126. PROHIBITION ON STEP THERAPY AND PRIOR AU21 THORIZATION UNDER GROUP HEALTH 

22 PLANS. 

23 Section 2719A of the Public Health Service Act (42 

24 U.S.C. 300gg–19a) is amended by adding at the end the 

25 following new subsection: 


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1 ‘‘(e) PROHIBITION AGAINST STEP THERAPY AND

2 PRIOR AUTHORIZATION.—Beginning with the first plan 

3 year following the date of the enactment of this subsection, 

4 a group health plan may not require a prior authorization 

5 determination for coverage of any benefit under such plan 

6 and may not apply treatment limitations through the use 

7 of step therapy protocols.’’. 

8 SEC. 127. MEDICARE OUTPATIENT OBSERVATION SERV9 ICES. 

10 Section 1861(i) of the Social Security Act (42 U.S.C. 

11 1395x(i)) is amended by adding at the end the following: 

12 ‘‘For purposes of this subsection, an individual receiving 

13 outpatient observation services shall be deemed to be an 

14 inpatient during such period, and the date such individual 

15 ceases receiving such services shall be deemed the hospital 

16 discharge date (unless such individual is admitted as a 

17 hospital inpatient at the end of such period)’’. 

18 SEC. 128. ABORTION COVERAGE. 

19 Notwithstanding any other provision of law, Federal 

20 funds may be used to provide for abortion services under 

21 any health program or activity. 

22 SEC. 129. APPLICABILITY OF MENTAL HEALTH PARITY. 

23 Section 2726 of the Public Health Service Act shall 

24 apply to all health coverage in the same manner and to 

25 the same extent as such section applies to health insurance 


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1 issuers and group health plans under title XXVII of such 

2 Act. 

3 SEC. 130. STUDENT LOAN FORGIVENESS FOR HEALTH CARE 

4 PROVIDERS PARTICIPATING IN MEDICARE 

5 FOR AMERICA. 

6 (a) IN GENERAL.—Beginning on the date after the 

7 date of the enactment of this Act, after the conclusion of 

8 each plan year, the Secretary of Health and Human Serv9 ices, in conjunction with the Secretary of Education, shall 

10 cancel the applicable percent specified in subsection (b) 

11 of the total amount due on any eligible Federal loan made 

12 20 years prior to date of enactment and any date after 

13 the date of enactment of this Act for a borrower who is 

14 a Medicare for America participating provider and sub15 mits an employment certification form described in sub16 section (d). 

17 (b) APPLICABLE PERCENT.—For purposes of sub18 section (a), the applicable percent is 10 percent of any 

19 eligible Federal loan for each year the health care provider 

20 participates in Medicare for America. 

21 (c) DEFINITIONS.—In this section: 

22 (1) ELIGIBLE FEDERAL LOAN.—The term ‘‘eli23 gible Federal loan’’ means any loan made under part 

24 D of title IV of the Higher Education Act of 1965 

25 (20 U.S.C. 1087a). 


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1 (2) HEALTH CARE PROVIDER.—The term 

2 ‘‘health care provider’’ means a physician, physician 

3 assistant, registered nurse, nurse practitioner, ad4 vanced practice nurse, licensed practical nurse, psy5 chologist, mental health counselor, marriage and 

6 family therapist, direct care worker, health social 

7 worker, dentist, dental hygienist, pharmacist, phys8 ical therapist, occupational therapist, or any other 

9 health care provider specified by the Secretary of 

10 Health and Human Services if the Secretary deter11 mines such specification for purposes of this section 

12 is necessary to ensure workforce adequacy. 

13 (3) MEDICARE FOR AMERICA PARTICIPATING

14 PROVIDER.—The term ‘‘Medicare for America par15 ticipating provider’’ means a health care provider 

16 that meets the definition of such term under section 

17 105 or works at a participating provider or entity as 

18 defined under section 105. 

19 (d) EMPLOYMENT CERTIFICATION FORM.— 

20 (1) IN GENERAL.—In order to receive loan can21 cellation under this paragraph, a borrower shall sub22 mit to the Secretary of Education an employment 

23 certification form that is developed by the Secretary 

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1 ployment and a separate part for employer certifi2 cation that indicates the dates of employment. 

3 (2) DEFERMENT.—If a borrower submits to the 

4 Secretary of Education the employment certification 

5 form described in paragraph (1), during the period 

6 in which the borrower is employed as a Medicare for 

7 America participating provider for which loan can8 cellation is eligible under this section, the borrower’s 

9 eligible Federal Direct Loan shall be placed in 

10 deferment. 

11 (e) INTEREST CANCELED.—If a portion of a loan is 

12 canceled under this section for any year, the entire amount 

13 of interest on such loan that accrues for such year shall 

14 be canceled. 

15 (f) REGULATIONS.—The Secretary of Health and 

16 Human Services and the Secretary of Education may pro17 mulgate regulations to implement this section. 

18 SEC. 131. CLARIFICATION OF THE DEFINITION OF PEDI19 ATRIC MEDICAL NECESSITY IN QUALIFYING 

20 GROUP COVERAGE. 

21 (a) DEFINITION.—The following definition of pedi22 atric medical necessity shall be incorporated into benefit 

23 standards of all plans subject to the requirements of sec24 tion 1302 of the Patient Protection and Affordable Care 

25 Act (42 U.S.C. 18022) and all group plans by 2026. 


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1 (b) DEVELOPMENT OF DEFINITION.—Pediatric med2 ical necessity, or pediatric medically necessary care, shall 

3 be defined as health care interventions that are evidence 

4 based, evidence informed, or based on consensus advisory 

5 opinion and that are recommended by recognized health 

6 care professionals, to promote optimal growth and devel7 opment in a child and to prevent, detect, diagnose, treat, 

8 ameliorate, or palliate the effects of physical, genetic, con9 genital, developmental, behavioral, or mental conditions, 

10 injuries, or disabilities. 

11 (c) UPDATES TO DEFINITION.—The Secretary of 

12 Health and Human Services, in consultation with experts 

13 in the field of pediatric care and key stakeholders, includ14 ing patient and family groups, shall review and update this 

15 definition on a biennial basis, consistent with up-to-date 

16 standards of pediatric healthcare practice that are based 

17 on— 

18 (1) the views of pediatric healthcare providers 

19 and experts practicing in relevant clinical areas; 

20 (2) recommendations of medical-specialty soci21 eties, other pediatric healthcare provider organiza22 tions, and family and patient groups; and 

23 (3) credible scientific evidence published in 

24 peer-reviewed literature that is generally recognized 

25 by the relevant health care provider community. 


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1 SEC. 132. SAFE STAFFING REQUIREMENTS. 

2 (a) MINIMUM DIRECT CARE REGISTERED NURSE

3 STAFFING REQUIREMENTS.—The Public Health Service 

4 Act (42 U.S.C. 201 et seq.) is amended by adding at the 

5 end the following new title: 

6 ‘‘TITLE XXXIV—MINIMUM DI7 RECT CARE REGISTERED 

8 NURSE STAFFING REQUIRE9 MENT 

10 ‘‘SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT. 

11 ‘‘(a) STAFFING PLAN.— 

12 ‘‘(1) IN GENERAL.—A hospital shall implement 

13 a staffing plan that— 

14 ‘‘(A) provides adequate, appropriate, and 

15 quality delivery of health care services and pro16 tects patient safety; and 

17 ‘‘(B) is consistent with the requirements of 

18 this title. 

19 ‘‘(2) EFFECTIVE DATES.— 

20 ‘‘(A) IMPLEMENTATION OF STAFFING

21 PLAN.—Subject to subparagraph (B), the re22 quirements under paragraph (1) shall take ef23 fect on a date to be determined by the Sec24 retary, but not later than 1 year after the date 

25 of the enactment of this title. 


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1 ‘‘(B) APPLICATION OF MINIMUM DIRECT

2 CARE REGISTERED NURSE-TO-PATIENT RA3 TIOS.—The requirements under subsection (b) 

4 shall take effect as soon as practicable, as de5 termined by the Secretary, but not later than— 

6 ‘‘(i) 2028; and 

7 ‘‘(ii) in the case of a hospital in a 

8 rural area (as defined in section 

9 1886(d)(2)(D) of the Social Security Act), 

10 2030. 

11 ‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE12 TO-PATIENT RATIOS.— 

13 ‘‘(1) IN GENERAL.—Except as provided in para14 graph (4) and other provisions of this section, a hos15 pital’s staffing plan shall provide that, at all times 

16 during each shift within a unit of the hospital, and 

17 with a full complement of ancillary and support 

18 staff, a direct care registered nurse may be assigned 

19 to not more than the following number of patients 

20 in that unit: 

21 ‘‘(A) One patient in trauma emergency 

22 units. 

23 ‘‘(B) One patient in operating room units, 

24 provided that a minimum of 1 additional person 

25 serves as a scrub assistant in such unit. 


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1 ‘‘(C) Two patients in critical care units, in2 cluding neonatal intensive care units, emer3 gency critical care and intensive care units, 

4 labor and delivery units, coronary care units, 

5 acute respiratory care units, postanesthesia 

6 units, and burn units. 

7 ‘‘(D) Three patients in emergency room 

8 units, pediatrics units, stepdown units, telem9 etry units, antepartum units, and combined 

10 labor, delivery, and postpartum units. 

11 ‘‘(E) Four patients in medical-surgical 

12 units, intermediate care nursery units, acute 

13 care psychiatric units, and other specialty care 

14 units. 

15 ‘‘(F) Five patients in rehabilitation units 

16 and skilled nursing units. 

17 ‘‘(G) Six patients in postpartum (3 cou18 plets) units and well-baby nursery units. 

19 ‘‘(2) SIMILAR UNITS WITH DIFFERENT

20 NAMES.—The Secretary may apply minimum direct 

21 care registered nurse-to-patient ratios established in 

22 paragraph (1) for a hospital unit referred to in such 

23 paragraph to a type of hospital unit not referred to 

24 in such paragraph if such type of hospital unit pro25 vides a level of care to patients whose needs are 


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1 similar to the needs of patients cared for in the hos2 pital unit referred to in such paragraph. 

3 ‘‘(3) APPLICATION OF RATIOS TO HOSPITAL

4 NURSING PRACTICE STANDARDS.— 

5 ‘‘(A) IN GENERAL.—A patient assignment 

6 may be included in the calculation of the direct 

7 care registered nurse-to-patient ratios required 

8 in this subsection only if care is provided by a 

9 direct care registered nurse and the provision of 

10 care to the particular patient is within that di11 rect care registered nurse’s competence. 

12 ‘‘(B) DEMONSTRATION OF UNIT-SPECIFIC

13 COMPETENCE.—A hospital shall not assign a di14 rect care registered nurse to a hospital unit un15 less that hospital determines that the direct 

16 care registered nurse has demonstrated current 

17 competence in providing care in that unit, and 

18 has also received orientation to that hospital’s 

19 unit sufficient to provide competent care to pa20 tients in that unit. 

21 ‘‘(C) DUTIES OF THE ASSIGNED DIRECT

22 CARE REGISTERED NURSE.—Each patient shall 

23 be assigned to a direct care registered nurse 

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1 tion of the nursing care provided to the patient 

2 at least every shift and has the responsibility 

3 for the provision of care to a particular patient 

4 within his or her scope of practice. 

5 ‘‘(D) NURSE ADMINISTRATORS AND SU6 PERVISORS.—A registered nurse who is a nurse 

7 administrator, nurse supervisor, nurse manager, 

8 charge nurse, case manager, or any other hos9 pital administrator or supervisor, shall not be 

10 included in the calculation of the direct care 

11 registered nurse-to-patient ratio unless that 

12 nurse has a current and active direct patient 

13 care assignment and provides direct patient 

14 care in compliance with the requirements of this 

15 section, including competency requirements. 

16 The exemption in this subsection shall apply 

17 only during the hours in which the individual 

18 registered nurse has the principal responsibility 

19 of providing direct patient care and has no ad20 ditional job duties as would a direct care reg21 istered nurse. 

22 ‘‘(E) OTHER PERSONNEL.—Other per23 sonnel may perform patient care tasks based on 

24 their training and demonstrated skill but may 

25 not perform or assist in direct care registered 


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1 nurse functions unless authorized to do in ac2 cordance with State scope of practice laws and 

3 regulations. 

4 ‘‘(F) TEMPORARY NURSING PERSONNEL.— 

5 A hospital shall not assign any nursing per6 sonnel from temporary nursing agencies patient 

7 care to any hospital unit without such personnel 

8 having demonstrated competence on the as9 signed unit and received orientation to that hos10 pital’s unit sufficient to provide competent care 

11 to patients in that unit. 

12 ‘‘(G) ANCILLARY AND ADDITIONAL STAFF13 ING.—The need for additional staffing of direct 

14 care registered nurses, licensed vocational or 

15 practical nurses, licensed psychiatric techni16 cians, certified nursing or patient care assist17 ants, or other licensed or unlicensed ancillary 

18 staff above the minimum registered nurse-to-pa19 tient ratios shall be based on the assessment of 

20 the individual patient’s nursing care require21 ment, the individual patient’s nursing care plan, 

22 and acuity level. 

23 ‘‘(4) RESTRICTIONS.— 

24 ‘‘(A) PROHIBITION AGAINST AVERAGING.— 

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1 tients and the total number of direct care reg2 istered nurses assigned to patients in a hospital 

3 unit during any 1 shift or over any period of 

4 time for purposes of meeting the requirements 

5 under this subsection. 

6 ‘‘(B) PROHIBITION AGAINST IMPOSITION

7 OF MANDATORY OVERTIME REQUIREMENTS.—A 

8 hospital shall not impose mandatory overtime 

9 requirements to meet the hospital unit direct 

10 care registered nurse-to-patient ratios required 

11 under this subsection. 

12 ‘‘(C) RELIEF DURING ROUTINE AB13 SENCES.—A hospital shall ensure that only a 

14 direct care registered nurse who has dem15 onstrated current competence to the hospital in 

16 providing care on a particular unit and has also 

17 received orientation to that hospital’s unit suffi18 cient to provide competent care to patients in 

19 that unit may relieve another direct care reg20 istered nurse during breaks, meals, and other 

21 routine, expected absences from a hospital unit. 

22 ‘‘(D) APPLICATION OF DIRECT CARE REG23 ISTERED NURSE-TO-PATIENT RATIOS IN PA24 TIENT-ACUITY ADJUSTABLE UNITS.—Patients 

25 shall be cared for only on units or patient care 


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1 areas where the direct care registered nurse-to2 patient ratios meet the level of intensity, type 

3 of care, and the individual requirements and 

4 needs of each patient. Notwithstanding para5 graph (2), hospitals that provide patient care in 

6 units or patient care areas that are acuity 

7 adaptable or acuity adjustable shall apply the 

8 direct care registered nurse-to-patient ratio re9 quired in this section for the highest patient 

10 acuity level or level of care in that unit or pa11 tient care area, and shall comply with all other 

12 requirements of this section. 

13 ‘‘(E) USE OF VIDEO MONITORS.—A hos14 pital shall not employ video monitors or any 

15 form of electronic visualization of a patient as 

16 a substitute for the direct observation required 

17 for patient assessment by the direct care reg18 istered nurse or required for patient protection. 

19 Video monitors or any form of electronic visual20 ization of a patient shall not be included in the 

21 calculation of the direct care registered nurse22 to-patient ratio required in this subsection and 

23 shall not replace the requirement of paragraph 

24 (3)(D) that each patient shall be assigned to a 

25 direct care registered nurse who shall directly 


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1 provide the assessment, planning, supervision, 

2 implementation, and evaluation of the nursing 

3 care provided to the patient at least every shift 

4 and have the responsibility for the provision of 

5 care to a particular patient within his or her 

6 scope of practice. 

7 ‘‘(F) USE OF OTHER TECHNOLOGY.—A 

8 hospital shall not employ technology that sub9 stitutes for the assigned registered nurse’s pro10 fessional judgment in assessment, planning, im11 plementation, and evaluation of care. 

12 ‘‘(5) ADJUSTMENT OF RATIOS.— 

13 ‘‘(A) IN GENERAL.—If necessary to protect 

14 patient safety, the Secretary may prescribe reg15 ulations that— 

16 ‘‘(i) increase minimum direct care reg17 istered nurse-to-patient ratios under this 

18 subsection to reduce the number of pa19 tients that may be assigned to each direct 

20 care nurse; or 

21 ‘‘(ii) add minimum direct care reg22 istered nurse-to-patient ratios for units not 

23 referred to in paragraphs (1) and (2). 


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1 ‘‘(B) CONSULTATION.—Such regulations 

2 shall be prescribed after consultation with af3 fected hospitals and registered nurses. 

4 ‘‘(6) ANCILLARY AND ADDITIONAL STAFFING.— 

5 ‘‘(A) IN GENERAL.—The Secretary may 

6 prescribe regulations requiring additional staff7 ing of direct care registered nurses, licensed vo8 cational or practice nurses, licensed psychiatric 

9 technicians, certified nursing or patient care as10 sistants, or other licensed or unlicensed ancil11 lary staff above the minimum registered nurse12 to-patient ratios that is based on the assess13 ment of the individual patient’s nursing care 

14 needs, the individual patient’s nursing care 

15 plan, and acuity level. 

16 ‘‘(B) CONSULTATION.—Such regulations 

17 shall be prescribed after consultation with af18 fected hospitals, registered nurses, and ancillary 

19 staff. 

20 ‘‘(7) RELATIONSHIP TO STATE-IMPOSED RA21 TIOS.—Nothing in this title shall preempt State 

22 standards that the Secretary determines to be as 

23 stringent as Federal requirements for a staffing plan 

24 established under this title. Minimum direct care 

25 registered nurse-to-patient ratios established under 


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1 this subsection shall not preempt State requirements 

2 that the Secretary determines are as stringent as to 

3 Federal requirements for direct care registered 

4 nurse-to-patient ratios established under this title. 

5 ‘‘(8) EXEMPTION IN EMERGENCIES.—The re6 quirements established under this subsection shall 

7 not apply during a state of emergency if a hospital 

8 is requested or expected to provide an exceptional 

9 level of emergency or other medical services. If a 

10 hospital seeks to apply the exemption under this 

11 paragraph in response to a complaint filed against 

12 the hospital for a violation of the provisions of this 

13 title, the hospital must demonstrate that prompt and 

14 diligent efforts were made to maintain required 

15 staffing levels. The Secretary shall issue guidance to 

16 hospitals that describes situations that constitute a 

17 state of emergency for purposes of the exemption 

18 under this paragraph and shall establish necessary 

19 penalties for violations of this paragraph consistent 

20 with section 3406. 

21 ‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF22 ING PLAN.— 

23 ‘‘(1) CONSIDERATIONS IN DEVELOPMENT OF

24 PLAN.—In developing the staffing plan, a hospital 

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1 tient ratios above the minimum direct care reg2 istered nurse-to-patient ratios required under sub3 section (b) if appropriate based upon consideration 

4 of, at a minimum, the following factors: 

5 ‘‘(A) The number of patients on a par6 ticular unit on a shift-by-shift basis. 

7 ‘‘(B) The acuity level and nursing care 

8 plan of patients on a particular unit on a shift9 by-shift basis. 

10 ‘‘(C) The anticipated admissions, dis11 charges, and transfers of patients during each 

12 shift that impacts direct patient care. 

13 ‘‘(D) Specialized experience required of di14 rect care registered nurses on a particular unit. 

15 ‘‘(E) Staffing levels and services provided 

16 by licensed vocational or practical nurses, li17 censed psychiatric technicians, certified nurse 

18 assistants, or other ancillary staff in meeting 

19 direct patient care needs not required by a di20 rect care registered nurse. 

21 ‘‘(F) The level of familiarity with hospital 

22 practices, policies, and procedures by temporary 

23 agency direct care registered nurses used dur24 ing a shift. 


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1 ‘‘(G) Obstacles to efficiency in the delivery 

2 of patient care presented by physical layout. 

3 ‘‘(2) DOCUMENTATION OF STAFFING.—A hos4 pital shall specify the system used to document ac5 tual staffing in each unit for each shift. 

6 ‘‘(3) ANNUAL REEVALUATION OF PLAN.— 

7 ‘‘(A) IN GENERAL.—A hospital shall annu8 ally evaluate its staffing plan in each unit in re9 lation to actual patient care requirements. 

10 ‘‘(B) UPDATE.—A hospital shall update its 

11 staffing plan to the extent appropriate based on 

12 such evaluation. 

13 ‘‘(4) TRANSPARENCY.— 

14 ‘‘(A) IN GENERAL.—Any staffing plan or 

15 method used to create and evaluate acuity-level 

16 and adopted by a hospital under this section 

17 shall be transparent in all respects, including 

18 disclosure of detailed documentation of the 

19 methodology used to determine nursing staff20 ing, identifying each factor, assumption, and 

21 value used in applying such methodology. 

22 ‘‘(B) PUBLIC AVAILABILITY.—The Sec23 retary shall establish procedures to provide that 

24 the documentation submitted under subsection 


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1 (d) is available for public inspection in its en2 tirety. 

3 ‘‘(5) REGISTERED NURSE PARTICIPATION.—A 

4 staffing plan of a hospital— 

5 ‘‘(A) shall be developed and subsequent re6 evaluations shall be conducted under this sub7 section on the basis of input from direct care 

8 registered nurses at the hospital from each unit 

9 or patient care area; and 

10 ‘‘(B) where such nurses are represented 

11 through collective bargaining, shall require bar12 gaining with the applicable recognized or cer13 tified collective bargaining representative of 

14 such nurses. Nothing in this title shall be con15 strued to permit conduct prohibited under the 

16 National Labor Relations Act or chapter 71 of 

17 title 5, United States Code. 

18 ‘‘(6) STAFFING COMMITTEES.—If a hospital 

19 maintains a staffing committee, then the committee 

20 shall include at least one registered nurse from each 

21 hospital unit and shall be composed of at least 50 

22 percent direct care registered nurses. The staffing 

23 committee shall include meaningful representation of 

24 other direct care nonmanagement staff. Direct care 

25 registered nurses who serve on the committee shall 


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1 be selected by other direct care registered nurses 

2 from their unit. Other direct care nonmanagement 

3 staff shall be selected by other direct care non4 management staff. Participation on staffing commit5 tees shall be considered a part of the employee’s reg6 ularly scheduled work week. 

7 ‘‘(d) SUBMISSION OF PLAN TO SECRETARY.—A hos8 pital shall submit to the Secretary its staffing plan and 

9 any annual updates under subsection (c)(3)(B). A feder10 ally operated hospital may submit its staffing plan 

11 through the department or agency operating the hospital. 

12 ‘‘SEC. 3402. POSTING, RECORDS, AND AUDITS. 

13 ‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos14 pital shall post a uniform notice in a form specified by 

15 the Secretary in regulation that— 

16 ‘‘(1) explains requirements imposed under sec17 tion 3401; 

18 ‘‘(2) includes actual direct care registered 

19 nurse-to-patient ratios during each shift; 

20 ‘‘(3) includes the actual number and titles of di21 rect care registered nurses assigned during each 

22 shift; and 

23 ‘‘(4) is visible, conspicuous, and accessible to 

24 staff, patients, and the public. 

25 ‘‘(b) RECORDS.— 


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1 ‘‘(1) MAINTENANCE OF RECORDS.—Each hos2 pital shall maintain accurate records of actual direct 

3 care registered nurse-to-patient ratios in each unit 

4 for each shift for no less than 3 years. Such records 

5 shall include— 

6 ‘‘(A) the number of patients in each unit; 

7 ‘‘(B) the identity and duty hours of— 

8 ‘‘(i) each direct care registered nurse 

9 assigned to each patient in each unit in 

10 each shift; and 

11 ‘‘(ii) ancillary staff who are under the 

12 coordination of the direct care registered 

13 nurse; 

14 ‘‘(C) certification that each nurse received 

15 rest and meal breaks and the identity and duty 

16 hours of each direct care registered nurse who 

17 provided such relief; and 

18 ‘‘(D) a copy of each notice posted under 

19 subsection (a). 

20 ‘‘(2) AVAILABILITY OF RECORDS.—Each hos21 pital shall make its records maintained under para22 graph (1) available to— 

23 ‘‘(A) the Secretary; 

24 ‘‘(B) registered nurses and their collective 

25 bargaining representatives (if any); and 


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1 ‘‘(C) the public under regulations estab2 lished by the Secretary, or in the case of a fed3 erally operated hospital, under section 552 of 

4 title 5, United States Code (commonly known 

5 as the Freedom of Information Act). 

6 ‘‘(c) AUDITS.—The Secretary shall conduct periodic 

7 audits to ensure— 

8 ‘‘(1) implementation of the staffing plan in ac9 cordance with this title; and 

10 ‘‘(2) accuracy in records maintained under this 

11 section. 

12 ‘‘SEC. 3403. MINIMUM DIRECT CARE LICENSED PRACTICAL 

13 NURSE STAFFING REQUIREMENTS. 

14 ‘‘(a) ESTABLISHMENT.—A hospital’s staffing plan 

15 shall comply with minimum direct care licensed practical 

16 nurse staffing requirements that the Secretary establishes 

17 for units in hospitals. Such staffing requirements shall be 

18 established not later than 18 months after the date of the 

19 enactment of this title, and shall be based on the study 

20 conducted under subsection (b). 

21 ‘‘(b) STUDY.—Not later than 1 year after the date 

22 of the enactment of this title, the Secretary, acting 

23 through the Director of the Agency for Healthcare Re24 search and Quality, shall complete a study of licensed 

25 practical nurse staffing and its effects on patient care in 


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1 hospitals. The Director may contract with a qualified enti2 ty or organization to carry out such study under this para3 graph. The Director shall consult with licensed practical 

4 nurses and organizations representing licensed practical 

5 nurses regarding the design and conduct of the study. 

6 ‘‘(c) APPLICATION OF REGISTERED NURSE PROVI7 SIONS TO LICENSED PRACTICAL NURSE STAFFING RE8 QUIREMENTS.—Paragraphs (2), (4)(A), (4)(B), (4)(C), 

9 and (6) of section 3401(b), paragraphs (1), (2), (3), and 

10 (4) of section 3401(c), and section 3402 shall apply to 

11 the establishment and application of direct care licensed 

12 practical nurse staffing requirements under this section 

13 pursuant to the additional staffing requirements under 

14 subsection (b)(3)(G) of section 3401 and in the same man15 ner that they apply to the establishment and application 

16 of direct care registered nurse-to-patient ratios under sec17 tions 3401 and 3402. 

18 ‘‘(d) EFFECTIVE DATE.—The requirements of this 

19 section shall take effect as soon as practicable, as deter20 mined by the Secretary, but not later than— 

21 ‘‘(1) 2 years after the date of the enactment of 

22 this title; and 

23 ‘‘(2) in the case of a hospital in a rural area 

24 (as defined in section 1886(d)(2)(D) of the Social 


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1 Security Act), 4 years after the date of the enact2 ment of this title. 

3 ‘‘(e) STUDY.—Not later than 1 year after the date 

4 of the enactment of this title, the Secretary, acting 

5 through the Director of the Agency for Healthcare Re6 search and Quality, shall complete a study of registered 

7 and practical nurse staffing requirements in clinics and 

8 other outpatient settings, and its effects on patient care 

9 in outpatient settings. The Director may contract with a 

10 qualified entity or organization to carry out such study 

11 under this subsection. The Director shall consult with reg12 istered nurses and licensed practice nurses working in out13 patient settings, including professional nursing associa14 tions and labor organizations representing both registered 

15 and practice nurses working in outpatient settings regard16 ing the design and conduct of the study. 

17 ‘‘SEC. 3404. WHISTLEBLOWER AND PATIENT PROTECTIONS. 

18 ‘‘(a) PROFESSIONAL OBLIGATION AND RIGHTS.—All 

19 nurses have a duty and right to act based on their profes20 sional judgment in accordance with State nursing laws 

21 and regulations of the State in which the direct nursing 

22 care is being performed and to provide care in the exclu23 sive interests of the patients and to act as the patient’s 

24 advocate. 


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1 ‘‘(b) ACCEPTANCE OF PATIENT CARE ASSIGN2 MENTS.—The nurse is responsible for providing com3 petent, safe, therapeutic, and effective nursing care to as4 signed patients. Before accepting a patient assignment, a 

5 nurse shall— 

6 ‘‘(1) have the necessary professional knowledge, 

7 judgment, skills, and ability to provide the required 

8 care; 

9 ‘‘(2) determine using professional judgment in 

10 accordance with State nursing laws and regulations 

11 of the State in which the direct nursing care is being 

12 performed whether the nurse is competent to per13 form the nursing care required; and 

14 ‘‘(3) determine whether acceptance of a patient 

15 assignment would expose the patient or nurse to risk 

16 of harm. 

17 ‘‘(c) OBJECTION TO OR REFUSAL OF ASSIGNMENT.— 

18 A nurse may object to, or refuse to participate in, any 

19 activity, policy, practice, assignment, or task if in good 

20 faith— 

21 ‘‘(1) the nurse reasonably believes it to be in 

22 violation of section 3401 or 3403; or 

23 ‘‘(2) the nurse is not prepared by education, 

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1 out compromising the safety of any patient or jeop2 ardizing the license of the nurse. 

3 ‘‘(d) RETALIATION FOR OBJECTION TO OR REFUSAL

4 OF ASSIGNMENT BARRED.— 

5 ‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE6 TALIATION.—No hospital shall discharge, retaliate, 

7 discriminate, or otherwise take adverse action in any 

8 manner with respect to any aspect of a nurse’s em9 ployment (as defined in section 3407), including dis10 charge, promotion, compensation, or terms, condi11 tions, or privileges of employment, based on the 

12 nurse’s refusal of a work assignment under sub13 section (c). 

14 ‘‘(2) NO FILING OF COMPLAINT.—No hospital 

15 shall file a complaint or a report against a nurse 

16 with a State professional disciplinary agency because 

17 of the nurse’s refusal of a work assignment under 

18 subsection (c). 

19 ‘‘(e) CAUSE OF ACTION.—Any nurse, collective bar20 gaining representative, or legal representative of any nurse 

21 who has been discharged, discriminated against, or retali22 ated against in violation of subsection (d)(1) or against 

23 whom a complaint or report has been filed in violation of 

24 subsection (d)(2) may (without regard to whether a com25 plaint has been filed under subsection (f) of this section 


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1 or subsection (b) of section 3406) bring a cause of action 

2 in a United States district court. A nurse who prevails 

3 on the cause of action shall be entitled to one or more 

4 of the following: 

5 ‘‘(1) Reinstatement. 

6 ‘‘(2) Reimbursement of lost wages, compensa7 tion, and benefits. 

8 ‘‘(3) Attorneys’ fees. 

9 ‘‘(4) Court costs. 

10 ‘‘(5) Other damages. 

11 ‘‘(f) COMPLAINT TO SECRETARY.—A nurse, patient, 

12 collective bargaining representative, or other individual 

13 may file a complaint with the Secretary against a hospital 

14 that violates the provisions of this title. For any complaint 

15 filed, the Secretary shall— 

16 ‘‘(1) receive and investigate the complaint; 

17 ‘‘(2) determine whether a violation of this title 

18 as alleged in the complaint has occurred; and 

19 ‘‘(3) if such a violation has occurred, issue an 

20 order that the complaining nurse or individual shall 

21 not suffer any discharge, retaliation, discrimination, 

22 or other adverse action prohibited by subsection (d) 

23 or subsection (h). 

24 ‘‘(g) TOLL-FREE TELEPHONE NUMBER.— 


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1 ‘‘(1) IN GENERAL.—The Secretary shall provide 

2 for the establishment of a toll-free telephone hotline 

3 to provide information regarding the requirements 

4 under sections 3401 through 3403 and to receive re5 ports of violations of such section. 

6 ‘‘(2) NOTICE TO PATIENTS.—A hospital shall 

7 provide each patient admitted to the hospital for in8 patient care with the hotline described in paragraph 

9 (1), and shall give notice to each patient that such 

10 hotline may be used to report inadequate staffing or 

11 care. 

12 ‘‘(h) PROTECTION FOR REPORTING.— 

13 ‘‘(1) PROHIBITION ON RETALIATION OR DIS14 CRIMINATION.—A hospital shall not discriminate or 

15 retaliate in any manner against any patient, em16 ployee, or contract employee of the hospital, or any 

17 other individual, on the basis that such individual, in 

18 good faith, individually or in conjunction with an19 other person or persons, has presented a grievance 

20 or complaint, or has initiated or cooperated in any 

21 investigation or proceeding of any governmental en22 tity, regulatory agency, or private accreditation 

23 body, made a civil claim or demand, or filed an ac24 tion relating to the care, services, or conditions of 

25 the hospital or of any affiliated or related facilities. 


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1 ‘‘(2) GOOD FAITH DEFINED.—For purposes of 

2 this subsection, an individual shall be deemed to be 

3 acting in good faith if the individual reasonably be4 lieves— 

5 ‘‘(A) the information reported or disclosed 

6 is true; and 

7 ‘‘(B) a violation of this title has occurred 

8 or may occur. 

9 ‘‘(i) PROHIBITION ON INTERFERENCE

10 WITH RIGHTS.— 

11 ‘‘(1) EXERCISE OF RIGHTS.—It shall be unlaw12 ful for any hospital to— 

13 ‘‘(A) interfere with, restrain, or deny the 

14 exercise, or attempt to exercise, by any person 

15 of any right provided or protected under this 

16 title; or 

17 ‘‘(B) coerce or intimidate any person re18 garding the exercise or attempt to exercise such 

19 right. 

20 ‘‘(2) OPPOSITION TO UNLAWFUL POLICIES OR

21 PRACTICES.—It shall be unlawful for any hospital to 

22 discriminate or retaliate against any person for op23 posing any hospital policy, practice, or actions which 

24 are alleged to violate, breach, or fail to comply with 

25 any provision of this title. 


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1 ‘‘(3) PROHIBITION ON INTERFERENCE WITH

2 PROTECTED COMMUNICATIONS.—A hospital (or an 

3 individual representing a hospital) shall not make, 

4 adopt, or enforce any rule, regulation, policy, or 

5 practice which in any manner directly or indirectly 

6 prohibits, impedes, or discourages a direct care 

7 nurse from, or intimidates, coerces, or induces a di8 rect care nurse regarding, engaging in free speech 

9 activities or disclosing information as provided under 

10 this title. 

11 ‘‘(4) PROHIBITION ON INTERFERENCE WITH

12 COLLECTIVE ACTION.—A hospital (or an individual 

13 representing a hospital) shall not in any way inter14 fere with the rights of nurses to organize, bargain 

15 collectively, and engage in concerted activity under 

16 section 7 of the National Labor Relations Act (29 

17 U.S.C. 157). 

18 ‘‘(j) NOTICE.—A hospital shall post in an appropriate 

19 location in each unit a conspicuous notice in a form speci20 fied by the Secretary that— 

21 ‘‘(1) explains the rights of nurses, patients, and 

22 other individuals under this section; 

23 ‘‘(2) includes a statement that a nurse, patient, 

24 or other individual may file a complaint with the 


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1 Secretary against a hospital that violates the provi2 sions of this title; and 

3 ‘‘(3) provides instructions on how to file such a 

4 complaint. 

5 ‘‘(k) EFFECTIVE DATE.— 

6 ‘‘(1) REFUSAL; RETALIATION; CAUSE OF AC7 TION.— 

8 ‘‘(A) IN GENERAL.—Subsections (c) 

9 through (e) shall apply to objections and refus10 als occurring on or after the effective date of 

11 the provision of this title to which the objection 

12 or refusal relates. 

13 ‘‘(B) EXCEPTION.—Subsection (c)(2) shall 

14 not apply to objections or refusals in any hos15 pital before the requirements of section 3401(a) 

16 or 3403(a), as applicable, apply to that hos17 pital. 

18 ‘‘(2) PROTECTIONS FOR REPORTING.—Sub19 section (h)(1) shall apply to actions occurring on or 

20 after the effective date of the provision to which the 

21 violation relates, except that such subsection shall 

22 apply to initiation, cooperation, or participation in 

23 an investigation or proceeding on or after the date 

24 of enactment of this title. 


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1 ‘‘(3) NOTICE.—Subsection (j) shall take effect 

2 18 months after the date of enactment of this title. 

3 ‘‘SEC. 3405. ENFORCEMENT. 

4 ‘‘(a) IN GENERAL.—The Secretary shall enforce the 

5 requirements and prohibitions of this title in accordance 

6 with this section. 

7 ‘‘(b) PROCEDURES FOR RECEIVING AND INVES8 TIGATING COMPLAINTS.—The Secretary shall establish 

9 procedures under which— 

10 ‘‘(1) any person may file a complaint alleging 

11 that a hospital has violated a requirement or a pro12 hibition of this title; and 

13 ‘‘(2) such complaints shall be investigated by 

14 the Secretary. 

15 ‘‘(c) REMEDIES.—If the Secretary determines that a 

16 hospital has violated a requirement of this title, the Sec17 retary— 

18 ‘‘(1) shall require the facility to establish a cor19 rective action plan to prevent the recurrence of such 

20 violation; and 

21 ‘‘(2) may impose civil money penalties, as de22 scribed in subsection (d). 

23 ‘‘(d) CIVIL PENALTIES.— 


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1 ‘‘(1) IN GENERAL.—In addition to any other 

2 penalties prescribed by law, the Secretary may im3 pose civil penalties as follows: 

4 ‘‘(A) HOSPITAL LIABILITY.—The Secretary 

5 may impose on a hospital found to be in viola6 tion of this title a civil money penalty of— 

7 ‘‘(i) not more than $25,000 for the 

8 first knowing violation of this title by such 

9 hospital; and 

10 ‘‘(ii) not more than $50,000 for any 

11 subsequent knowing violation of this title 

12 by such hospital. 

13 ‘‘(B) INDIVIDUAL LIABILITY.—The Sec14 retary may impose on an individual who— 

15 ‘‘(i) is employed by a hospital found 

16 by the Secretary to have violated this title; 

17 and 

18 ‘‘(ii) knowingly violates this title, a 

19 civil money penalty of not more than 

20 $20,000 for each such violation by the in21 dividual. 

22 ‘‘(2) PROCEDURES.—The provisions of section 

23 1128A of the Social Security Act (other than sub24 sections (a) and (b)) shall apply with respect to a 

25 civil money penalty or proceeding under this subVerDate Sep 11 2014 16:53 Feb 03, 2025 Jkt 059200 PO 00000 Frm 00123 Fmt 6652 Sfmt 6201 E:\BILLS\H10526.IH H10526

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1 section in the same manner as such provisions apply 

2 with respect to a civil money penalty or proceeding 

3 under such section 1128A. 

4 ‘‘(e) PUBLIC NOTICE OF VIOLATIONS.— 

5 ‘‘(1) INTERNET WEBSITE.—The Secretary shall 

6 publish on the internet website of the Department of 

7 Health and Human Services the names of hospitals 

8 on which a civil money penalty has been imposed 

9 under this section, the violation for which such pen10 alty was imposed, and such additional information 

11 as the Secretary determines appropriate. 

12 ‘‘(2) CHANGE OF OWNERSHIP.—With respect to 

13 a hospital that had a change of ownership, as deter14 mined by the Secretary, penalties imposed on the 

15 hospital while under previous ownership shall no 

16 longer be published by the Secretary pursuant to 

17 paragraph (1) after the 1-year period beginning on 

18 the date of change of ownership. 

19 ‘‘(f) USE OF FUNDS.—Funds collected by the Sec20 retary pursuant to this section are authorized to be appro21 priated to carry out this title. 

22 ‘‘SEC. 3406. DEFINITIONS. 

23 ‘‘For purposes of this title: 

24 ‘‘(1) ACUITY LEVEL.—The term ‘acuity level’ 

25 means the determination, using a hospital acuity 


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1 measurement tool that has been developed and es2 tablished in coordination with direct care registered 

3 nurses and made transparent pursuant to section 

4 3401(c)(4), of nursing care requirements, based on 

5 the assigned direct care registered nurse’s profes6 sional judgment of— 

7 ‘‘(A) the severity and complexity of an in8 dividual patient’s illness or injury; 

9 ‘‘(B) the need for specialized equipment; 

10 and 

11 ‘‘(C) the intensity of nursing interventions 

12 required. 

13 ‘‘(2) COMPETENCE.—The term ‘competence’ or 

14 ‘competent’ means the satisfactory application of the 

15 duties and responsibilities of a registered nurse in 

16 providing nursing care to specific patient popu17 lations and for acuity levels for each patient care 

18 unit or area pursuant to the State nursing laws and 

19 regulations of the State in which the direct nursing 

20 care is being performed. 

21 ‘‘(3) DIRECT CARE LICENSED PRACTICAL

22 NURSE.—The term ‘direct care licensed practical 

23 nurse’ means an individual who has been granted a 

24 license by at least one State to practice as a licensed 


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1 practical nurse or a licensed vocational nurse and 

2 who provides bedside care for one or more patients. 

3 ‘‘(4) DIRECT CARE REGISTERED NURSE.—The 

4 term ‘direct care registered nurse’ means an indi5 vidual who has been granted a license by at least 

6 one State to practice as a registered nurse and who 

7 provides bedside care for one or more patients. 

8 ‘‘(5) EMPLOYMENT.—The term ‘employment’ 

9 includes the provision of services under a contract or 

10 other arrangement. 

11 ‘‘(6) HOSPITAL.—The term ‘hospital’ has the 

12 meaning given that term in section 1861(e) of the 

13 Social Security Act. 

14 ‘‘(7) NURSE.—The term ‘nurse’ means any di15 rect care registered nurse or direct care licensed 

16 practice nurse (as the case may be), regardless of 

17 whether or not the nurse is an employee. 

18 ‘‘(8) NURSING CARE PLAN.—The term ‘nursing 

19 care plan’ means a plan developed by the assigned 

20 direct care registered nurse (in accordance with 

21 nursing law in the State in which the nursing care 

22 is performed) that indicates the nursing care to be 

23 given to individual patients that— 

24 ‘‘(A) considers the acuity level of the pa25 tient; 


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1 ‘‘(B) is developed in coordination with the 

2 patient, the patient’s family, or other represent3 atives when appropriate, and staff of other dis4 ciplines involved in the care of the patient; 

5 ‘‘(C) reflects all elements of the nursing 

6 process; and 

7 ‘‘(D) recommends the number and skill 

8 mix of additional licensed and unlicensed direct 

9 care staff needed to fully implement the nursing 

10 care plan. 

11 ‘‘(9) PROFESSIONAL JUDGMENT.—The term 

12 ‘professional judgment’ means, in accordance with 

13 State nursing laws and regulations of the State in 

14 which the direct nursing care is being performed, the 

15 direct care registered nurse’s application of knowl16 edge, expertise, and experience in conducting a com17 prehensive nursing assessment of each patient and 

18 in making independent decisions about patient care 

19 including the need for additional staff. 

20 ‘‘(10) STAFFING PLAN.—The term ‘staffing 

21 plan’ means a staffing plan required under section 

22 3401. 

23 ‘‘(11) STATE OF EMERGENCY.—The term ‘state 

24 of emergency’— 


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1 ‘‘(A) means a state of emergency that is 

2 an unpredictable or unavoidable occurrence at 

3 an unscheduled or unpredictable interval, relat4 ing to health care delivery and requiring imme5 diate medical interventions and care; and 

6 ‘‘(B) does not include a state of emergency 

7 that results from a labor dispute in the health 

8 care industry or consistent understaffing. 

9 ‘‘SEC. 3407. RULE OF CONSTRUCTION. 

10 ‘‘Nothing in this title shall be construed to authorize 

11 disclosure of private and confidential patient information, 

12 if such disclosure is not authorized or required by other 

13 applicable law.’’. 

14 (b) RECOMMENDATIONS TO CONGRESS.—Not later 

15 than 1 year after the date of enactment of this Act, the 

16 Secretary of Health and Human Services shall submit to 

17 Congress a report containing recommendations for ensur18 ing that sufficient numbers of nurses are available to meet 

19 the requirements imposed by title XXXIV of the Public 

20 Health Service Act, as added by subsection (a). 

21 (c) REPORT BY HRSA.— 

22 (1) IN GENERAL.—Not later than 2 years after 

23 the date of enactment of this Act, the Administrator 

24 of the Health Resources and Services Administra25 tion, in consultation with the National Health Care 


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1 Workforce Commission, shall submit to Congress a 

2 report regarding the relationship between nurse 

3 staffing levels and nurse retention in hospitals. 

4 (2) UPDATED REPORT.—Not later than 5 years 

5 after the date of enactment of this Act, the Adminis6 trator of the Health Resources and Services Admin7 istration, in consultation with the National Health 

8 Care Workforce Commission, shall submit to Con9 gress an update of the report submitted under para10 graph (1). 

11 (d) ENFORCEMENT OF REQUIREMENTS THROUGH

12 FEDERAL PROGRAMS.— 

13 (1) MEDICARE PROGRAM.—Section 1866(a)(1) 

14 of the Social Security Act (42 U.S.C. 1395cc(a)(1)) 

15 is amended— 

16 (A) in subparagraph (X), by striking ‘‘, 

17 and’’ and inserting a comma; 

18 (B) in subparagraph (Y), by striking the 

19 period at the end and inserting ‘‘, and’’; and 

20 (C) by inserting after subparagraph (Y) 

21 the following new subparagraph: 

22 ‘‘(Z) in the case of a hospital, to comply 

23 with the provisions of title XXXIV of the Public 

24 Health Service Act.’’. 


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1 (2) MEDICAID PROGRAM.—Section 1902(a) of 

2 the Social Security Act (42 U.S.C. 1396a(a)) is 

3 amended— 

4 (A) by striking ‘‘and’’ at the end of para5 graph (82); 

6 (B) by striking the period at the end of 

7 paragraph (83) and inserting ‘‘; and’’; and 

8 (C) by inserting after paragraph (83) the 

9 following new paragraph: 

10 ‘‘(84) provide that any hospital that receives a 

11 payment under such plan comply with the provisions 

12 of title XXXIV of the Public Health Service Act (re13 lating to minimum direct care registered nurse staff14 ing requirements).’’. 

15 (e) NURSING HOMES.—No later than one year after 

16 enactment of this Act, the Secretary of Health and 

17 Human Services shall promulgate a rule for minimum 

18 staffing standards for skilled nursing facilities under the 

19 Medicare program and for nursing facilities under the 

20 Medicaid program that align with the standards set in this 

21 section. 

22 SEC. 133. ENHANCEMENTS FOR REDUCED COST-SHARING. 

23 (a) IN GENERAL.—Section 1402 of the Patient Pro24 tection and Affordable Care Act (42 U.S.C. 18071) is 

25 amended— 


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1 (1) in subsection (b)(1), by striking ‘‘silver’’ 

2 and inserting ‘‘gold’’; 

3 (2) by amending subsection (c)(1)(B) to read as 

4 follows: 

5 ‘‘(B) COORDINATION WITH ACTUARIAL

6 LIMITS.—The Secretary shall ensure the reduc7 tion under this paragraph shall not result in the 

8 plan’s share of the total allowed costs of bene9 fits provided under the plan becoming less 

10 than— 

11 ‘‘(i) 95 percent in the case of an eligi12 ble insured described in paragraph (2)(A); 

13 ‘‘(ii) 90 percent in the case of an eli14 gible insured described in paragraph 

15 (2)(B); and 

16 ‘‘(iii) 85 percent in the case of an eli17 gible insured described in paragraph 

18 (2)(C).’’; and 

19 (3) by amending subsection (c)(2) to read as 

20 follows: 

21 ‘‘(2) ADDITIONAL REDUCTION.—The Secretary 

22 shall establish procedures under which the issuer of 

23 a qualified health plan to which this section applies 

24 shall further reduce cost-sharing under the plan in 

25 a manner sufficient to— 


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1 ‘‘(A) in the case of an eligible insured 

2 whose household income is not less than 100 

3 percent but not more than 200 percent of the 

4 poverty line for a family of the size involved, in5 crease the plan’s share of the total allowed 

6 costs of benefits provided under the plan to 95 

7 percent of such costs; 

8 ‘‘(B) in the case of an eligible insured 

9 whose household income is more than 200 per10 cent but not more than 300 percent of the pov11 erty line for a family of the size involved, in12 crease the plan’s share of the total allowed 

13 costs of benefits provided under the plan to 90 

14 percent of such costs; and 

15 ‘‘(C) in the case of an eligible insured 

16 whose household income is more than 300 per17 cent but not more than 400 percent of the pov18 erty line for a family of the size involved, in19 crease the plan’s share of the total allowed 

20 costs of benefits provided under the plan to 85 

21 percent of such costs.’’. 

22 (b) EFFECTIVE DATE.—The amendments made by 

23 this subsection shall apply to plan years beginning after 

24 December 31, 2025. 


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1 (c) FUNDING.—Section 1402 of the Patient Protec2 tion and Affordable Care Act (42 U.S.C. 18071) is amend3 ed by adding at the end the following new subsection: 

4 ‘‘(g) FUNDING.—Out of any funds in the Treasury 

5 not otherwise appropriated, there are appropriated to the 

6 Secretary such sums as may be necessary for payments 

7 under this section.’’. 

8 SEC. 134. REPEAL OF BONUS PAYMENTS FOR MEDICARE 

9 ADVANTAGE PLANS. 

10 Section 1853(o) of the Social Security Act (42 U.S.C. 

11 1395w–23(o)) is repealed. 

12 TITLE II—TAX PROVISIONS 

13 SEC. 201. SUNSET OF PUBLIC LAW 115–97. 

14 (a) IN GENERAL.—All provisions of, and amend15 ments made by, Public Law 115–97 shall not apply to cal16 endar, taxable, plan, or limitation years beginning after 

17 December 31, 2026. 

18 (b) APPLICATION OF CERTAIN LAWS.—The Internal 

19 Revenue Code of 1986 shall be applied and administered 

20 to years described in subsection (a) as if the provisions 

21 and amendments described in subsection (a) had never 

22 been enacted. 


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1 SEC. 202. SURTAX. 

2 There is hereby imposed a tax of 5 percent on the 

3 adjusted gross income of each taxpayer to the extent such 

4 income exceeds $500,000. 

5 SEC. 203. BASIS OF PROPERTY ACQUIRED FROM A DECE6 DENT. 

7 (a) IN GENERAL.—Section 1014 of the Internal Rev8 enue Code of 1986 is amended by striking ‘‘person, be’’ 

9 and all that follows through the period at the end and 

10 inserting the following: ‘‘person, be the basis in the hands 

11 of the decedent.’’. 

12 (b) EFFECTIVE DATE.—The amendments made by 

13 this section to property acquired or passed after the date 

14 of enactment of this Act. 

15 SEC. 204. MEDICARE PAYROLL TAX. 

16 (a) IN GENERAL.—Section 3101(b)(2) of the Internal 

17 Revenue Code of 1986 is amended by striking ‘‘0.9 per18 cent’’ and inserting ‘‘4 percent’’. 

19 (b) EFFECTIVE DATE.—The amendments made by 

20 this section shall apply with respect to taxable years begin21 ning after the date of the enactment of this Act. 

22 SEC. 205. NET INVESTMENT INCOME TAX. 

23 (a) IN GENERAL.—Section 1411(a) of the Internal 

24 Revenue Code of 1986 is amended by striking ‘‘3.8 per25 cent’’ each place such term appears and inserting ‘‘6.9 

26 percent’’. 


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1 (b) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply with respect to taxable years begin3 ning after the date of the enactment of this Act. 

4 SEC. 206. TERMINATION OF DEDUCTION FOR CONTRIBU5 TIONS TO HEALTH SAVINGS ACCOUNTS. 

6 Section 223(b) of the Internal Revenue Code of 1986 

7 is amended by adding at the end the following new para8 graph: 

9 ‘‘(9) TERMINATION OF DEDUCTION.—Notwith10 standing any other provision of this subsection, the 

11 monthly limitation for any month beginning after 

12 December 31, 2023, is zero.’’. 

13 SEC. 207. INCREASE IN EXCISE TAX ON SMALL CIGARS AND 

14 CIGARETTES AND OTHER TOBACCO PROD15 UCTS. 

16 (a) SMALL CIGARS.—Section 5701(a)(1) of the Inter17 nal Revenue Code of 1986 is amended by striking 

18 ‘‘$50.33’’ and inserting ‘‘$100.66’’. 

19 (b) CIGARETTES.—Section 5701(b) of such Code is 

20 amended— 

21 (1) by striking ‘‘$50.33’’ in paragraph (1) and 

22 inserting ‘‘$100.66’’; and 

23 (2) by striking ‘‘$105.69’’ in paragraph (2) and 

24 inserting ‘‘$211.38’’. 


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1 (c) PIPE TOBACCO.—Section 5701(f) of the Internal 

2 Revenue Code of 1986 is amended by striking ‘‘$2.8311 

3 cents’’ and inserting ‘‘$50.00’’. 

4 (d) ROLL-YOUR-OWN TOBACCO.—Section 5701(g) of 

5 such Code is amended by striking ‘‘$24.78’’ and inserting 

6 ‘‘$49.56’’. 

7 (e) LARGE CIGARS.—Paragraph (2) of section 

8 5701(a) of the Internal Revenue Code of 1986 is amended 

9 by striking ‘‘52.75 percent’’ and all that follows through 

10 the period and inserting ‘‘$24.78 per pound (and a propor11 tionate tax at the like rate on all fractional parts of a 

12 pound) but not less than 5.033 cents per cigar.’’. 

13 (f) SMOKELESS TOBACCO.— 

14 (1) IN GENERAL.—Section 5701(e) of the Inter15 nal Revenue Code of 1986 is amended— 

16 (A) in paragraph (1), by striking ‘‘$1.51’’ 

17 and inserting ‘‘$28.04’’; 

18 (B) in paragraph (2), by striking ‘‘50.33 

19 cents’’ and inserting ‘‘$12.42’’; and 

20 (C) by adding at the end the following: 

21 ‘‘(3) SMOKELESS TOBACCO SOLD IN DISCRETE

22 SINGLE-USE UNITS.—On discrete single-use units, 

23 $107.65 per each 1,000 single-use units.’’. 

24 (2) DISCRETE SINGLE-USE UNIT.—Section 

25 5702(m) of such Code is amended— 


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1 (A) in paragraph (1), by striking ‘‘or chew2 ing tobacco’’ and inserting ‘‘chewing tobacco, 

3 discrete single-use unit’’; 

4 (B) in paragraphs (2) and (3), by inserting 

5 ‘‘that is not a discrete single-use unit’’ before 

6 the period in each such paragraph; and 

7 (C) by adding at the end the following: 

8 ‘‘(4) DISCRETE SINGLE-USE UNIT.—The term 

9 ‘discrete single-use unit’ means any product con10 taining tobacco that— 

11 ‘‘(A) is not intended to be smoked; and 

12 ‘‘(B) is in the form of a lozenge, tablet, 

13 pill, pouch, dissolvable strip, or other discrete 

14 single-use or single-dose unit’’. 

15 SEC. 208. EXCISE TAX ON ALCOHOL. 

16 (a) DISTILLED SPIRITS.—Section 5001(a)(1) of the 

17 Internal Revenue Code of 1986 is amended by striking 

18 ‘‘$13.50’’ and inserting ‘‘$16.00’’. 

19 (b) WINE.—(1) Section 5041(b)(1) of the Internal 

20 Revenue Code of 1986 is amended by striking ‘‘$1.07 per 

21 wine gallon’’ and inserting ‘‘$16.00 per proof gallon’’. 

22 (2) Section 5041(b)(2) of the Internal Revenue 

23 Code of 1986 is amended by striking ‘‘$1.57 per 

24 wine gallon’’ and inserting ‘‘$16.00 per proof gal25 lon’’. 


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1 (3) Section 5041(b)(3) of the Internal Revenue 

2 Code of 1986 is amended by striking ‘‘$3.15 per 

3 wine gallon’’ and inserting ‘‘$16.00 per proof gal4 lon’’. 

5 (4) Section 5041(b)(4) of the Internal Revenue 

6 Code of 1986 is amended by striking ‘‘$3.40 per 

7 wine gallon’’ and inserting ‘‘$16.00 per proof gal8 lon’’. 

9 (5) Section 5041(b)(5) of the Internal Revenue 

10 Code of 1986 is amended by striking ‘‘$3.30 per 

11 wine gallon’’ and inserting ‘‘$16.00 per proof gal12 lon’’. 

13 (6) Section 5041(b)(3) of the Internal Revenue 

14 Code of 1986 is amended by striking ‘‘$22.6 cents 

15 per wine gallon’’ and inserting ‘‘$16.00 per proof 

16 gallon’’. 

17 (c) BEER.—Section 5051(B) of the Internal Revenue 

18 Code of 1986 is amended by striking ‘‘$18 for per barrel’’ 

19 and inserting ‘‘$16 per proof gallon’’. 

20 SEC. 209. TAX ON SUGARED DRINKS. 

21 (a) IN GENERAL.—Subchapter D of chapter 32 of the 

22 Internal Revenue Code of 1986 is amended by inserting 

23 after part I the following new part: 

24 ‘‘PART II—SUGAR-SWEETENED BEVERAGES 

‘‘Sec. 4171. Imposition of tax. 

‘‘Sec. 4172. Definitions. 

‘‘Sec. 4173. Special rules. 


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1 ‘‘SEC. 4171. IMPOSITION OF TAX. 

2 ‘‘(a) IN GENERAL.—There is hereby imposed a tax 

3 on the sale or transfer of any specified sugar-sweetened 

4 beverage product by the manufacturer, producer, or im5 porter thereof. 

6 ‘‘(b) RATE OF TAX.—The rate of tax imposed under 

7 subsection (a) shall be equal to one cent per 4.2 grams 

8 of caloric sweetener contained in such specified sugar9 sweetened beverage product. 

10 ‘‘(c) PERSONS LIABLE FOR TAX.—The manufac11 turer, producer, or importer referred to in subsection (a) 

12 shall be liable for the tax imposed by such subsection. 

13 ‘‘SEC. 4172. DEFINITIONS. 

14 ‘‘(a) SPECIFIED SUGAR-SWEETENED BEVERAGE

15 PRODUCT.—For purposes of this part— 

16 ‘‘(1) IN GENERAL.—For purposes of this part, 

17 the term ‘specified sugar-sweetened beverage prod18 uct’ means— 

19 ‘‘(A) any liquid intended for human con20 sumption which contains a caloric sweetener, 

21 and 

22 ‘‘(B) any liquid, or solid mixture of ingre23 dients, which— 

24 ‘‘(i) contains a caloric sweetener, and 


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1 ‘‘(ii) is intended for use as an ingre2 dient in a liquid described in subparagraph 

3 (A). 

4 ‘‘(2) EXCEPTIONS.—The following shall not be 

5 treated as liquids described in paragraph (1)(A): 

6 ‘‘(A) Any liquid the primary ingredients of 

7 which are milk or soy, rice, or similar plant8 based milk substitute. 

9 ‘‘(B) Any liquid composed entirely of one 

10 or more of the following: 

11 ‘‘(i) The original liquid resulting from 

12 the pressing of fruit or vegetables. 

13 ‘‘(ii) The liquid resulting from the re14 constitution of fruit or vegetable juice con15 centrate. 

16 ‘‘(iii) The liquid resulting from the 

17 restoration of water to dehydrated fruit or 

18 vegetable juice. 

19 ‘‘(C) Infant formula. 

20 ‘‘(D) Any liquid products manufactured for 

21 use as— 

22 ‘‘(i) an oral nutritional therapy for 

23 persons who cannot absorb or metabolize 

24 dietary nutrients from food or beverages, 


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1 ‘‘(ii) a source of necessary nutrition 

2 used due to a medical condition, or 

3 ‘‘(iii) an oral electrolyte solution for 

4 infants and children formulated to prevent 

5 dehydration due to illness. 

6 ‘‘(E) Any liquid with respect to which tax 

7 is imposed under chapter 51 (relating to dis8 tilled spirits, wines, and beer) or under section 

9 7652 by reason of the tax imposed under chap10 ter 51 being imposed on like articles of domes11 tic manufacture. 

12 ‘‘(b) CALORIC SWEETENER.—For purposes of this 

13 part, the term ‘caloric sweetener’ means monosaccharides, 

14 disaccharides, and high-fructose corn syrup. 

15 ‘‘SEC. 4173. SPECIAL RULES. 

16 ‘‘(a) SWEETENER TAXED ONLY ONCE.—In the case 

17 of any specified sugar-sweetened beverage product which 

18 is manufactured or produced by including one or more 

19 other specified sugar-sweetened beverage products, no tax 

20 shall be imposed under this section on any caloric sweet21 ener contained in the resulting specified sugar-sweetened 

22 beverage product if tax was previously imposed under this 

23 section on such caloric sweetener when contained in the 

24 specified sugar-sweetened beverage product so included. 


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1 ‘‘(b) INFLATION ADJUSTMENT.—In the case of any 

2 sale after December 31, 2015, the one cent amount in sec3 tion 4171(b) shall be increased by an amount equal to— 

4 ‘‘(1) such amount, multiplied by 

5 ‘‘(2) the cost-of-living adjustment determined 

6 under section 1(f)(3) for the calendar year in which 

7 such sale occurs, determined by substituting ‘cal8 endar year 2014’ for ‘calendar year 1992’ in sub9 paragraph (B) thereof. 

10 Any increase determined under this subsection shall 

11 be rounded to the nearest multiple of one-tenth of 

12 a cent.’’. 

13 (b) CONFORMING AMENDMENTS.— 

14 (1) Section 4221(a) is amended by adding at 

15 the end the following: ‘‘Paragraphs (1), (4), (5), and 

16 (6) shall not apply to the tax imposed under section 

17 4171.’’. 

18 (2) The table of parts for subchapter D of 

19 chapter 32 of such Code is amended by inserting 

20 after the item relating to part I the following new 

21 item: 

22 ‘‘Part II—Sugar-Sweetened Beverages’’. 

23 (c) EFFECTIVE DATE.— 

24 (1) IN GENERAL.—Except as provided in para25 graph (2), the amendments made by this section 


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1 shall take effect on the date of the enactment of this 

2 Act. 

3 (2) EXCISE TAX.—The amendments made by 

4 subsections (a) and (b) shall apply to sales after the 

5 date of the enactment of this Act. 

6 SEC. 210. REPEAL OF EXCISE TAX ON HIGH-COST EM7 PLOYER-SPONSORED HEALTH COVERAGE. 

8 (a) IN GENERAL.—Chapter 43 of the Internal Rev9 enue Code of 1986 is amended by striking section 4980I. 

10 (b) CONFORMING AMENDMENT.—Section 6051 of 

11 such Code is amended— 

12 (1) in paragraph (14) of subsection (a), by 

13 striking ‘‘section 4980I(d)(1)’’ and inserting ‘‘sub14 section (g)’’, and 

15 (2) by adding at the end the following: 

16 ‘‘(g) APPLICABLE EMPLOYER-SPONSORED COV17 ERAGE.—For purposes of subsection (a)(14)— 

18 ‘‘(1) IN GENERAL.—The term ‘applicable em19 ployer-sponsored coverage’ means, with respect to 

20 any employee, coverage under any group health plan 

21 made available to the employee by an employer 

22 which is excludable from the employee’s gross in23 come under section 106, or would be so excludable 

24 if it were employer-provided coverage (within the 

25 meaning of such section 106). 


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1 ‘‘(2) EXCEPTIONS.—The term ‘applicable em2 ployer-sponsored coverage’ shall not include— 

3 ‘‘(A) any coverage (whether through insur4 ance or otherwise) described in section 

5 9832(c)(1) (other than subparagraph (G) there6 of) or for long-term care; 

7 ‘‘(B) any coverage under a separate policy, 

8 certificate, or contract of insurance which pro9 vides benefits substantially all of which are for 

10 treatment of the mouth (including any organ or 

11 structure within the mouth) or for treatment of 

12 the eye; or 

13 ‘‘(C) any coverage described in section 

14 9832(c)(3) the payment for which is not exclud15 able from gross income and for which a deduc16 tion under section 162(l) is not allowable. 

17 ‘‘(3) COVERAGE INCLUDES EMPLOYEE PAID

18 PORTION.—Coverage shall be treated as applicable 

19 employer-sponsored coverage without regard to 

20 whether the employer or employee pays for the cov21 erage. 

22 ‘‘(4) GOVERNMENTAL PLANS INCLUDED.—Ap23 plicable employer-sponsored coverage shall include 

24 coverage under any group health plan established 

25 and maintained primarily for its civilian employees 


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1 by the Government of the United States, by the gov2 ernment of any State or political subdivision thereof, 

3 or by any agency or instrumentality of any such gov4 ernment. 

5 ‘‘(5) COST OF COVERAGE.— 

6 ‘‘(A) HEALTH FSAS.—In the case of appli7 cable employer-sponsored coverage consisting of 

8 coverage under a flexible spending arrangement 

9 (as defined in section 2205(g)), the cost of the 

10 coverage shall be equal to the amount deter11 mined under rules similar to the rules of section 

12 4980B(f)(4) with respect to any reimbursement 

13 under the arrangement reduced by the contribu14 tions described in subsection (a)(14)(B). 

15 ‘‘(B) ARCHER MSAS AND HSAS.—In the 

16 case of applicable employer-sponsored coverage 

17 consisting of coverage under an arrangement 

18 under which the employer makes contributions 

19 described in subsection (b) or (d) of section 

20 106, the cost of the coverage shall be equal to 

21 the amount of employer contributions under the 

22 arrangement until the termination of HSAs as 

23 described under section 206 of such Act. 

24 ‘‘(C) ALLOCATION ON A MONTHLY

25 BASIS.—If cost is determined on other than a 


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1 monthly basis, the cost shall be allocated to 

2 months in a taxable period on such basis as the 

3 Secretary may prescribe.’’. 

4 (c) CLERICAL AMENDMENT.—The table of sections 

5 for chapter 43 of such Code is amended by striking the 

6 item relating to section 4980I. 

7 (d) EFFECTIVE DATE.—The amendments made by 

8 this section shall apply to taxable years beginning after 

9 December 31, 2026. 

10 TITLE III—DRUG-RELATED 

11 PROVISIONS 

12 SEC. 301. ESTABLISHMENT OF THE PRESCRIPTION DRUG 

13 AND MEDICAL DEVICE REVIEW BOARD. 

14 There is established in the Department of Health and 

15 Human Services a board to be known as the Prescription 

16 Drug and Medical Device Price Review Board (in this Act 

17 referred to as the ‘‘Board’’). 

18 SEC. 302. MEMBERSHIP; STAFF. 

19 (a) MEMBERS.—The Board shall be composed of the 

20 members as follows: 

21 (1) The Assistant Secretary for Planning and 

22 Evaluation of the Department of Health and Human 

23 Services (or the Assistant Secretary’s designee). 

24 (2) The Administrator of the Centers for Medi25 care & Medicaid Services or, beginning with 2025, 


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1 the Administrator of the Center for Health Care (or 

2 the Administrator’s designee). 

3 (3) The Assistant Director for the Health Serv4 ices Division of the Federal Bureau of Prisons (or 

5 the Assistant Director’s designee). 

6 (4) The Secretary of Defense (or the Sec7 retary’s designee). 

8 (5) The Secretary of Veterans Affairs (or the 

9 Secretary’s designee). 

10 (6) The Commissioner of Food and Drugs (or 

11 the Commissioner’s designee). 

12 (7) The Director of the National Institutes of 

13 Health (or the Director’s designee). 

14 (b) CHAIRPERSON.—The Board shall designate 1 

15 member of the Board to serve as the chairperson. 

16 (c) DIRECTOR AND STAFF.— 

17 (1) DIRECTOR.—The Board shall have a direc18 tor who shall be appointed by the chairperson of the 

19 Board, subject to rules prescribed by the Board. 

20 (2) STAFF.—The director may appoint and fix 

21 the pay of such additional personnel as the chair22 person considers appropriate, subject to rules pre23 scribed by the Board. 

24 (3) APPLICABILITY OF CERTAIN CIVIL SERVICE

25 LAWS.—The director and staff of the Board shall be 


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1 appointed subject to the provisions of title 5, United 

2 States Code, governing appointments in the competi3 tive service, and shall be paid in accordance with the 

4 requirements of chapter 51 and subchapter III of 

5 chapter 53 of such title relating to classification and 

6 General Schedule pay rates; except that an indi7 vidual so appointed may not receive pay in excess of 

8 the maximum annual rate of basic pay payable for 

9 grade GS–15 of the General Schedule. 

10 (d) ASSISTANCE FOR THE BOARD.—Subject to sec11 tion 306(g), in carrying out this title, the Board— 

12 (1) may seek assistance from outside experts in 

13 the fields of consumer advocacy, medicine, pharma14 cology, pharmacy, and prescription drug reimburse15 ment; and 

16 (2) shall establish and maintain an advisory 

17 group and a stakeholder group for purposes of seek18 ing such assistance. 

19 (e) INITIAL MEETING.—The Board shall hold its ini20 tial meeting not later than 90 days after the date of the 

21 enactment of this Act. 

22 (f) BANNED INDIVIDUALS.— 

23 (1) DRUG COMPANY LOBBYISTS.—No former 

24 registered drug manufacturer lobbyist— 


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1 (A) may be appointed to the position of 

2 Director of the Office; or 

3 (B) may be employed by the Office during 

4 the 6-year period beginning on the date on 

5 which the registered lobbyist terminates its reg6 istration in accordance with section 4(d) of the 

7 Lobbying Disclosure Act of 1995 (2 U.S.C. 

8 1603(d)) or the agent terminates its status, as 

9 applicable. 

10 (2) SENIOR EXECUTIVES OF LAW-BREAKING

11 COMPANIES.—No former senior executive of a cov12 ered entity— 

13 (A) may be appointed to the position of 

14 Director of the Office; or 

15 (B) may be employed by the Office during 

16 the 6-year period beginning on the later of— 

17 (i) the date of the settlement; and 

18 (ii) the date on which the enforcement 

19 action has concluded. 

20 (3) COVERED ENTITY.—The term ‘‘covered en21 tity’’ means any entity that is— 

22 (A) a drug manufacturer; and 

23 (B)(i) operating under Federal settlement, 

24 including a Federal consent decree; or 


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1 (ii) the subject of an enforcement ac2 tion in a court of the United States or by 

3 an agency. 

4 SEC. 303. PROHIBITION AGAINST EXCESSIVE PRICE. 

5 (a) PROHIBITION.—Beginning on the effective date 

6 of the regulation required by subsection (b), the manufac7 turer of a prescription drug or medical device shall not 

8 charge an excessive price, as determined pursuant to such 

9 regulation, for such drug or device. 

10 (b) FORMULA.—The Board shall by regulation pre11 scribe a formula for determining whether the average 

12 manufacturer price of such drug or device over an annual 

13 quarter is an excessive price. 

14 (c) DETERMINATION OF EXCESSIVE PRICE.—If the 

15 Board determines, on its own initiative or in response to 

16 a petition submitted under subsection (d), that the manu17 facturer of a prescription drug or medical device charges 

18 an excessive price for such drug or device in violation of 

19 subsection (a)— 

20 (1) the Board shall give the manufacturer— 

21 (A) notice of such violation; and 

22 (B) subject to subsection (d), a period to 

23 correct such violation; and 

24 (2) if the manufacturer fails to correct the vio25 lation by the end of such period, the manufacturer 


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1 shall be subject to section 304, section 

2 1927(c)(2)(E) of the Social Security Act (as added 

3 by subsection (c) of section 304), and section 4192 

4 of the Internal Revenue Code of 1986, as added by 

5 subsection (d) of section 304. 

6 (d) PETITIONS.—Any person may petition the Board 

7 to make a determination under subsection (c) regarding 

8 the pricing of a prescription drug or medical device. Not 

9 later than 90 days after the date of receipt of such a peti10 tion, the Board shall— 

11 (1) make a determination under subsection (c) 

12 regarding such pricing; or 

13 (2) decline to make such a determination. 

14 (e) CONTINUING VIOLATION.—The Board shall not 

15 be required to give a manufacturer an opportunity to cor16 rect a violation, as described in subsection (c)(1)(B), be17 fore the manufacturer becomes subject to the provisions 

18 described in subsection (c)(2) for such violation, if— 

19 (1) the Board has already provided such an op20 portunity to correct to the manufacturer; and 

21 (2) the Board finds that the violation of sub22 section (a) is a continuation of an earlier violation 

23 with respect to which such an opportunity was pro24 vided. 


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1 (f) CONSIDERATIONS.—The formula required by sub2 section (a) shall at a minimum take into consideration— 

3 (1) the average manufacturer price of the pre4 scription drug or medical device over the respective 

5 annual quarter or quarters; 

6 (2) the average manufacturer price of other 

7 prescription drugs or medical devices in the same 

8 therapeutic class over the same quarter or quarters; 

9 (3) the average price at which the prescription 

10 drug or medical device and other prescription drugs 

11 and medical devices in the same therapeutic class 

12 have been sold by manufacturers in countries other 

13 than the United States; 

14 (4) the costs associated with producing and 

15 marketing the prescription drug or medical device, 

16 the value of the drug or device to patients where suf17 ficient data is available to determine such value, the 

18 total Federal investment in the development of the 

19 drug or device, the size of the patient population re20 ceiving the drug or device, and other factors deter21 minative as to the true cost of production; and 

22 (5) whether the price of the prescription drug 

23 or medical device increased during any annual quar24 ter by a percentage that is more than 2 percent 

25 greater than the CPI increase percentage (as defined 


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1 in section 215(i) of the Social Security Act (42 

2 U.S.C. 415)) for the respective annual quarter. 

3 (g) VALUE OR COST-EFFECTIVENESS ASSESS4 MENTS.—The use of Quality-Adjusted Life Years, Dis5 ability-Adjusted Life Years, or other similar mechanisms 

6 is prohibited for use in value or cost-effectiveness assess7 ments for purposes of this section. 

8 SEC. 304. ENFORCEMENT PROVISIONS. 

9 (a) REDUCED PATENT TERM.—If the Board finds 

10 that the manufacturer of a prescription drug or medical 

11 device, who is also an owner of a patent for such drug 

12 or device, charged an excessive price for such drug or de13 vice in violation of section 303(a), the Board may— 

14 (1) reduce the term, by not more than 5 years, 

15 of any patent issued under title 35, United States 

16 Code, relating to such drug or device; or 

17 (2) if the term of each patent for such drug or 

18 device has expired, reduce the term, by not more 

19 than 5 years, of another patent owned by the patent 

20 owner relating to a prescription drug or medical de21 vice. 

22 (b) CIVIL PENALTIES.—If the Board determines 

23 under section 303(c) that a manufacturer of a prescription 

24 drug or medical device charged an excessive price for a 

25 prescription drug or medical device in violation of section 


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1 303(a), the Board may impose a civil penalty on the man2 ufacturer of not more than 10 percent of the manufactur3 er’s gross sales of the drug or device during the period 

4 beginning on the date on which an excessive price is first 

5 charged and ending on the date on which the manufac6 turer ceases to charge an excessive price. 

7 (c) TAX ON EXCESS PRESCRIPTION DRUG AND MED8 ICAL DEVICE PROFITS.— 

9 (1) DETERMINATION OF AMOUNT.—If the 

10 Board determines under section 303(a) that a man11 ufacturer, producer, or importer of a prescription 

12 drug or medical device charged an excessive price for 

13 such prescription drug or medical device during a 

14 taxable year, the Board may determine under this 

15 paragraph a reasonable price for such drug or device 

16 for such taxable year. 

17 (2) IMPOSITION OF TAX.— 

18 (A) IN GENERAL.—The Internal Revenue 

19 Code of 1986 is amended by inserting after sec20 tion 4191 the following new section: 

21 ‘‘SEC. 4192. EXCESSIVE PRESCRIPTION DRUG AND MEDICAL 

22 DEVICE PRICE. 

23 ‘‘(a) IN GENERAL.—There is hereby imposed on the 

24 sale of any prescription drug or medical device by the 

25 manufacturer, producer, or importer a tax equal to the 


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1 difference between the price at which such drug or device 

2 is so sold and the reasonable price determined by the Pre3 scription Drug and Medical Device Price Review Board 

4 under section 303(c)(1) of the Medicare for America Act 

5 for such drug or device for the taxable year for sales after 

6 the determination. 

7 ‘‘(b) PRESCRIPTION DRUG OR MEDICAL DEVICE.— 

8 For purposes of this section, the term ‘prescription drug 

9 or medical device’ means any prescription drug (as defined 

10 in section 9008 of the Patient Protection and Affordable 

11 Care Act) or device (as defined in section 201(h) of the 

12 Federal Food, Drug, and Cosmetic Act) intended for hu13 mans.’’. 

14 (B) CLERICAL AMENDMENT.—The table of 

15 parts for chapter 32 of such Code is amended— 

16 (i) in the item relating to subchapter 

17 E, by striking ‘‘Medical’’ and inserting 

18 ‘‘Drugs and medical’’; and 

19 (ii) by inserting after the item relating 

20 to section 4191 the following new item: 

21 ‘‘SEC. 4192. EXCESSIVE PRESCRIPTION DRUG AND MEDICAL 

22 DEVICE PRICE.’’. 

23 (3) EFFECTIVE DATE.—This subsection and the 

24 amendments made by this subsection shall apply 

25 with respect to sales after December 31, 2025. 


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1 SEC. 305. AUTHORITY. 

2 (a) OBTAINING OFFICIAL DATA.—The chairperson of 

3 the Board may secure directly from any Federal agency 

4 information necessary to enable the Board to carry out 

5 its duties. Upon request of the chairperson, the head of 

6 the agency shall furnish such information to the Board 

7 to the extent such information is not prohibited from dis8 closure by law. 

9 (b) MAILS.—The Board may use the United States 

10 mails in the same manner and under the same conditions 

11 as other Federal agencies. 

12 (c) ADMINISTRATIVE SUPPORT SERVICES.—Upon the 

13 request of the chairperson of the Board, the Administrator 

14 of General Services shall provide to the Board, on a reim15 bursable basis, the administrative support services nec16 essary for the Board to carry out its duties. 

17 (d) CONTRACT AUTHORITY.—The Board may con18 tract with and compensate government and private agen19 cies or persons for the purpose of conducting research, 

20 surveys, and other services necessary to enable the Board 

21 to carry out its duties. 

22 (e) INVESTIGATIONS.—The Board may make such in23 vestigations as it considers necessary to determine whether 

24 there is or may be a violation of any regulation promul25 gated under this Act and may require or permit any per26 son to file with it a statement in writing, under oath or 


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1 otherwise as the Board shall determine, as to all the facts 

2 and circumstances concerning the matter to be inves3 tigated. 

4 (f) SUBPOENA POWER.— 

5 (1) IN GENERAL.—The Board may issue sub6 poenas requiring the attendance and testimony of 

7 witnesses and the production of any evidence relat8 ing to any matter under investigation by the Board. 

9 The attendance of witnesses and the production of 

10 evidence may be required from any place within the 

11 United States at any designated place of hearing 

12 within the United States. 

13 (2) FAILURE TO OBEY A SUBPOENA.—If a per14 son refuses to obey a subpoena issued under para15 graph (1), the Board may apply to a United States 

16 district court for an order requiring that person to 

17 appear before the Board to give testimony, produce 

18 evidence, or both, relating to the matter under inves19 tigation. The application may be made within the ju20 dicial district where the hearing is conducted or 

21 where that person is found, resides, or transacts 

22 business. Any failure to obey the order of the court 

23 may be punished by the court as civil contempt. 

24 (3) SERVICE OF SUBPOENAS.—The subpoenas 

25 of the Board shall be served in the manner provided 


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1 for subpoenas issued by a United States district 

2 court under the Federal Rules of Civil Procedure for 

3 the United States district courts. 

4 (4) SERVICE OF PROCESS.—All process of any 

5 court to which application is made under paragraph 

6 (2) may be served in the judicial district in which 

7 the person required to be served resides or may be 

8 found. 

9 (5) NOTICE.—Upon issuing any subpoena 

10 under this subsection, the Board shall give notice of 

11 such issuance to the appropriate committees of Con12 gress, including the Committee on Appropriations of 

13 the House of Representatives and the Committee on 

14 Appropriations of the Senate. 

15 (g) CONFIDENTIALITY.—Under this title, the Sec16 retary shall enforce applicable law concerning a trade se17 cret or confidential information subject to section 

18 552(b)(4) of title 5, United States Code, or section 1905 

19 of title 18. 

20 SEC. 306. REGULATIONS. 

21 (a) IN GENERAL.—Not later than 1 year after the 

22 date of the initial meeting held under section 302(e), the 

23 Board shall issue final regulations to carry out this Act. 

24 (b) NOTICE AND COMMENT REQUIREMENT.—The 

25 regulations developed under subsection (a) shall be issued 


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1 in accordance with the notice and comment procedures es2 tablished under section 553 of title 5, United States Code. 

3 SEC. 307. REPORT TO FEDERAL AGENCIES. 

4 Not later than 1 year after the effective date of the 

5 regulations under section 306 and annually thereafter, the 

6 Board shall submit to each Federal agency that dispenses 

7 or makes payments for the dispensing of prescription 

8 drugs or medical devices a report containing a list of each 

9 prescription drug and medical device for which an exces10 sive price was charged during the preceding calendar year, 

11 as determined by the Board under section 303. The Sec12 retary shall make this report publicly available. 

13 SEC. 308. DEFINITIONS. 

14 In this title: 

15 (1) AFFILIATE.—The term ‘‘affiliate’’ means, 

16 with respect to a manufacturer, any entity that con17 trols, is controlled by, or is under common control 

18 with such manufacturer. 

19 (2) AVERAGE MANUFACTURER PRICE.—The 

20 term ‘‘average manufacturer price’’ means the aver21 age price charged by the manufacturer of a prescrip22 tion drug or medical device, as applicable, for sales 

23 of the drug or device by the manufacturer in the 

24 United States over the respective annual quarter. 


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1 (3) MEDICAL DEVICE.—The term ‘‘medical de2 vice’’ means a device (as defined in section 201 of 

3 the Federal Food, Drug, and Cosmetic Act (21 

4 U.S.C. 321)). 

5 (4) PRESCRIPTION DRUG.—The term ‘‘prescrip6 tion drug’’ means a drug (as defined in section 201 

7 of the Federal Food, Drug, and Cosmetic Act (21 

8 U.S.C. 321)) that is subject to section 503(b)(1) of 

9 such Act (21 U.S.C. 353(b)(1)). 

10 (5) MANUFACTURER.—The term ‘‘manufac11 turer’’ means the person— 

12 (A) that holds the application for a drug 

13 approved under section 505 of the Federal 

14 Food, Drug, and Cosmetic Act or the license 

15 issued under section 351 of the Public Health 

16 Service Act; or 

17 (B) who is responsible for setting the price 

18 for the drug. 

19 (6) WHOLESALE ACQUISITION COST.—The term 

20 ‘‘wholesale acquisition cost’’ has the meaning given 

21 that term in section 1847A(c)(6)(B) of the Social 

22 Security Act (42 U.S.C. 1395w–3a(c)(6)(B)). 


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1 SEC. 309. MORATORIUM ON DIRECT-TO-CONSUMER DRUG 

2 ADVERTISING. 

3 The Federal Food, Drug, and Cosmetic Act (21 

4 U.S.C. 301 et seq.) is amended— 

5 (1) in section 301 (21 U.S.C. 331), by adding 

6 at the end the following: 

7 ‘‘(eee) The conduct of direct-to-consumer advertising 

8 of a drug in violation of section 506J.’’; and’’. 

9 (2) in chapter V, by inserting after section 506I 

10 (21 U.S.C. 356f) the following: 

11 ‘‘SEC. 506J. DIRECT-TO-CONSUMER DRUG ADVERTISING. 

12 ‘‘(a) PROHIBITIONS.— 

13 ‘‘(1) FIRST THREE YEARS.— 

14 ‘‘(A) IN GENERAL.—Subject to subpara15 graph (B), no person shall conduct direct-to16 consumer advertising of a drug for which an 

17 application is submitted under section 505(b) 

18 before the end of the 3-year period beginning 

19 on the date of the approval of such application. 

20 ‘‘(B) WAIVER.—The Secretary may waive 

21 the application of subparagraph (A) to a drug 

22 during the third year of the 3-year period de23 scribed in such subparagraph if— 

24 ‘‘(i) the sponsor of the drug submits 

25 an application to the Secretary pursuant to 

26 subparagraph (C); and 


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1 ‘‘(ii) the Secretary, after considering 

2 the application and any accompanying ma3 terials, determines that direct-to-consumer 

4 advertising of the drug would have an af5 firmative value to public health. 

6 ‘‘(C) APPLICATION FOR WAIVER.—To seek 

7 a waiver under subparagraph (B), the sponsor 

8 of a drug shall submit an application to the 

9 Secretary at such time, in such manner, and 

10 containing such information as the Secretary 

11 may require. 

12 ‘‘(2) SUBSEQUENT YEARS.—The Secretary may 

13 prohibit direct-to-consumer advertising of a drug 

14 during the period beginning at the end of the 3-year 

15 period described in paragraph (1)(A) if the Sec16 retary determines that the drug has significant ad17 verse health effects based on post-approval studies, 

18 risk-benefit analyses, adverse event reports, the sci19 entific literature, any clinical or observational stud20 ies, or any other appropriate resource. 

21 ‘‘(b) REGULATIONS.—Not later than 1 year after the 

22 date of the enactment of this section, the Secretary shall 

23 revise the regulations promulgated under this Act gov24 erning drug advertisements to the extent necessary to im25 plement this section. 


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1 ‘‘(c) RULE OF CONSTRUCTION.—This section shall 

2 not be construed to diminish the authority of the Secretary 

3 to prohibit or regulate direct-to-consumer advertising of 

4 drugs under other provisions of law.’’. 

5 SEC. 310. REPORTING ON JUSTIFICATION FOR DRUG PRICE 

6 INCREASES. 

7 Title III of the Public Health Service Act (42 U.S.C. 

8 241 et seq.) is amended by adding at the end the fol9 lowing: 

10 ‘‘PART W—DRUG PRICE REPORTING; DRUG 

11 VALUE FUND 

12 ‘‘SEC. 399OO. REPORTING ON JUSTIFICATION FOR DRUG 

13 PRICE INCREASES. 

14 ‘‘(a) DEFINITIONS.—In this section: 

15 ‘‘(1) MANUFACTURER.—The term ‘manufac16 turer’ means the person— 

17 ‘‘(A) that holds the application for a drug 

18 approved under section 505 of the Federal 

19 Food, Drug, and Cosmetic Act or the license 

20 issued under section 351 of the Public Health 

21 Service Act; or 

22 ‘‘(B) who is responsible for setting the 

23 price for the drug. 

24 ‘‘(2) QUALIFYING DRUG.—The term ‘qualifying 

25 drug’ means any drug that is approved under subVerDate Sep 11 2014 16:53 Feb 03, 2025 Jkt 059200 PO 00000 Frm 00163 Fmt 6652 Sfmt 6201 E:\BILLS\H10526.IH H10526

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1 section (c) or (j) of section 505 of the Federal Food, 

2 Drug, and Cosmetic Act or licensed under subsection 

3 (a) or (k) of section 351 of this Act— 

4 ‘‘(A) that has a wholesale acquisition cost 

5 of $100 or more per month supply or per a 

6 course of treatment that lasts less than a 

7 month and is— 

8 ‘‘(i)(I) subject to section 503(b)(1) of 

9 the Federal Food, Drug, and Cosmetic 

10 Act; or 

11 ‘‘(II) commonly administered by 

12 hospitals (as determined by the Sec13 retary); 

14 ‘‘(ii) not designated as a drug for a 

15 rare disease or condition under section 526 

16 of the Federal Food, Drug, and Cosmetic 

17 Act; and 

18 ‘‘(iii) not designated by the Secretary 

19 as a vaccine; and 

20 ‘‘(B) for which, during the previous cal21 endar year, at least 1 dollar of the total amount 

22 of sales were for individuals enrolled under the 

23 Medicare program under title XVIII of the So24 cial Security Act (42 U.S.C. 1395 et seq.) or 

25 under a State Medicaid plan under title XIX of 


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1 such Act (42 U.S.C. 1396 et seq.) or under a 

2 waiver of such plan. 

3 ‘‘(3) WHOLESALE ACQUISITION COST.—The 

4 term ‘wholesale acquisition cost’ has the meaning 

5 given that term in section 1847A(c)(6)(B) of the So6 cial Security Act (42 U.S.C. 1395w–3a(c)(6)(B)). 

7 ‘‘(b) REPORT.— 

8 ‘‘(1) REPORT REQUIRED.—The manufacturer of 

9 a qualifying drug shall submit a report to the Sec10 retary for each price increase of a qualifying drug 

11 that will result in an increase in the wholesale acqui12 sition cost of that drug that is equal to— 

13 ‘‘(A) 10 percent or more over a 12-month 

14 period; or 

15 ‘‘(B) 25 percent or more over a 36-month 

16 period. 

17 ‘‘(2) REPORT DEADLINE.—Each report de18 scribed in paragraph (1) shall be submitted to the 

19 Secretary not later than 30 days prior to the 

20 planned effective date of such price increase. 

21 ‘‘(c) CONTENTS.—A report under subsection (b) 

22 shall, at a minimum, include— 

23 ‘‘(1) with respect to the qualifying drug— 

24 ‘‘(A) the percentage by which the manufac25 turer will raise the wholesale acquisition cost of 


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1 the drug on the planned effective date of such 

2 price increase; 

3 ‘‘(B) a justification for, and description of, 

4 each manufacturer’s price increase that will 

5 occur during the 12-month period described in 

6 subsection (b)(1)(A) or the 36-month period de7 scribed in subsection (b)(1)(B), as applicable; 

8 ‘‘(C) the identity of the initial developer of 

9 the drug; 

10 ‘‘(D) a description of the history of the 

11 manufacturer’s price increases for the drug 

12 since the approval of the application for the 

13 drug under section 505 of the Federal Food, 

14 Drug, and Cosmetic Act or the issuance of the 

15 license for the drug under section 351, or since 

16 the manufacturer acquired such approved appli17 cation or license; 

18 ‘‘(E) the current list price of the drug; 

19 ‘‘(F) the total expenditures of the manu20 facturer on— 

21 ‘‘(i) materials and manufacturing for 

22 such drug; and 

23 ‘‘(ii) acquiring patents and licensing 

24 for such drug; 


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1 ‘‘(G) the percentage of total expenditures 

2 of the manufacturer on research and develop3 ment for such drug that was derived from Fed4 eral funds; 

5 ‘‘(H) the total expenditures of the manu6 facturer on research and development for such 

7 drug that is used for— 

8 ‘‘(i) basic and preclinical research; 

9 ‘‘(ii) clinical research; 

10 ‘‘(iii) new drug development; 

11 ‘‘(iv) pursuing new or expanded indi12 cations for such drug through supple13 mental applications under section 505 of 

14 the Federal Food, Drug, and Cosmetic Act 

15 or section 351 of the Public Health Service 

16 Act; and 

17 ‘‘(v) carrying out postmarket require18 ments related to such drug, including those 

19 under section 505(o)(3) of the Federal 

20 Food, Drug, and Cosmetic Act; 

21 ‘‘(I) the total revenue and the net 

22 profit generated from the qualifying 

23 drug for each calendar year since the 

24 approval of the application for the 

25 drug under section 505 of the Federal 


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1 Food, Drug, and Cosmetic Act or the 

2 issuance of the license for the drug 

3 under section 351, or since the manu4 facturer acquired such approved appli5 cation or license; and 

6 ‘‘(J) the total costs associated with mar7 keting and advertising for the qualifying drug; 

8 ‘‘(2) with respect to the manufacturer— 

9 ‘‘(A) the total revenue and the net profit 

10 of the manufacturer for each of the 12- and 36- 

11 month periods preceding the submission of the 

12 report; 

13 ‘‘(B) all stock-based performance metrics 

14 used by the manufacturer to determine execu15 tive compensation for each of the 12- and 36- 

16 month periods preceding the submission of the 

17 report; and 

18 ‘‘(C) any additional information the manu19 facturer chooses to provide related to drug pric20 ing decisions, such as total expenditures on— 

21 ‘‘(i) drug research and development; 

22 or 

23 ‘‘(ii) clinical trials on drugs that failed 

24 to receive approval by the Food and Drug 

25 Administration; and 


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1 ‘‘(3) such other related information as the Sec2 retary considers appropriate. 

3 ‘‘(d) CIVIL PENALTY.—Any manufacturer of a quali4 fying drug that fails to submit a report for the drug as 

5 required by this section shall be subject to a civil penalty 

6 of $100,000 for each day on which the violation continues. 

7 ‘‘(e) PUBLIC POSTING.— 

8 ‘‘(1) IN GENERAL.—Subject to paragraph (3), 

9 not later than 30 days after the submission of a re10 port under subsection (b), the Secretary shall post 

11 the report on the public website of the Department 

12 of Health and Human Services. 

13 ‘‘(2) FORMAT.—In developing the format of 

14 such report for public posting, the Secretary shall 

15 consult stakeholders, including beneficiary groups, 

16 and shall seek feedback on the content and format 

17 from consumer advocates and readability experts to 

18 ensure such public reports are user-friendly to the 

19 public and are written in plain language that con20 sumers can readily understand. 

21 ‘‘(3) TRADE SECRETS AND CONFIDENTIAL IN22 FORMATION.—In carrying out this section, the Sec23 retary shall enforce applicable law concerning the 

24 protection of confidential commercial information 

25 and trade secrets. 


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1 ‘‘SEC. 399OO–1. USE OF CIVIL PENALTY AMOUNTS. 

2 ‘‘The Secretary shall, without further appropriation, 

3 collect civil penalties under section 399OO and use the 

4 funds derived from such civil penalties, in addition to any 

5 other amounts available to the Secretary, to carry out ac6 tivities described in this part and to improve consumer and 

7 provider information about drug value and drug price 

8 transparency. 

9 ‘‘SEC. 399OO–2. ANNUAL REPORT TO CONGRESS. 

10 ‘‘(a) IN GENERAL.—Subject to subsection (b), the 

11 Secretary shall submit to Congress, and post on the public 

12 website of the Department of Health and Human Services 

13 in a way that is easy to use and understand, an annual 

14 report— 

15 ‘‘(1) summarizing the information reported pur16 suant to section 399OO; and 

17 ‘‘(2) including copies of the reports and sup18 porting detailed economic analyses submitted pursu19 ant to such section. 

20 ‘‘(b) TRADE SECRETS AND CONFIDENTIAL INFORMA21 TION.—In carrying out this section, the Secretary shall 

22 enforce applicable law concerning the protection of con23 fidential commercial information and trade secrets.’’. 


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1 TITLE IV—OUTCOMES AND 

2 REPORTING 

3 SEC. 401. SENSE OF CONGRESS. 

4 It is the sense of Congress that Medicare for America 

5 will have a significant impact on the health and well-being 

6 of the United States population and the social deter7 minants of the health of beneficiaries of Medicare for 

8 America. 

9 SEC. 402. EVALUATION OF BILL’S OUTCOME. 

10 (a) IN GENERAL.—To assess the impact of this Act 

11 on the health of the population, not later than 2 years 

12 after the date of the enactment of this Act, the Secretary 

13 of Health and Human Services shall allow for analysis of 

14 administrative records that have removed all personally 

15 identifiable information from the Center for Health Care 

16 to existing population surveys conducted by the Federal 

17 Government and federally supported surveys. 

18 (b) CDC AND NIH.—The Directors of the Centers 

19 for Disease Control and Prevention and the National In20 stitutes of Health shall solicit a comprehensive, longitu21 dinal study to evaluate any differential individual impact 

22 on coverage expansion based on— 

23 (1) race and ethnicity; 

24 (2) socioeconomic status; or 

25 (3) health status. 


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1 (c) REPORT.—Ten years after the date of the enact2 ment of this Act and every ten years thereafter, the Sec3 retary shall submit a report to the House Committee on 

4 Energy and Commerce and the Senate Committee on 

5 Health, Education, Labor, and Pensions regarding the im6 pact of this Act on the health of the United States popu7 lation based on the results of subsection (b) contributions 

8 from all other relevant agencies. 

Æ 


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