I 

115TH CONGRESS 

2D SESSION H. R. 7339 

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, 2018 

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, Education and the 

Workforce, Natural Resources, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of 

such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To 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 2018’’. 

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

7 this Act is as follows: 

Sec. 1. Short title; table of contents. 


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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. Employer health plan options. 

Sec. 125. Prohibition on step therapy and prior authorization under group 

health plans. 

Sec. 126. Medicare outpatient observation services. 

Sec. 127. Abortion coverage. 

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 health savings accounts. 

Sec. 207. Termination of flexible spending arrangements. 

Sec. 208. Increase in excise tax on small cigars and cigarettes and other tobacco products. 

Sec. 209. Excise tax on alcohol. 

Sec. 210. Tax on sugared drinks. 

TITLE III—DRUG-RELATED PROVISIONS 

Sec. 301. Establishment of the prescription drug and medical device review 

board. 

Sec. 302. Membership; staff. 

Sec. 303. Reporting requirements. 

Sec. 304. Prohibition against excessive price. 

Sec. 305. Enforcement provisions. 

Sec. 306. Authority. 

Sec. 307. Regulations. 

Sec. 308. Report to Federal agencies. 

Sec. 309. Definitions. 


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Sec. 310. Moratorium on direct-to-consumer drug advertising. 

Sec. 311. Reporting on justification for drug price increases. 

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 2020 and 2021 in 

13 accordance with this subtitle. 

14 SEC. 102. ELIGIBILITY. 

15 (a) IN GENERAL.—Subject to subsection (b), an indi16 vidual is eligible to enroll in such public health plan option 

17 if the individual is otherwise eligible to purchase individual 

18 health insurance coverage through an Exchange and the 

19 individual resides in a rating area in which the Secretary 

20 makes the public health plan option available. 

21 (b) PRIORITY.—In determining in which rating areas 

22 the Secretary initially will make the public health plan op23 tion available, the Secretary shall give priority to rating 

24 areas in which— 


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1 (1) not more than 1 health insurance issuer of2 fers plans on the applicable State or Federal Amer3 ican Health Benefit Exchange; or 

4 (2) there is a shortage of health providers or 

5 lack of competition that results in a high cost of 

6 health care services, including health professional 

7 shortage areas and rural areas. 

8 SEC. 103. BENEFITS. 

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

10 shall be a qualified health plan within the meaning of sec11 tion 1301(a) of the Patient Protection and Affordable 

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

13 (1) meets all requirements applicable to quali14 fied health plans under subtitle D of title I of the 

15 Patient Protection and Affordable Care Act (other 

16 than the requirement under section 

17 1301(a)(1)(C)(ii) of such Act (42 U.S.C. 

18 18021(a)(1)(C)(ii))) and title XXVII of the Public 

19 Health Service Act; 

20 (2) provides coverage of the essential health 

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

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

23 18022(b)); 

24 (3) provides silver and gold-level coverage de25 scribed in section 1302(d)(1)(C) of the Patient ProVerDate Sep 11 2014 21:24 Jan 03, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H7339.IH H7339

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1 tection and Affordable Care Act (42 U.S.C. 

2 18022(d)(1)(C)); and 

3 (4) provides coverage of abortions and all other 

4 reproductive health services. 

5 (b) PREEMPTION.—Notwithstanding section 

6 1303(a)(1) of the Patient Protection and Affordable Care 

7 Act (42 U.S.C. 18023(a)(1))— 

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

9 plan option from offering the coverage described in 

10 subsection (a)(4); and 

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

12 plan from offering such coverage shall apply to such 

13 plan. 

14 SEC. 104. PREMIUMS. 

15 The Secretary shall establish premium rates for the 

16 public health plan option that— 

17 (1) are adjusted based on the applicable rating 

18 area; 

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

20 (A) the costs of health benefits provided by 

21 such plans; and 

22 (B) administrative costs related to oper23 ating the plans; and 


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1 (3) comply with the requirements under section 

2 2701 of the Public Health Service Act (42 U.S.C. 

3 300gg). 

4 SEC. 105. PROVIDERS AND REIMBURSEMENT RATES. 

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

6 rate schedule for reimbursing types of health care pro7 viders furnishing items and services under the public 

8 health insurance plan option at rates based on rates ap9 plied for such items and services under title XVIII of the 

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

11 this Act, that are necessary to maintain network ade12 quacy. The Secretary shall establish a rate schedule for 

13 items and services not currently covered under title XVIII 

14 of the Social Security Act at a level to ensure adequate 

15 access to providers. 

16 (b) PARTICIPATING PROVIDERS.— 

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

18 is a participating provider of services or supplier 

19 under the Medicare program under title XVIII of 

20 the Social Security Act or under the Medicaid pro21 gram under title XIX of such Act on the date of en22 actment of this title shall be a participating provider 

23 for public health insurance plan option. 

24 (2) ADDITIONAL PROVIDERS.—The Secretary 

25 shall establish a process to allow health care proVerDate Sep 11 2014 21:24 Jan 03, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H7339.IH H7339

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1 viders not described in paragraph (1) to become par2 ticipating providers for the public health insurance 

3 plan option. 

4 (c) PRESCRIPTION DRUGS.—The Secretary shall 

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

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

7 drugs under the public health plan option in the same 

8 manner as such provisions apply with respect to applicable 

9 covered part D drugs under such section. 

10 SEC. 106. ACCOUNT; FUNDING. 

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

12 Treasury of the United States an account for the receipts 

13 and disbursements attributable to the operation of the 

14 public health plan option. 

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

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

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

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

19 carrying out this part. 

20 (c) PROHIBITION OF STATE IMPOSITION OF

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

22 U.S.C. 1395w–24(g)) shall apply to receipts and disburse23 ments described in subsection (a) in the same manner as 

24 such section applies to payments or premiums described 

25 in such section. 


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

2 the use of Federal funds with respect to any reproductive 

3 health service shall not apply to funds appropriated under 

4 subsection (b) or with respect to the account under sub5 section (a). 

6 Subtitle B—Medicare for America 

7 SEC. 111. ESTABLISHMENT AND ADMINISTRATION OF MEDI8 CARE FOR AMERICA. 

9 The Social Security Act is amended by adding at the 

10 end the following new title: 

11 ‘‘TITLE XXII—MEDICARE FOR 

12 AMERICA 

13 ‘‘PART A—COMPREHENSIVE HEALTH COVERAGE 

14 ‘‘SEC. 2201. ESTABLISHMENT. 

15 ‘‘The Secretary shall establish a public health insur16 ance program, to be known as ‘Medicare for America’, 

17 which shall for calendar year 2022 and each subsequent 

18 calendar year provide comprehensive health benefits in ac19 cordance with this part to individuals enrolled for coverage 

20 under this title. 

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

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

23 title, every individual who is a resident of the United 

24 States is entitled to benefits for health care services under 

25 this title. The Secretary shall promulgate a rule that proVerDate Sep 11 2014 21:24 Jan 03, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H7339.IH H7339

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1 vides criteria for determining residency for eligibility pur2 poses under this title. 

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

4 ‘‘(1) IN GENERAL.—Beginning in 2022, the 

5 Secretary shall provide a mechanism for the enroll6 ment of individuals entitled to benefits under this 

7 title and, in conjunction with such enrollment, the 

8 issuance of a Medicare card which may be used for 

9 purposes of identification and processing of claims 

10 for benefits under this title. As a condition of par11 ticipation in the program, participating providers 

12 shall facilitate enrollment as specified by the Sec13 retary. 

14 ‘‘(2) AUTOMATIC ENROLLMENTS.—The mecha15 nism provided under paragraph (1) shall, subject to 

16 paragraph (4), provide, for plan years beginning 

17 with plan year 2022, for the following automatic en18 rollments under Medicare for America: 

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

20 years (beginning with plan year 2022), a proc21 ess, established by the Secretary in consultation 

22 with the Commissioner of Social Security, for 

23 the automatic enrollment of eligible individuals 

24 born during such plan year. 


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1 ‘‘(B) CURRENT MEDICARE BENE2 FICIARIES.— 

3 ‘‘(i) CURRENT MEDICARE BENE4 FICIARIES.—For plan years (beginning 

5 with plan year 2022), a process established 

6 by the Secretary for the automatic enroll7 ment of all individuals who are enrolled for 

8 benefits under part A or B of title XVIII 

9 (other than individuals who are enrolled 

10 for such benefits and receiving benefits 

11 under title XIX). 

12 ‘‘(ii) CONTINUING POPULATION.—For 

13 plan years (beginning with plan year 

14 2022), a process established by the Sec15 retary for the automatic enrollment of eli16 gible individuals who attain the age of 65 

17 during such plan year. 

18 ‘‘(iii) DUALS.—For plan years (begin19 ning with plan year 2024), a process estab20 lished by the Secretary for the automatic 

21 enrollment of eligible individuals who are 

22 enrolled for benefits under part A or B of 

23 title XVIII and receiving benefits under 

24 title XIX. 


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1 ‘‘(C) OTHER INDIVIDUALS WITHOUT

2 QUALIFIED HEALTH COVERAGE.—For plan 

3 years (beginning with plan year 2022), a proc4 ess established by the Secretary for the auto5 matic enrollment of eligible individuals who are 

6 not enrolled in other qualified health coverage 

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

8 year. 

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

10 provided under paragraph (1) shall provide for the 

11 following: 

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

13 and processes for each plan year (beginning 

14 with plan year 2022) for enrollment under 

15 Medicare for America of any eligible individual 

16 not otherwise described in paragraph (2). 

17 ‘‘(B) SMALL EMPLOYERS.—For plan years 

18 (beginning with plan year 2022), a process and 

19 methodology under which a small employer, as 

20 defined in section 124(d)(3) of the Medicare for 

21 America Act, may provide for the enrollment of 

22 the employees of such employer under Medicare 

23 for America. For purposes of the previous sen24 tence, the term ‘small employer’ means any em25 ployer for any calendar year if the annual payVerDate Sep 11 2014 21:24 Jan 03, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H7339.IH H7339

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1 roll of such employer for the preceding calendar 

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

3 than 100 employees. 

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

5 (beginning with plan year 2026), the Secretary 

6 shall provide for a process and methodology 

7 under which a large employer may provide for 

8 the enrollment of the employees of such em9 ployer under Medicare for America. For pur10 poses of the preceding sentence, the term ‘large 

11 employer’ means an employer with at least 100 

12 employees. 

13 ‘‘(4) OPT OUT FOR INDIVIDUALS ENROLLED

14 UNDER QUALIFIED HEALTH COVERAGE.— 

15 ‘‘(A) IN GENERAL.—The mechanism pro16 vided under paragraph (1) shall provide, with 

17 respect to a plan year, for a process that en18 ables individuals who are enrolled in qualified 

19 health coverage for such plan year to opt out of 

20 coverage under Medicare for America for such 

21 year. 

22 ‘‘(B) QUALIFIED HEALTH COVERAGE DE23 FINED.—For purposes of this section, the term 

24 ‘qualified health coverage’ means coverage 

25 under any of the following: 


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1 ‘‘(i) For plan years 2022 and 2023: 

2 ‘‘(I) Qualified employer coverage, 

3 as defined in section 124 of the Medi4 care for America Act. 

5 ‘‘(II) Medical coverage under 

6 chapter 55 of title 10, United States 

7 Code, including coverage under the 

8 TRICARE program. 

9 ‘‘(III) A health care program 

10 under chapter 17 or 18 of title 38, 

11 United States Code, as determined by 

12 the Secretary of Veterans Affairs, in 

13 coordination with the Secretary of 

14 Health and Human Services and the 

15 Secretary. 

16 ‘‘(IV) The health benefit program 

17 under chapter 89 of title 5, United 

18 States Code. 

19 ‘‘(V) Medical benefits and serv20 ices provided by or through the Indian 

21 Health Service. 

22 ‘‘(VI) The Medicaid program 

23 under title XIX of the Social Security 

24 Act. 


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1 ‘‘(VII) The CHIP program under 

2 title XXI of the Social Security Act. 

3 ‘‘(ii) For plan years 2024 and 2025: 

4 ‘‘(I) Coverage described in sub5 clause (I), (II), (III), (IV), or (V) of 

6 clause (i). 

7 ‘‘(II) Coverage described in sub8 clause (VI) of clause (i), but only with 

9 respect to coverage that is not for in10 dividuals described in subclause (VIII) 

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

12 are also enrolled for benefits under 

13 title XVIII. 

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

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

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

17 ‘‘(c) WAIVER.—The Secretary shall establish a proc18 ess under which the Secretary may grant waivers to States 

19 for additional time before populations described in a pre20 vious subsection of this section of such State are automati21 cally enrolled under Medicare for America. 

22 ‘‘SEC. 2203. BENEFITS. 

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

24 accordance with this section, provide coverage for all the 

25 benefits, as determined to be medically necessary and reaVerDate Sep 11 2014 21:24 Jan 03, 2019 Jkt 089200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\H7339.IH H7339

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1 sonable, as covered and defined under parts A and B of 

2 title XVIII and title XIX as of the date of the enactment 

3 of this title, including the following: 

4 ‘‘(1) Ambulatory patient services. 

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

6 ‘‘(3) Hospitalization. 

7 ‘‘(4) Maternity and newborn care. 

8 ‘‘(5) Behavioral health, mental health and sub9 stance use disorder services, including the following: 

10 ‘‘(A) Home-based services. 

11 ‘‘(B) Acute services for mental health cri12 ses, including crisis stabilization services such 

13 as mobile crisis services, including emergency 

14 mobile psychiatric services. 

15 ‘‘(C) 23-hour observation. 

16 ‘‘(D) Outpatient services provided by hos17 pitals, freestanding clinics, and behavioral 

18 health providers in independent practice. 

19 ‘‘(E) Smoking and tobacco cessation. 

20 ‘‘(F) Case management. 

21 ‘‘(G) Peer support services. 

22 ‘‘(H) Counseling. 

23 ‘‘(I) Other intensive outpatient community24 based services, such as Assertive Community 


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1 Treatment and supported employment, provided 

2 through the LTSS benefit. 

3 ‘‘(J) Other intensive community-based 

4 services provided through the Early and Peri5 odic Screening, Diagnostic, and Treatment 

6 (EPSDT) benefit (as defined in subpart B of 

7 part 441 of title 42 of the Code of Federal Reg8 ulations). 

9 ‘‘(K) Medication assisted treatment and 

10 maintenance services. 

11 ‘‘(L) Inpatient detoxification. 

12 ‘‘(M) Ambulatory detoxification. 

13 ‘‘(N) Psychological testing. 

14 ‘‘(O) Home health agency services. 

15 ‘‘(6) Prescription drugs. 

16 ‘‘(7) Rehabilitative and habilitative services and 

17 devices, including the following: 

18 ‘‘(A) Physical therapy. 

19 ‘‘(B) Speech therapy. 

20 ‘‘(C) Occupational therapy. 

21 ‘‘(8) Laboratory services. 

22 ‘‘(9) Preventive and wellness services and 

23 chronic disease management. 

24 ‘‘(10) Pediatric services, including oral and vi25 sion care and all services that would otherwise be 


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1 covered under Early and Periodic Screening, Diag2 nostic, and Treatment under the Medicaid program 

3 under title XIX. 

4 ‘‘(11) Dental. 

5 ‘‘(12) Hearing health services including aids 

6 and exams. 

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

8 supports and services. 

9 ‘‘(14) Chiropractic services. 

10 ‘‘(15) Durable medical equipment, including the 

11 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. 

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

6 ‘‘(16) Family planning, including the following: 

7 ‘‘(A) Reproductive health exams. 

8 ‘‘(B) Patient counseling and education re9 lated to family planning. 

10 ‘‘(C) Abortion. 

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

12 pre- and post-test counseling for sexually trans13 mitted diseases and HIV. 

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

15 medication, condom, implant, or other devices 

16 used to prevent pregnancy. 

17 ‘‘(F) Sterilization for beneficiaries over the 

18 age of 21. 

19 ‘‘(G) Infertility treatment. 

20 ‘‘(17) Gender-confirming medical procedures 

21 and treatment. 

22 ‘‘(18) Dietary and nutrition counseling. 

23 ‘‘(19) Medically necessary food and vitamins for 

24 digestive and inherited metabolic disorders. 

25 ‘‘(20) Nursing facilities. 


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1 ‘‘(21) Orthotic and prosthetics devices. 

2 ‘‘(22) Oxygen. 

3 ‘‘(23) Acupuncture. 

4 ‘‘(24) Telehealth. 

5 ‘‘(25) Services otherwise included under the 

6 maternal, infant, and early childhood home visiting 

7 program under section 511 of the Social Security 

8 Act, as of the date of the enactment of this title. 

9 ‘‘(26) Any additional benefit or service not in10 cluded in this section that is covered by any State 

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

12 on the date of the enactment of this title. 

13 ‘‘(b) UPDATES.—Benefits covered under Medicare for 

14 America shall be updated in accordance with the National 

15 Coverage Determination process that had, as of the date 

16 before the date of the enactment of this title, applied with 

17 respect to benefits covered under title XVIII. 

18 ‘‘(c) PROHIBITION AGAINST DUPLICATING COV19 ERAGE.— 

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

21 health insurer (other than an insurer with respect to 

22 a Medicare Advantage for America plan under part 

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

24 to sell health insurance coverage that duplicates the 


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1 benefits provided under Medicare for America under 

2 this part. 

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

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

5 health insurance coverage for any additional benefits 

6 not covered by this part, insofar as the coverage sat7 isfies the conditions of paragraph (3). 

8 ‘‘(3) APPLICATION OF PROTECTIONS.—For pur9 poses of paragraph (2), health insurance coverage 

10 for any additional benefits must satisfy the following 

11 conditions: 

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

13 Public Health Service Act, relating to a medical 

14 loss ratio. 

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

16 Public Health Service Act, relating to guaran17 teed issue. 

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

19 Public Health Service Act, relating to commu20 nity rating. 

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

22 Public Health Service Act, relating to the ban 

23 on pre-existing conditions exclusions. 

24 ‘‘(d) 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 ‘‘(e) 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.—(1) Subject to paragraph (2), 

11 each individual enrolled for benefits under this title for 

12 a year shall pay monthly community-rated premiums for 

13 such year in an amount determined by the Secretary in 

14 accordance with subsection (b). 

15 ‘‘(2) GRANDFATHERED MEDICARE BENE16 FICIARIES.—In the case of an individual enrolled under 

17 part B of title XVIII as of the date of the enactment of 

18 this part, the premium applied under this section for such 

19 individual for benefits under this title shall be the lesser 

20 of— 

21 ‘‘(A) the premium otherwise applicable to such 

22 individual under such title XVIII if this title had not 

23 been enacted; or 


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

2 such individual under this title without the applica3 tion 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 2022), 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, with the premiums ranging between the 


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1 amount determined for individuals described in 

2 clause (i) and for individuals described in clause 

3 (iii); and 

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

5 more than 9.69 percent of monthly income to6 ward such monthly premium. 

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

8 making a firm-wide contribution under this title in 

9 lieu of offering employer sponsored insurance (as 

10 specified in section 124(b)(1)(B) of the Medicare for 

11 America Act), such individual shall pay a premium 

12 in accordance with this subsection. 

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

14 their employer sponsored insurance in order to enroll 

15 in Medicare for America as specified in section 

16 124(c) of such Act, the individual shall pay the pre17 mium described in this subsection. 

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

19 coverage under this title shall be deposited in the Treasury 

20 to the credit of the Trust Fund established under section 

21 2206. 

22 ‘‘(d) APPEALS FOR CERTAIN MEDICARE GRAND23 FATHERED POPULATION.—In calculating premiums for 

24 purposes of subsection (a)(2): 


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

2 enrollment penalty under part B of title XVIII shall 

3 have the right to appeal the assessment of the pen4 alty for good faith enrollment mistakes. 

5 ‘‘(2) In any case in which the Secretary finds 

6 that an individual’s enrollment or nonenrollment in 

7 the insurance program established by this part or 

8 part A of title XVIII pursuant to section 1818 is un9 intentional, inadvertent, or erroneous, whether the 

10 result of the error, misrepresentation, or inaction of 

11 an officer, employee, or agent of the Federal Govern12 ment or its instrumentalities, an employer, a rep13 resentative of a group health plan, a State, or for 

14 any other good faith reason on the part of such indi15 vidual, the Secretary shall take such action (includ16 ing the designation for such individual of a special 

17 initial or subsequent enrollment period, including 

18 retroactive enrollment, with a coverage period deter19 mined on the basis thereof and with appropriate ad20 justments of premiums) as may be necessary to cor21 rect or eliminate the effects of such error, misrepre22 sentation, or inaction. The failure of an individual to 

23 enroll in the insurance program established by this 

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1 ant to title XXII of the Public Health Service Act, 

2 section 4980B of the Internal Revenue Code of 

3 1986, title VI of the Employee Retirement Income 

4 Security Act of 1974, or title XIX; or enrollment 

5 under a qualified health plan offered through an Ex6 change established under title I of the Patient Pro7 tection and Affordable Care Act shall under this 

8 subsection absent exceptional circumstances, as de9 termined by the Secretary. 

10 ‘‘(3) 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 ‘‘(4) 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 ‘‘(5) 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 submitted pursuant to para7 graph (2) relating to enrollment under part A or 

8 part B. 

9 ‘‘(6) An individual who receives an adverse de10 termination under paragraph (3) with respect to an 

11 application submitted pursuant to paragraph (2) 

12 may appeal to an independent review organization 

13 designated by the Commission. Any such appeal 

14 must be sent to the independent review organization 

15 within 90 days of the date the individual received 

16 the determination to be eligible for review. The inde17 pendent review organization shall review and reach 

18 a determination of the review in writing within 45 

19 days of the receipt of any such appeal. 

20 ‘‘(7) The Secretary of the Treasury may not 

21 enter into a contract under paragraph (5) with an 

22 independent review organization— 

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

24 has the appropriate knowledge of, and experi25 ence with, the eligibility and coordination of 


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1 benefits rules and regulations under this title; 

2 and 

3 ‘‘(B) to the extent the organization is a fis4 cal intermediary under section 1816, a carrier 

5 under section 1842, or a Medicare administra6 tive contractor under section 1874A. 

7 ‘‘(8) The Secretary of Health and Human Serv8 ices shall provide for access by independent review 

9 organizations conducting appeal determinations 

10 under this subsection, to the database of the Coordi11 nation of Benefits Contractor of the Centers for 

12 Medicare & Medicaid Services as necessary in order 

13 to conduct the duties of such organizations to deter14 mine appeals pursuant to this subsection. 

15 ‘‘SEC. 2205. PAYMENT OF BENEFITS; COST-SHARING; OUT16 OF-POCKET LIMITS. 

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

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

19 is enrolled under Medicare for America and incurs ex20 penses for items and services with respect to which bene21 fits are payable under this part, after application of sub22 section (b) and subject to subsection (c), 80 percent of 

23 the reimbursement rates established pursuant to section 

24 2206 for such items and services, except that with respect 

25 to USPTF recommended preventive and chronic disease 


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1 services, and generic drugs, the amounts paid under this 

2 section shall be equal to 100 percent of the reimbursement 

3 rates established pursuant to section 2206 for such items 

4 and services. 

5 ‘‘(b) DEDUCTIBLE.— 

6 ‘‘(1) IN GENERAL.—There shall be a deductible 

7 applied under this part for each plan year that shall 

8 be determined on a linear sliding scale for household 

9 income that is at least 200 percent of the poverty 

10 line, but not more than 600 percent of the poverty 

11 line, and shall not exceed, subject to paragraphs (2) 

12 and (3)— 

13 ‘‘(A) $350 for an individual; or 

14 ‘‘(B) $500 total for all members of a 

15 household. 

16 ‘‘(2) INDEXING.—In the case of plan years be17 ginning after 2021, the dollar amounts described in 

18 paragraph (1) shall be increased by the percentage 

19 increase over the previous year in the medical care 

20 expenditure category of the Consumer Price Index 

21 for All Urban Consumers (United States city aver22 age), published by the Bureau of Labor Statistics. 

23 ‘‘(3) EXCEPTION.—There shall be no deductible 

24 applied under this part for months in a plan year for 


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1 individuals and households with annual income below 

2 200 percent of the federal poverty line. 

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

4 ‘‘(1) IN GENERAL.—The coverage under Medi5 care shall provide benefits, after the eligible indi6 vidual has incurred out-of-pocket expenses for items 

7 and services with respect to which benefits are pay8 able under this part in a year equal to the annual 

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

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

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

12 ‘‘(A) IN GENERAL.—For purposes of para13 graph (1), subject to subparagraphs (B) and 

14 (C), the annual out-of-pocket threshold speci15 fied in this paragraph is a threshold that shall 

16 be determined on a linear sliding scale for 

17 household income that is at least 200 percent of 

18 the poverty line, but not more than 600 percent 

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

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

21 $3,500; or 

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

23 $5,000. 

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

25 beginning after 2021, the threshold described in 


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

2 plan year after application of this subpara3 graph) shall be increased by the percentage in4 crease over the previous year in the medical 

5 care expenditure category of the Consumer 

6 Price Index for All Urban Consumers (United 

7 States city average), published by the Bureau 

8 of Labor Statistics. 

9 ‘‘(C) EXCEPTION.—For purposes of para10 graph (1), the annual out-of-pocket threshold 

11 for individuals and households with annual in12 come below 200 percent of the federal poverty 

13 line is $0. 

14 ‘‘(d) NO BALANCE BILLING.—No provider may im15 pose a charge to an enrolled individual for covered services 

16 for which benefits are provided under this part in an 

17 amount higher than the reimbursement rate for such serv18 ices under section 2206 and may not impose a charge to 

19 such individual for such service other than with respect 

20 to the deductible or other cost-sharing described in this 

21 section. 

22 ‘‘SEC. 2206. PROVIDERS NETWORK AND REIMBURSEMENT 

23 RATES. 

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

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1 viders furnishing items and services under Medicare for 

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

3 and are necessary to maintain network adequacy. 

4 ‘‘(b) RATES.— 

5 ‘‘(1) IN GENERAL.—Except as provided in para6 graphs (2) and (3), the Secretary shall provide for 

7 rates to be provided to health care providers and 

8 suppliers furnishing items and services under Medi9 care for America based on rates that would be ap10 plied (including as computed, updated, and adjusted) 

11 under title XVIII for such type of health care pro12 viders and suppliers and item and service if such 

13 title remained in effect and, in the case of a type of 

14 provider and supplier or item or service covered 

15 under Medicare for America but not otherwise cov16 ered under title XVIII, shall provide for rates that 

17 ensure adequate access to care. 

18 ‘‘(2) EXCEPTIONS.—For purposes of this sec19 tion, in applying paragraph (1) the Secretary shall 

20 ensure that rates to hospitals for inpatient services 

21 or outpatient services furnished under Medicare for 

22 America are at least 110 percent of such rates on 

23 average or in the aggregate for furnishing such inpa24 tient or outpatient services otherwise applied under 

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1 served areas as specified by the Secretary, such 

2 rates are increased as necessary to ensure adequate 

3 access to care. 

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

5 title XVIII for purposes of this part, the following 

6 shall apply: 

7 ‘‘(A) The Secretary shall provide for site8 neutral payments for items and services fur9 nished in an outpatient hospital and physician 

10 office, the rate of payment for such service shall 

11 be the same. 

12 ‘‘(B) The Secretary shall increase the aver13 age relative value of primary care and other 

14 mental and behavioral health and cognitive 

15 services by not less than 20 percent in order to 

16 ensure adequate access to inpatient and out17 patient care. 

18 ‘‘(C) As a condition of participation in the 

19 program, participating providers shall accept 

20 Medicare for America rates paid by employer21 sponsored insurance plans and Medicare Advan22 tage plans. 

23 ‘‘(c) PARTICIPATING PROVIDERS.— 

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

25 is a participating provider of services or supplier 


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1 under the Medicare program under title XVIII on 

2 the date of enactment of this title shall remain a 

3 participating provider for Medicare for America. 

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

5 shall establish a process to allow health care pro6 viders not described in paragraph (1) to become par7 ticipating providers for Medicare for America. 

8 ‘‘(d) PRESCRIPTION DRUGS.— 

9 ‘‘(1) IN GENERAL.—Any payment rate under 

10 this part for a prescription drug shall be at a rate 

11 negotiated by the Secretary based on value assess12 ments by one or more independent nonprofit organi13 zations certified by the National Academy of Medi14 cine and MedPAC. If the Secretary is unable to 

15 reach a negotiated agreement on such a reimburse16 ment rate, the Secretary shall apply prices paid by 

17 the Department of Veterans Affairs for such drugs 

18 or the average price of such drugs in nations which 

19 are members of the Organization for Economic Co20 operation and Development, whichever is lower. 

21 ‘‘(2) FAILURE TO NEGOTIATE.—If a drug man22 ufacturer refuses to negotiate with the Secretary, 

23 then Medicare for America will not cover any of the 

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1 able for people with chronic conditions. Individuals 

2 shall continue to have access to drugs during the ap3 peals process. The Secretary shall modify such rates 

4 in order to accommodate payments for drugs that 

5 are not otherwise covered under the original Medi6 care fee-for-service program under title XVIII. 

7 ‘‘(3) VALUE OR COST-EFFECTIVENESS ASSESS8 MENTS.—The use of Quality-Adjusted Life Years, 

9 Disability-Adjusted Life Years, or other similar 

10 mechanisms is prohibited for use in value or cost-ef11 fectiveness assessments for purposes of this sub12 section. 

13 ‘‘SEC. 2207. TRUST FUND; FUNDING. 

14 ‘‘(a) TRUST FUND.—There shall be established a uni15 fied Medicare Trust Fund in which funds provided under 

16 this title are deposited and from which expenditures under 

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

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

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

20 as provided in this Act. 

21 ‘‘(b) FUNDING.— 

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

23 the Trust Fund for each fiscal year beginning with 

24 fiscal year 2022, out of any moneys in the Treasury 

25 not otherwise appropriated, amounts equivalent to 


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1 100 percent of the net increase in revenues to the 

2 Treasury which is attributable to the amendments 

3 made by title II of the Medicare for America Act 

4 and premiums collected under this title. The 

5 amounts appropriated by the preceding sentence 

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

7 frequently than monthly) from the general fund in 

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

9 determined on the basis of estimates by the Sec10 retary of the Treasury of the taxes paid to or depos11 ited into the Treasury; and proper adjustments shall 

12 be made in amounts subsequently transferred to the 

13 extent prior estimates were in excess of or were less 

14 than the amounts that should have been so trans15 ferred. 

16 ‘‘(2) CURRENT PROGRAM RECEIPTS.—Notwith17 standing any other provision of law, there are hereby 

18 appropriated to the Trust Fund for each fiscal year, 

19 beginning with fiscal year 2022, the amounts that 

20 would otherwise have been appropriated to carry out 

21 the following programs: 

22 ‘‘(A) The Medicare program under title 

23 XVIII. 

24 ‘‘(B) The Medicaid program under title 

25 XIX, beginning as of 2026. 


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1 ‘‘(3) ADDITIONAL APPROPRIATIONS.—Addi2 tional sums are authorized to be appropriated annu3 ally as needed to maintain maximum quality, effi4 ciency, and access under this part. 

5 ‘‘(4) MEDICAID MAINTENANCE OF EFFORT PAY6 MENTS.—There shall be transferred to the Trust 

7 Fund the maintenance of effort payments made 

8 under section 2209. 

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

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

11 title restricting the use of Federal funds for any reproduc12 tive health service, including abortion, shall not apply to 

13 monies in the Trust Fund. 

14 ‘‘(d) INCORPORATION OF PROVISIONS.—The provi15 sions of subsections (b) through (i) of section 1817 shall 

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

17 manner as such provisions applied to the Federal Hospital 

18 Insurance Trust Fund under such section 1817, except 

19 that, for purposes of applying such subsections to this sec20 tion, the ‘Board of Trustees of the Trust Fund’ shall mean 

21 the ‘Secretary’. 

22 ‘‘(e) TRANSFER OF FUNDS.—Any amounts remain23 ing in the Federal Hospital Insurance Trust Fund under 

24 section 1817 or the Federal Supplementary Medical Insur25 ance Trust Fund under section 1841 after the payment 


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1 of claims for items and services furnished under title 

2 XVIII have been completed, shall be transferred into the 

3 Trust Fund under this section. 

4 ‘‘SEC. 2208. ADMINISTRATIVE PROVISIONS. 

5 ‘‘(a) CENTER FOR MEDICARE.—Beginning 2022, the 

6 Centers for Medicare & Medicaid Services shall be re7 named the Center for Medicare and all references in law 

8 and regulation to such Centers shall be deemed a reference 

9 to such Center. All powers, duties, and responsibilities of 

10 the Centers for Medicare & Medicaid Services shall be 

11 transferred to the Center for Medicare. 

12 ‘‘(b) AUTHORITY.—The Secretary shall have the au13 thority to issue interim final rules with respect to any pro14 vision in this part. 

15 ‘‘(c) ADMINISTRATIVE LAW JUDGES.— 

16 ‘‘(1) IN GENERAL.—The Center for Medicare is 

17 not authorized to appoint administrative law judges, 

18 in accordance with pages 11420 through 499 of title 

19 70 of the Federal Register (March 8, 2005). 

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

21 law judges must issue a decision within 90 days of 

22 receipt of a hearing request, as specified in sub23 sections (a) and (c) of section 405.1016 of title 2, 

24 Code of Federal Regulations. 

25 ‘‘(d) COVERAGE DETERMINATIONS APPEALS.— 


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1 ‘‘(1) Individuals may appeal a coverage deter2 mination under this title before the individual ob3 tains the service or item that is the subject of the 

4 appeal. 

5 ‘‘(2) The Secretary shall eliminate the redeter6 mination by a Medicare administrative contractor 

7 from the appeals process under the Medicare pro8 gram for beneficiaries. 

9 ‘‘(e) PRIVATE RIGHT OF ACTION.— 

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

11 aggrieved by any law, regulation, policy or practice 

12 in violation of a provision of this title may bring a 

13 civil action seeking any remedy available in law or 

14 equity to remedy that violation. In addition to any 

15 cause of action that may be available in a State 

16 court, the district courts of the United States shall 

17 have concurrent jurisdiction in the matters under 

18 the provisions of this title. 

19 ‘‘(2) REASONABLE ATTORNEY FEES.—In any 

20 action or proceeding to enforce this title, the court 

21 may award reasonable attorneys’ fees and litigation 

22 costs (including expert fees) reasonably incurred 

23 against the defendant or defendants. 

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

25 this section shall be subject to appeal as provided in 


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1 sections 1291 and 1292 of title 28 of the United 

2 States Code. 

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

4 ‘‘(a) IN GENERAL.—A State is not eligible for pay5 ment under any program specified in subsection (d) for 

6 a calendar quarter in a plan year beginning after 2026 

7 unless the State makes to the Secretary for transfer to 

8 the unified Medicare Trust Fund under section 2207 the 

9 maintenance of effort payment applicable to such State 

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

11 extend such a waiver (including the availability of Federal 

12 financial participation under such waiver) for such period 

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

14 of the previous sentence. 

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

16 purposes of this section, a maintenance of effort payment 

17 with respect to a State and plan year is— 

18 ‘‘(1) for plan year 2027 and a State, a payment 

19 in an amount equal to the total amount of expendi20 tures of the State for medical assistance under title 

21 XIX and child health assistance under title XXI in22 cluding administrative costs for the plan year before 

23 the date of the enactment of this title; 

24 ‘‘(2) for plan year 2028 and each subsequent 

25 plan year before plan year 2032— 


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

2 PPACA expansion State, the payment amount 

3 applied under this subsection for the previous 

4 plan year, increased by growth in GDP per cap5 ita plus 0.4 percent; and 

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

7 PPACA expansion State, the payment amount 

8 applied under this subsection for the previous 

9 plan year, increased by growth in GDP per cap10 ita plus 0.7 percent; and 

11 ‘‘(3) beginning in 2032, for each subsequent 

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

13 amount applied under this subsection for the pre14 vious year, increased by growth in GDP per capita 

15 plus 0.7 percent. 

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

17 section, the programs specified in this subsection are each 

18 of the following: 

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

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

21 the Public Health Service Act. 

22 ‘‘(2) Block grants and programs for social serv23 ices and elder justice under title XX of the Social 

24 Security Act. 


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

2 grants under title V of the Social Security Act. 

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

4 of substance abuse under subpart II of part B of 

5 title XIX of the Public Health Service Act. 

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

7 Grant Community Services Block Grant. 

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

9 Health Service Act. 

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

11 under title XXVI of the Public Health Service Act. 

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

13 ‘‘Except as specified otherwise in this title, in imple14 menting Medicare for America, the Secretary shall to the 

15 greatest extent practicable apply the following provisions 

16 of title XVIII to the program under this title, benefits cov17 ered under this title, individuals entitled to benefits under 

18 this title, and providers of services and suppliers partici19 pating under the program under this title in a similar 

20 manner as such provisions applied to the program under 

21 title XVIII, benefits covered under such title, individuals 

22 entitled to benefits or enrolled under such title, and pro23 viders of services and suppliers participating under the 

24 program under such title: 

25 ‘‘(1) Section 1801. 


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1 ‘‘(2) Section 1805. 

2 ‘‘(3) Section 1806. 

3 ‘‘(4) Section 1807. 

4 ‘‘(5) Section 1809. 

5 ‘‘(6) Section 1812. 

6 ‘‘(7) Section 1814. 

7 ‘‘(8) Section 1815. 

8 ‘‘(9) Section 1816. 

9 ‘‘(10) Section 1818. 

10 ‘‘(11) Section 1818A. 

11 ‘‘(12) Section 1819. 

12 ‘‘(13) Section 1820. 

13 ‘‘(14) Section 1832. 

14 ‘‘(15) Section 1834. 

15 ‘‘(16) Section 1834A. 

16 ‘‘(17) Section 1835. 

17 ‘‘(18) Section 1843. 

18 ‘‘(19) Section 1846. 

19 ‘‘(20) Section 1847. 

20 ‘‘(21) Section 1851. 

21 ‘‘(22) Section 1852. 

22 ‘‘(23) Section 1855. 

23 ‘‘(24) Section 1856. 

24 ‘‘(25) Section 1857. 

25 ‘‘(26) Section 1858. 


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1 ‘‘(27) Section 1861. 

2 ‘‘(28) Section 1863. 

3 ‘‘(29) Section 1864. 

4 ‘‘(30) Section 1866B. 

5 ‘‘(31) Section 1866C. 

6 ‘‘(32) Section 1866E. 

7 ‘‘(33) Section 1867. 

8 ‘‘(34) Section 1868. 

9 ‘‘(35) Section 1869. 

10 ‘‘(36) Section 1871. 

11 ‘‘(37) Section 1874A. 

12 ‘‘(38) Section 1880. 

13 ‘‘(39) Section 1881. 

14 ‘‘(40) Section 1881A. 

15 ‘‘(41) Section 1891. 

16 ‘‘(42) Section 1894. 

17 ‘‘(43) Section 1895. 

18 ‘‘(44) Section 1896. 

19 ‘‘PART B—LONG-TERM SERVICES AND SUPPORTS 

20 ‘‘SEC. 2221. LONG-TERM SERVICES AND SUPPORTS BEN21 EFIT. 

22 ‘‘All individuals enrolled under Medicare for America 

23 under this title shall have coverage for long-term services 

24 and supports benefits. 


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1 ‘‘SEC. 2222. ELIGIBILITY. 

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

3 eligible for long-term care benefits under this part is an 

4 individual who satisfies each of the following: 

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

6 America. 

7 ‘‘(2) The individual is determined to have a 

8 condition, as certified by a licensed health care prac9 titioner, that results in substantially reduced func10 tional capacity in one or more of the following areas: 

11 ‘‘(A) Communication. 

12 ‘‘(B) Social interaction. 

13 ‘‘(C) Learning. 

14 ‘‘(D) Mobility. 

15 ‘‘(E) Self-care. 

16 ‘‘(F) Self-management. 

17 ‘‘(G) Impairments that affect the person’s 

18 capacity for social or economic participation. 

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

20 of an individual described in subsection (a) who, due to 

21 the nature of the condition of the individual, experience 

22 periods in which their functional capacity changes or im23 proves, such individual shall continue to have access to 

24 benefits under this part as needed. If such an individual’s 

25 functional capacity improves to a point in which the indi26 vidual no longer requires long term supports and services, 


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1 or requires fewer services, the individual shall be able to 

2 immediately and seamlessly resume receiving all needed 

3 services if and when their functional needs recur. Eligi4 bility for services shall be maintained if, without the serv5 ices, the individual would have reduced functional capac6 ity. The presence of supports and services or other miti7 gating measures shall not be taken into account when 

8 looking at functional impairment. 

9 ‘‘(c) BENEFITS.— 

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

11 the term ‘long-term services and supports benefit’ 

12 means the daily living supports needed by eligible in13 dividuals and includes all long-term services and 

14 supports covered, as of the date of the enactment of 

15 this title, under any State plan under title XIX, in16 cluding— 

17 ‘‘(A) home and community-based services; 

18 and 

19 ‘‘(B) any additional services and supports 

20 developed to help people with disabilities live, 

21 work, and participate in their communities, in22 cluding— 

23 ‘‘(i) home health aides and home24 makers; 


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1 ‘‘(ii) direct support professionals and 

2 personal attendant care services; 

3 ‘‘(iii) hospice; 

4 ‘‘(iv) nursing care; 

5 ‘‘(v) medical social services; 

6 ‘‘(vi) case management, fiscal inter7 mediary, and support brokerage services; 

8 ‘‘(vii) short-term inpatient care, in9 cluding respite care and care for pain con10 trol; 

11 ‘‘(viii) behavioral health long-term 

12 services and supports, including assertive 

13 community treatment, peer support serv14 ices, intensive case management, supported 

15 employment, and supported housing wrap16 around; and 

17 ‘‘(ix) all additional services coverable 

18 in Medicaid under state plan services, sec19 tions 1115, 1915(c), 1915(k), 1915(i), and 

20 1915(j), for people with disabilities. 

21 ‘‘(2) SELF-DIRECTED MODEL.—All eligible indi22 viduals shall be defaulted into a self-directed care 

23 option (as defined by the Secretary). 

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

25 this part shall be provided with a community-first 


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1 presumption and eligible individuals should be ini2 tially provided home and community-based services, 

3 as defined for purposes of section 1915(i). Before an 

4 eligible individual is admitted into a long term care 

5 institution, the State mental health or developmental 

6 disability authority or State agency that administers 

7 the State plan under title XIX shall conduct a man8 datory assessment to determine whether their needs 

9 could be met through home and community-based 

10 services and if so, the services would have to be ar11 ranged for by the State and the coverage would not 

12 be provided for the individual with respect to such 

13 an admission. This assessment shall be conducted at 

14 least annually or upon a change in condition for all 

15 individual already admitted to an institution. 

16 ‘‘(d) COORDINATION WITH OTHER FEDERAL BENE17 FITS.— 

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

19 this part shall be construed as prohibiting benefits 

20 paid under this part from being used to compensate 

21 a caregiver who provides community living assistance 

22 services and supports to a dependent relative not 

23 less than 80 hours a month for providing community 

24 living assistance services and supports to an eligible 

25 individual under this part. 


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

2 term ‘dependent relative’ means— 

3 ‘‘(A) a child, grandchild, niece, or nephew 

4 (of such caregiver or such caregiver’s spouse or 

5 domestic partner); 

6 ‘‘(B) a child to which the caregiver or the 

7 caregiver’s spouse or domestic partner is stand8 ing in loco parentis; 

9 ‘‘(C) a parent, grandparent, sibling, aunt, 

10 or uncle (of such caregiver or his or her spouse 

11 or domestic partner); or 

12 ‘‘(D) such caregiver’s spouse or domestic 

13 partner, if such child, grandchild, niece, neph14 ew, parent, grandparent, sibling, aunt, uncle, 

15 spouse, or domestic partner is an eligible indi16 vidual. 

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

18 received under this part by a caregiver shall supple19 ment, but not supplant, other benefits for which the 

20 individual is eligible under any other Federally fund21 ed program that provides benefits or assistance. 

22 ‘‘(4) DISREGARD.—Benefits paid to a caregiver 

23 under this part shall be disregarded for purposes of 

24 determining or continuing the eligibility of the indi25 vidual or the spouse of the individual for receipt of 


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1 benefits under any other Federal, State, or locally 

2 funded assistance program, including benefits paid 

3 under titles II or XVI under the laws administered 

4 by the Secretary of Veterans Affairs, under low-in5 come housing assistance programs, under the sup6 plemental nutrition assistance program established 

7 under the Food and Nutrition Act of 2008, or under 

8 programs administered by State vocational rehabili9 tation agencies. 

10 ‘‘PART C—MEDICARE ADVANTAGE FOR AMERICA 

11 ‘‘SEC. 2231. ALL PRIVATE PLANS. 

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

13 plan year 2026, a health insurance issuer may offer health 

14 insurance coverage in the individual market only if such 

15 issuer has entered into a contract with the Secretary 

16 under subsection (b) to offer such coverage. 

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

18 an agreement with an MA for America sponsor to offer 

19 MA for America plans under this part for the coverage 

20 of individuals enrolled under Medicare for America who 

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

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

23 SPONSOR.—For purposes of this part— 

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

25 America plan is a Medicare Advantage plan under 


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

2 coverage for individuals enrolled under Medicare for 

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

4 at least the benefits covered under such part A. 

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

6 America sponsor is a sponsor of an MA for America 

7 plan. 

8 ‘‘SEC. 2232. APPLICATION OF MEDICARE ADVANTAGE PRO9 VISIONS. 

10 ‘‘For purposes of applying this part, except as other11 wise specified under this part, the provisions of part C 

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

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

14 sponsor, MA for America plan, individuals eligible for cov15 erage under this part, individuals enrolled under such 

16 plan, and benefits covered under part A in a similar man17 ner and to a similar extent as such provisions applied to 

18 an MA organization, MA plan, individuals eligible for 

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

20 MA plan, and benefits covered under fee-for-service Medi21 care as of such date. 

22 ‘‘SEC. 2233. INCREASED PREMIUM FOR MEDICARE ADVAN23 TAGE FOR AMERICA PLANS. 

24 ‘‘Nothing in this part shall preclude an individual 

25 from choosing a Medicare Advantage for America plan 


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1 which requires the individual to pay an additional amount 

2 because of supplemental benefits or because it is a more 

3 expensive plan. In such case the individual enrolled under 

4 such plan would be responsible for the increased monthly 

5 premium. 

6 ‘‘SEC. 2234. REFERENCES. 

7 ‘‘Beginning in 2022, all references in law and regula8 tion to Medicare Advantage shall be deemed a reference 

9 to Medicare Advantage for America.’’. 

10 SEC. 112. MODIFICATIONS TO AND COORDINATION WITH 

11 EXISTING FEDERAL HEALTH PROGRAMS. 

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

13 HEALTH INSURANCE PROGRAM (SCHIP).— 

14 (1) IN GENERAL.—Notwithstanding any other 

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

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

17 added by section 111— 

18 (A) no benefits shall be available under 

19 title XVIII of the Social Security Act for any 

20 item or service furnished— 

21 (i) beginning on or after January 1, 

22 2022 (except in the case of an individual 

23 enrolled under such title and title XIX of 

24 such Act); and 


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1 (ii) beginning on or after January 1, 

2 2024, with respect to all individuals, in3 cluding individuals enrolled under such 

4 title and title XIX of such Act; 

5 (B) no individual is entitled to medical as6 sistance under a State plan approved under 

7 title XIX of such Act— 

8 (i) for any item or service furnished 

9 on or after January 1, 2024, in the case 

10 of an individual enrolled under such title 

11 and title XVIII of the Social Security Act 

12 or an individual described in subclause 

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

14 (ii) for any item or service furnished 

15 on or after January 1, 2026; 

16 (C) no individual is entitled to medical as17 sistance under a State child health plan under 

18 title XXI of such Act for any item or service 

19 furnished on or after January 1, 2024; and 

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

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

22 with respect to medical assistance or child 

23 health assistance— 

24 (i) for any item or service furnished 

25 on or after January 1, 2024, in the case 


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1 of an individual enrolled under such title 

2 and title XVIII of the Social Security Act 

3 or an individual described in subclause 

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

5 (ii) for any item or service furnished 

6 on or after January 1, 2026. 

7 (2) TRANSITION.—In the case of inpatient hos8 pital services and extended care services during a 

9 continuous period of stay which began before Janu10 ary 1, 2024 for Medicare and 2026 for Medicaid or 

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

12 which benefits are provided under title XVIII of the 

13 Social Security Act, under a State plan under title 

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

15 under title XXI such Act, the Secretary of Health 

16 and Human Services shall provide for continuation 

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

18 the period of stay. 

19 (b) OTHER FEDERAL HEALTH PROGRAMS.— 

20 (1) FEDERAL EMPLOYEES HEALTH BENEFITS

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

22 made by this Act, shall affect benefits made avail23 able under chapter 89 of title 5, United States Code. 

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

25 amendments made by this Act, shall affect benefits 


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1 made available under sections 1079 and 1086 of 

2 title 10, United States Code. 

3 (3) TREATMENT OF BENEFITS FOR VETERANS

4 AND NATIVE AMERICANS.— 

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

6 the amendments made by this Act, shall affect 

7 the eligibility of veterans for the medical bene8 fits and services provided under title 38, United 

9 States Code, or of Indians for the medical bene10 fits and services provided by or through the In11 dian Health Service. 

12 (B) REEVALUATION.—No reevaluation of 

13 the Indian Health Service shall be undertaken 

14 without consultation with tribal leaders and 

15 stakeholders. 

16 (c) SUNSET OF PROVISIONS RELATED TO THE STATE

17 EXCHANGES.—Effective January 1, 2022, the Federal 

18 and State Exchanges established pursuant to title I of the 

19 Patient Protection and Affordable Care Act (Public Law 

20 111–148) shall terminate, and any other provision of law 

21 that relies upon participation in or enrollment through 

22 such an Exchange, including such provisions of the Inter23 nal Revenue Code of 1986, shall cease to have force or 

24 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 2019, 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 2019, 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 

25 the removal. 


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1 ‘‘(ii) APPLICATION.— 

2 ‘‘(I) APPLICATION OF NEW PROC3 ESS.—In the case of a removal of a 

4 provider of services or supplier from a 

5 network of an MA plan occurring on 

6 or after the effective date published in 

7 a final rule for such fair notice and 

8 appeal process, such process shall 

9 apply in lieu of the process for the 

10 termination or suspension of a pro11 vider contract under section 

12 422.202(a) of title 42, Code of Fed13 eral Regulations. 

14 ‘‘(II) CONTINUATION OF OLD

15 PROCESS.—In the case of a removal of 

16 a provider of services or supplier from 

17 a network of an MA plan occurring 

18 before such effective date, the process 

19 for the termination or suspension of a 

20 provider contract under section 

21 422.202(a) of title 42, Code of Fed22 eral Regulations, shall apply. 

23 ‘‘(E) PARTICIPANT NOTICE AND PROTEC24 TION.— 


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1 ‘‘(i) NOTICE TO PARTICIPANTS OF

2 PROVIDER REMOVAL.—Not less than 60 

3 days before the date on which a provider 

4 of services or supplier is removed from a 

5 network of an MA plan, the MA organiza6 tion offering such plan shall provide writ7 ten notification of the removal to each in8 dividual enrolled in such plan receiving 

9 items or services from the provider or sup10 plier during the plan year in effect on the 

11 date of removal or during the previous 

12 plan year. Such notification shall include 

13 at the minimum— 

14 ‘‘(I) the names and telephone 

15 numbers of available in-network pro16 viders of services and suppliers offer17 ing items and services that are the 

18 same or similar to the items and serv19 ices offered by the removed provider 

20 or supplier; 

21 ‘‘(II) information regarding the 

22 options available to an individual en23 rolled in such plan to request the con24 tinuation of medical treatment or 


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1 therapy with the removed provider or 

2 supplier; and 

3 ‘‘(III) one or more customer serv4 ice telephone numbers that an indi5 vidual enrolled in such plan may ac6 cess to obtain information regarding 

7 changes to the network of the plan. 

8 ‘‘(ii) ANNUAL NOTICE OF CHANGE.— 

9 In addition to providing the notification of 

10 removal as required under clause (i), the 

11 MA organization offering such MA plan 

12 shall include such notification in the an13 nual notice of change for the MA plan for 

14 the upcoming plan year. 

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

16 case in which a provider of services or sup17 plier is removed from a network of an MA 

18 plan, such plan shall ensure that the re19 moval satisfies the continuity of care re20 quirements under paragraph (1)(A) with 

21 respect to each individual enrolled in such 

22 plan receiving items or services from the 

23 provider or supplier during the plan year 

24 in effect on the date of removal or during 

25 the previous plan year. 


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

2 in this paragraph shall be construed as affect3 ing the ability of a provider of services or sup4 plier to decline to participate in a network of an 

5 MA plan. 

6 ‘‘(8) TRANSPARENCY IN MEASURES USED BY

7 MA ORGANIZATIONS TO ESTABLISH OR MODIFY PRO8 VIDER NETWORKS.— 

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

10 year 2019, an MA organization offering an MA 

11 plan shall include the information described in 

12 subparagraph (B)— 

13 ‘‘(i) in the annual bid information 

14 submitted by the MA organization with re15 spect to the MA plan under section 1854; 

16 and 

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

18 MA plan. 

19 ‘‘(B) INFORMATION DESCRIBED.—The in20 formation described in this subparagraph is the 

21 following: 

22 ‘‘(i) Information regarding the meas23 ures used by the MA organization to estab24 lish or modify the provider network of the 

25 MA plan, including measures of the quality 


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1 and efficiency of providers. Such informa2 tion shall include the specifications, meth3 odology, and sample size of such measures. 

4 ‘‘(ii) Other information related to the 

5 establishment or modification of such pro6 vider network that the Secretary deter7 mines appropriate. 

8 ‘‘(C) LIMITATION.—The information de9 scribed in subparagraph (B) shall not include 

10 any individually identifiable information of any 

11 provider or supplier of services.’’. 

12 (b) ENFORCEMENT.— 

13 (1) SANCTIONS FOR NONCOMPLIANCE.—Section 

14 1857(g)(1) of the Social Security Act (42 U.S.C. 

15 1395w–27(g)(1)) is amended— 

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

17 (B) by redesignating subparagraph (K) as 

18 subparagraph (L); 

19 (C) by inserting after subparagraph (J) 

20 the following new subparagraph: 

21 ‘‘(K) fails to comply with section 

22 1852(d)(7) or 1852(d)(8); or’’; and 

23 (D) in subparagraph (L) (as so redesig24 nated), by striking ‘‘through (J)’’ and inserting 

25 ‘‘through (K)’’. 


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

2 Title XVIII of the Social Security Act is amended— 

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

4 U.S.C. 1395w–112(b)(3)(E)), by striking 

5 ‘‘paragraph (1)(F)’’ and inserting ‘‘paragraphs 

6 (1)(F) and (1)(K)’’; and 

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

8 1395eee(e)(6)(B)), by inserting ‘‘(other than 

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

10 ‘‘1857(g)(1)’’. 

11 (c) MEDICARE ADVANTAGE PLAN COMPARE TOOL.— 

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

13 this Act, the Secretary of Health and Human Services 

14 shall take such measures as are necessary to ensure that 

15 the Medicare Advantage Compare Tool takes into account 

16 the preferences and utilization needs of such individuals. 

17 SEC. 122. NETWORK ADEQUACY. 

18 (a) IN GENERAL.—Section 1852(d) of the Social Se19 curity Act (42 U.S.C. 1395w–22(d)) is amended by adding 

20 at the end the following: 

21 ‘‘(9) NETWORK ADEQUACY REQUIREMENTS.— 

22 Beginning in plan year 2019, notwithstanding any 

23 other provision of law, the following shall apply: 

24 ‘‘(A) PROVIDER AVAILABILITY.—When es25 tablishing a plan network, a Medicare AdvanVerDate Sep 11 2014 21:24 Jan 03, 2019 Jkt 089200 PO 00000 Frm 00063 Fmt 6652 Sfmt 6201 E:\BILLS\H7339.IH H7339

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1 tage organization offering an MA plan shall, 

2 among other factors determined by the Sec3 retary, consider the following: 

4 ‘‘(i) The anticipated enrollment in the 

5 plan. 

6 ‘‘(ii) The expected types of services 

7 provided and utilization of services by en8 rollees under the plan. 

9 ‘‘(iii) The number and types of pro10 viders needed to provide such services. 

11 ‘‘(iv) The number of network pro12 viders who are not accepting new patients. 

13 ‘‘(v) The location of providers and en14 rollees. 

15 ‘‘(vi) The full-time equivalent avail16 ability of a provider to provide such serv17 ices. 

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

19 MANNER.—A Medicare Advantage organization 

20 offering an MA plan shall ensure that providers 

21 are able to provide services in a timely manner, 

22 as defined by the Secretary, under the plan. 

23 ‘‘(C) APPLICATION OF NETWORK ACCESS

24 ADEQUACY STANDARDS.—In applying the net25 work access adequacy standards pursuant to 


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1 paragraph (1), the Secretary shall seek input 

2 from patient advocacy groups, providers of serv3 ices and suppliers, and MA plans under this 

4 part. 

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

6 Medicare Advantage organization shall certify 

7 to the Secretary, with respect to each MA plan 

8 offered by the organization, that the providers, 

9 including specialists and subspecialists, in the 

10 plan network are able to provide the services re11 quired under the organization’s contract with 

12 the Secretary under section 1857 with respect 

13 to the offering of such plan and to meet the 

14 needs of the enrollees within the plan service 

15 area during the year. 

16 ‘‘(E) ANNUAL REPORTING.—Each plan 

17 year, a Medicare Advantage organization shall 

18 report to the Secretary the following with re19 spect to each MA plan offered by the organiza20 tion: 

21 ‘‘(i) AVERAGE WAIT TIME.—The aver22 age wait time for primary and specialty 

23 care for enrollees under the plan. 


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1 ‘‘(ii) UTILIZATION OF OUT-OF-NET2 WORK PROVIDERS.—The utilization of out3 of-network providers under the plan. 

4 ‘‘(iii) AVERAGE COST PER PATIENT.— 

5 The average annual spending per patient 

6 for primary and specialty care for enrollees 

7 under the plan. 

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

9 annual, coordinated election period under sec10 tion 1851(e)(3), a Medicare Advantage organi11 zation shall certify to the Secretary the accu12 racy of provider directories for each plan of13 fered by the organization. 

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

15 shall ensure that the network of each MA plan 

16 offered by a Medicare Advantage organization 

17 meets the network adequacy guidelines estab18 lished under this paragraph and under section 

19 422.112(a)(4) of title 42, Code of Federal Reg20 ulations (or any successor regulation to such 

21 section), at least once every 3 years or when a 

22 material change in network occurs.’’. 

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

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


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

2 1852(d)(8)’’ and inserting ‘‘, 1852(d)(8), or 1852(d)(9)’’. 

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

4 FOR MEDICARE COVERAGE FOR INDIVID5 UALS WITH DISABILITIES. 

6 (a) IN GENERAL.—Section 226(b) of the Social Secu7 rity Act (42 U.S.C. 426(b)) is amended— 

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

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

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

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

12 (3) in paragraph (2)(C)(ii), by striking ‘‘, in13 cluding the requirement that he has been entitled to 

14 the specified benefits for 24 months,’’; 

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

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

17 (II) the twenty-fifth month of his entitlement or sta18 tus as a qualified railroad retirement beneficiary de19 scribed in paragraph (2), and’’ and inserting ‘‘for 

20 each month for which the individual meets the re21 quirements of paragraph (2), beginning with the 

22 month following the month in which the individual 

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

24 and 


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1 (5) in the second sentence, by striking ‘‘the 

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

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

4 (b) CONFORMING AMENDMENTS.— 

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

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

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

8 (h); and 

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

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

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

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

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

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

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

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

17 is amended by striking ‘‘25th month of’’ and insert18 ing ‘‘month following the first month of’’. 

19 (4) RAILROAD RETIREMENT SYSTEM.—Section 

20 7(d)(2)(ii) of the Railroad Retirement Act of 1974 

21 (45 U.S.C. 231f(d)(2)(ii)) is amended— 

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

23 annuity’’ and inserting ‘‘is entitled to an annu24 ity’’; 


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

2 months’’; and 

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

4 for 24 calendar months, and’’. 

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

6 this section shall apply to insurance benefits under title 

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

8 services furnished in months beginning after the date of 

9 enactment of this Act. 

10 SEC. 124. EMPLOYER HEALTH PLAN OPTIONS. 

11 (a) DEFINITION.—A qualifying employer sponsored 

12 plan is— 

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

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

15 Act); or 

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

17 benefits criteria of title XXII of the Social Security 

18 Act, as added by section 111, and the criteria under 

19 subsection (b), 

20 that provides health coverage that is equivalent to an actu21 arial value of at least 80 percent and makes a premium 

22 contribution of at least 70 percent. 

23 (b) OBLIGATION.—Large employers shall, with re24 spect to any full-time employee of such employer— 


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1 (1) offer a qualifying employer sponsored plan 

2 to such employee, in accordance with subsection (c); 

3 or 

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

5 annual payroll to the Medicare Trust Fund under 

6 title XXII of the Social Security Act. 

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

8 of a qualifying employer sponsored plan as satisfied by 

9 subsection (b)(1) in order to enroll in Medicare for Amer10 ica. The employer shall be exempt from the contribution 

11 specified in subsection (b)(2). The Secretary of Health 

12 and Human Services shall have authority to set standards 

13 for determining whether employers or insurers are under14 taking any actions to affect the risk pool within Medicare 

15 for America by inducing individuals to decline coverage 

16 under a qualifying employer sponsored plan and instead 

17 to enroll in Medicare for America. An employer violating 

18 such standards shall be treated as not meeting the require19 ments of subsection (a). 

20 (d) SPECIAL RULES.— 

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

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

23 respect to any employer for any calendar year, the 

24 aggregate wages paid by the employer during such 

25 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 (e) TIMING AND MANNER.—Each employer that 

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

22 under this section (other than with respect to coverage 

23 under a group health plan) shall pay such contribution in 

24 a form and manner, specified by the Secretary of the 

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1 ployer excise taxes are required to be paid under section 

2 3111 of the Internal Revenue Code of 1986. 

3 (f) 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) REGULATIONS.—The Secretary of Health 

11 and Human Services may promulgate regulations to 

12 implement this subsection. 

13 SEC. 125. PROHIBITION ON STEP THERAPY AND PRIOR AU14 THORIZATION UNDER GROUP HEALTH 

15 PLANS. 

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

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

18 following new subsection: 

19 ‘‘(e) PROHIBITION AGAINST STEP THERAPY AND

20 PRIOR AUTHORIZATION.—Beginning with the first plan 

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

22 a group health plan may not require a prior authorization 

23 determination for coverage of any benefit under such plan 

24 and may not apply treatment limitations through the use 

25 of step therapy protocols.’’. 


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1 SEC. 126. MEDICARE OUTPATIENT OBSERVATION SERV2 ICES. 

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

4 1395x(i)) is amended by adding at the end the following: 

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

6 outpatient observation services shall be deemed to be an 

7 inpatient during such period, and the date such individual 

8 ceases receiving such services shall be deemed the hospital 

9 discharge date (unless such individual is admitted as a 

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

11 SEC. 127. ABORTION COVERAGE. 

12 Notwithstanding any other provision of law, Federal 

13 funds may be used to provide for abortion services under 

14 any health program under any of the following: 

15 (1) Indian Health Service. 

16 (2) Benefits provided to women veterans. 

17 (3) Benefits provided through the United States 

18 Immigration and Customs Enforcement to women in 

19 detention centers under the jurisdiction of such 

20 agency. 

21 TITLE II—TAX PROVISIONS 

22 SEC. 201. SUNSET OF PUBLIC LAW 115–97. 

23 (a) IN GENERAL.—All provisions of, and amend24 ments made by, Public Law 115–97 shall not apply to cal25 endar, taxable, plan, or limitation years beginning after 

26 December 22, 2017. 


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1 (b) APPLICATION OF CERTAIN LAWS.—The Internal 

2 Revenue Code of 1986 shall be applied and administered 

3 to years described in subsection (a) as if the provisions 

4 and amendments described in subsection (a) had never 

5 been enacted. 

6 SEC. 202. SURTAX. 

7 There is hereby imposed a tax of 5 percent on the 

8 adjusted gross income of each taxpayer to the extent such 

9 income exceeds $500,000. 

10 SEC. 203. BASIS OF PROPERTY ACQUIRED FROM A DECE11 DENT. 

12 (a) IN GENERAL.—Section 1014 of the Internal Rev13 enue Code of 1986 is amended by striking ‘‘person, be’’ 

14 and all that follows through the period at the end and 

15 inserting the following: ‘‘person, be the basis in the hands 

16 of the decedent.’’. 

17 (b) EFFECTIVE DATE.—The amendments made by 

18 this section to property acquired or passed after the date 

19 of enactment of this Act. 

20 SEC. 204. MEDICARE PAYROLL TAX. 

21 (a) IN GENERAL.—Section 3101(b)(2) of the Internal 

22 Revenue Code of 1986 is amended by striking ‘‘0.9 per23 cent’’ and inserting ‘‘4 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. 205. NET INVESTMENT INCOME TAX. 

5 (a) IN GENERAL.—Section 1411(a) of the Internal 

6 Revenue Code of 1986 is amended by striking ‘‘3.8 per7 cent’’ each place such term appears and inserting ‘‘6.9 

8 percent’’. 

9 (b) EFFECTIVE DATE.—The amendments made by 

10 this section shall apply with respect to taxable years begin11 ning after the date of the enactment of this Act. 

12 SEC. 206. TERMINATION OF HEALTH SAVINGS ACCOUNTS. 

13 Section 223(a) of the Internal Revenue Code of 1986 

14 is amended by inserting after ‘‘during such taxable year’’ 

15 the following: ‘‘and before December 31, 2019’’. 

16 SEC. 207. TERMINATION OF FLEXIBLE SPENDING AR17 RANGEMENTS. 

18 Section 125(i)(1) of the Internal Revenue Code of 

19 1986 is amended by striking ‘‘may not elect for any tax20 able year to have salary reduction contributions in excess 

21 of $2,500 made to such arrangement’’ and inserting the 

22 following: ‘‘may not elect to have salary reduction con23 tributions made to such arrangement— 

24 ‘‘(A) for taxable years beginning before 

25 January 1, 2020, in excess of $2,500, and 


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1 ‘‘(B) for taxable years beginning after De2 cember 31, 2019, in excess of $0.’’. 

3 SEC. 208. INCREASE IN EXCISE TAX ON SMALL CIGARS AND 

4 CIGARETTES AND OTHER TOBACCO PROD5 UCTS. 

6 (a) SMALL CIGARS.—Section 5701(a)(1) of the Inter7 nal Revenue Code of 1986 is amended by striking 

8 ‘‘$50.33’’ and inserting ‘‘$100.66’’. 

9 (b) CIGARETTES.—Section 5701(b) of such Code is 

10 amended— 

11 (1) by striking ‘‘$50.33’’ in paragraph (1) and 

12 inserting ‘‘$100.66’’, and 

13 (2) by striking ‘‘$105.69’’ in paragraph (2) and 

14 inserting ‘‘$211.38’’. 

15 (c) PIPE TOBACCO.—Section 5701(f) of the Internal 

16 Revenue Code of 1986 is amended by striking ‘‘$2.8311 

17 cents’’ and inserting ‘‘$50.00’’. 

18 (d) ROLL-YOUR-OWN TOBACCO.—Section 5701(g) of 

19 such Code is amended by striking ‘‘$24.78’’ and inserting 

20 ‘‘$49.56’’. 

21 (e) LARGE CIGARS.—Paragraph (2) of section 

22 5701(a) of the Internal Revenue Code of 1986 is amended 

23 by striking ‘‘52.75 percent’’ and all that follows through 

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1 tionate tax at the like rate on all fractional parts of a 

2 pound) but not less than 5.033 cents per cigar.’’. 

3 (f) SMOKELESS TOBACCO.— 

4 (1) IN GENERAL.—Section 5701(e) of the Inter5 nal Revenue Code of 1986 is amended— 

6 (A) in paragraph (1), by striking ‘‘$1.51’’ 

7 and inserting ‘‘$28.04’’, 

8 (B) in paragraph (2), by striking ‘‘50.33 

9 cents’’ and inserting ‘‘$12.42’’, and 

10 (C) by adding at the end the following: 

11 ‘‘(3) SMOKELESS TOBACCO SOLD IN DISCRETE

12 SINGLE-USE UNITS.—On discrete single-use units, 

13 $107.65 per each 1,000 single-use units.’’. 

14 (2) DISCRETE SINGLE-USE UNIT.—Section 

15 5702(m) of such Code is amended— 

16 (A) in paragraph (1), by striking ‘‘or chew17 ing tobacco’’ and inserting ‘‘chewing tobacco, 

18 discrete single-use unit’’; 

19 (B) in paragraphs (2) and (3), by inserting 

20 ‘‘that is not a discrete single-use unit’’ before 

21 the period in each such paragraph; and 

22 (C) by adding at the end the following: 

23 ‘‘(4) DISCRETE SINGLE-USE UNIT.—The term 

24 ‘discrete single-use unit’ means any product con25 taining tobacco that— 


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1 ‘‘(A) is not intended to be smoked, and 

2 ‘‘(B) is in the form of a lozenge, tablet, 

3 pill, pouch, dissolvable strip, or other discrete 

4 single-use or single-dose unit.’’. 

5 SEC. 209. EXCISE TAX ON ALCOHOL. 

6 (a) DISTILLED SPIRITS.—Section 5001(a)(1) of the 

7 Internal Revenue Code of 1986 is amended by striking 

8 ‘‘$13.50’’ and inserting ‘‘$16.00’’. 

9 (b) WINE.— 

10 (1) Section 5041(b)(1) of the Internal Revenue 

11 Code of 1986 is amended by striking ‘‘$1.07 per 

12 wine gallon’’ and inserting ‘‘$16.00 per proof gal13 lon’’. 

14 (2) Section 5041(b)(2) of the Internal Revenue 

15 Code of 1986 is amended by striking ‘‘$1.57 per 

16 wine gallon’’ and inserting ‘‘$16.00 per proof gal17 lon’’. 

18 (3) Section 5041(b)(3) of the Internal Revenue 

19 Code of 1986 is amended by striking ‘‘$3.15 per 

20 wine gallon’’ and inserting ‘‘$16.00 per proof gal21 lon’’. 

22 (4) Section 5041(b)(4) of the Internal Revenue 

23 Code of 1986 is amended by striking ‘‘$3.40 per 

24 wine gallon’’ and inserting ‘‘$16.00 per proof gal25 lon’’. 


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1 (5) Section 5041(b)(5) of the Internal Revenue 

2 Code of 1986 is amended by striking ‘‘$3.30 per 

3 wine gallon’’ and inserting ‘‘$16.00 per proof gal4 lon’’. 

5 (6) Section 5041(b)(3) of the Internal Revenue 

6 Code of 1986 is amended by striking ‘‘$22.6 cents 

7 per wine gallon’’ and inserting ‘‘$16.00 per proof 

8 gallon’’. 

9 (c) BEER.—Section 5051(B) of the Internal Revenue 

10 Code of 1986 is amended by striking ‘‘$18 for per barrel’’ 

11 and inserting ‘‘$16 per proof gallon’’. 

12 SEC. 210. TAX ON SUGARED DRINKS. 

13 (a) IN GENERAL.—Subchapter D of chapter 32 of the 

14 Internal Revenue Code of 1986 is amended by inserting 

15 after part I the following new part: 

16 ‘‘PART II—SUGAR-SWEETENED BEVERAGES 

‘‘Sec. 4171. Imposition of tax. 

‘‘Sec. 4172. Definitions. 

‘‘Sec. 4173. Special rules. 

17 ‘‘SEC. 4171. IMPOSITION OF TAX. 

18 ‘‘(a) IN GENERAL.—There is hereby imposed a tax 

19 on the sale or transfer of any specified sugar-sweetened 

20 beverage product by the manufacturer, producer, or im21 porter thereof. 

22 ‘‘(b) RATE OF TAX.—The rate of tax imposed under 

23 subsection (a) shall be equal to one cent per 4.2 grams 


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1 of caloric sweetener contained in such specified sugar2 sweetened beverage product. 

3 ‘‘(c) PERSONS LIABLE FOR TAX.—The manufac4 turer, producer, or importer referred to in subsection (a) 

5 shall be liable for the tax imposed by such subsection. 

6 ‘‘SEC. 4172. DEFINITIONS. 

7 ‘‘(a) SPECIFIED SUGAR-SWEETENED BEVERAGE

8 PRODUCT.—For purposes of this part— 

9 ‘‘(1) IN GENERAL.—For purposes of this part, 

10 the term ‘specified sugar-sweetened beverage prod11 uct’ means— 

12 ‘‘(A) any liquid intended for human con13 sumption which contains a caloric sweetener, 

14 and 

15 ‘‘(B) any liquid, or solid mixture of ingre16 dients, which— 

17 ‘‘(i) contains a caloric sweetener, and 

18 ‘‘(ii) is intended for use as an ingre19 dient in a liquid described in subparagraph 

20 (A). 

21 ‘‘(2) EXCEPTIONS.—The following shall not be 

22 treated as liquids described in paragraph (1)(A): 

23 ‘‘(A) Any liquid the primary ingredients of 

24 which are milk or soy, rice, or similar plant25 based milk substitute. 


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1 ‘‘(B) Any liquid composed entirely of one 

2 or more of the following: 

3 ‘‘(i) The original liquid resulting from 

4 the pressing of fruit or vegetables. 

5 ‘‘(ii) The liquid resulting from the re6 constitution of fruit or vegetable juice con7 centrate. 

8 ‘‘(iii) The liquid resulting from the 

9 restoration of water to dehydrated fruit or 

10 vegetable juice. 

11 ‘‘(C) Infant formula. 

12 ‘‘(D) Any liquid products manufactured for 

13 use as— 

14 ‘‘(i) an oral nutritional therapy for 

15 persons who cannot absorb or metabolize 

16 dietary nutrients from food or beverages, 

17 ‘‘(ii) a source of necessary nutrition 

18 used due to a medical condition, or 

19 ‘‘(iii) an oral electrolyte solution for 

20 infants and children formulated to prevent 

21 dehydration due to illness. 

22 ‘‘(E) Any liquid with respect to which tax 

23 is imposed under chapter 51 (relating to dis24 tilled spirits, wines, and beer) or under section 

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1 ter 51 being imposed on like articles of domes2 tic manufacture. 

3 ‘‘(b) CALORIC SWEETENER.—For purposes of this 

4 part, the term ‘caloric sweetener’ means monosaccharides, 

5 disaccharides, and high-fructose corn syrup. 

6 ‘‘SEC. 4173. SPECIAL RULES. 

7 ‘‘(a) SWEETENER TAXED ONLY ONCE.—In the case 

8 of any specified sugar-sweetened beverage product which 

9 is manufactured or produced by including one or more 

10 other specified sugar-sweetened beverage products, no tax 

11 shall be imposed under this section on any caloric sweet12 ener contained in the resulting specified sugar-sweetened 

13 beverage product if tax was previously imposed under this 

14 section on such caloric sweetener when contained in the 

15 specified sugar-sweetened beverage product so included. 

16 ‘‘(b) INFLATION ADJUSTMENT.—In the case of any 

17 sale after December 31, 2015, the one cent amount in sec18 tion 4171(b) shall be increased by an amount equal to— 

19 ‘‘(1) such amount, multiplied by 

20 ‘‘(2) the cost-of-living adjustment determined 

21 under section 1(f)(3) for the calendar year in which 

22 such sale occurs, determined by substituting ‘cal23 endar year 2014’ for ‘calendar year 1992’ in sub24 paragraph (B) thereof. 


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1 Any increase determined under this subsection shall be 

2 rounded to the nearest multiple of one-tenth of a cent.’’. 

3 (b) CONFORMING AMENDMENTS.— 

4 (1) Section 4221(a) is amended by adding at 

5 the end the following: ‘‘Paragraphs (1), (4), (5), and 

6 (6) shall not apply to the tax imposed under section 

7 4171.’’. 

8 (2) The table of parts for subchapter D of 

9 chapter 32 of such Code is amended by inserting 

10 after the item relating to part I the following new 

11 item: 

‘‘PART II—SUGAR-SWEETENED BEVERAGES’’. 

12 (c) REVENUES USED FOR PREVENTION, TREAT13 MENT, AND RESEARCH OF DIET-RELATED HEALTH CON14 DITIONS IN PRIORITY POPULATIONS.— 

15 (1) TRANSFER TO PREVENTION AND PUBLIC

16 HEALTH FUND.—There are hereby appropriated to 

17 the Prevention and Public Health Fund created 

18 under section 4002 of the Patient Protection and 

19 Affordable Care Act (in addition to any other 

20 amounts appropriated to such Fund) amounts equiv21 alent to taxes received in the Treasury under part 

22 II of subchapter D of chapter 32. Rules similar to 

23 the rules of section 9601 of the Internal Revenue 

24 Code of 1986 shall apply with respect to amounts 

25 appropriated under this paragraph. 


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1 (2) RESTRICTION ON USE OF FUNDS.—Not2 withstanding subsections (c) and (d) of section 4002 

3 of the Patient Protection and Affordable Care Act, 

4 amounts appropriated to the Prevention and Public 

5 Health Fund under paragraph (1) may be trans6 ferred to accounts in the Department of Health and 

7 Human Services only for the purpose of making ex8 penditures for programs and research designed to 

9 reduce the human and economic costs of diabetes, 

10 obesity, dental caries, and other diet-related health 

11 conditions in priority populations (within the mean12 ing of section 901(c) of the Public Health Service 

13 Act). 

14 (d) EFFECTIVE DATE.— 

15 (1) IN GENERAL.—Except as provided in para16 graph (2), the amendments made by this section 

17 shall take effect on the date of the enactment of this 

18 Act. 

19 (2) EXCISE TAX.—The amendments made by 

20 subsections (a) and (b) shall apply to sales after the 

21 date of the enactment of this Act. 


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1 TITLE III—DRUG-RELATED 

2 PROVISIONS 

3 SEC. 301. ESTABLISHMENT OF THE PRESCRIPTION DRUG 

4 AND MEDICAL DEVICE REVIEW BOARD. 

5 There is established in the Department of Health and 

6 Human Services a board to be known as the Prescription 

7 Drug and Medical Device Price Review Board (in this Act 

8 referred to as the ‘‘Board’’). 

9 SEC. 302. MEMBERSHIP; STAFF. 

10 (a) MEMBERS.—The Board shall be composed of the 

11 members as follows: 

12 (1) The Assistant Secretary for Planning and 

13 Evaluation of the Department of Health and Human 

14 Services (or the Assistant Secretary’s designee). 

15 (2) The Administrator of the Centers for Medi16 care & Medicaid Services or, beginning with 2022, 

17 the Administrator of the Center for Medicare (or the 

18 Administrator’s designee). 

19 (3) The Assistant Director for the Health Serv20 ices Division of the Federal Bureau of Prisons (or 

21 the Assistant Director’s designee). 

22 (4) The Secretary of Defense (or the Sec23 retary’s designee). 

24 (5) The Secretary of Veterans Affairs (or the 

25 Secretary’s designee). 


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1 (6) The Commissioner of Food and Drugs (or 

2 the Commissioner’s designee). 

3 (7) The Director of the National Institutes of 

4 Health. 

5 (b) CHAIRPERSON.—The Board shall designate 1 

6 member of the Board to serve as the chairperson. 

7 (c) DIRECTOR AND STAFF.— 

8 (1) DIRECTOR.—The Board shall have a direc9 tor who shall be appointed by the chairperson of the 

10 Board, subject to rules prescribed by the Board. 

11 (2) STAFF.—The director may appoint and fix 

12 the pay of such additional personnel as the chair13 person considers appropriate, subject to rules pre14 scribed by the Board. 

15 (3) APPLICABILITY OF CERTAIN CIVIL SERVICE

16 LAWS.—The director and staff of the Board shall be 

17 appointed subject to the provisions of title 5, United 

18 States Code, governing appointments in the competi19 tive service, and shall be paid in accordance with the 

20 requirements of chapter 51 and subchapter III of 

21 chapter 53 of such title relating to classification and 

22 General Schedule pay rates; except that an indi23 vidual so appointed may not receive pay in excess of 

24 the maximum annual rate of basic pay payable for 

25 grade GS–15 of the General Schedule. 


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1 (d) ASSISTANCE FOR THE BOARD.—Subject to sec2 tion 306(g), in carrying out this title, the Board— 

3 (1) may seek assistance from outside experts in 

4 the fields of consumer advocacy, medicine, pharma5 cology, pharmacy, and prescription drug reimburse6 ment; and 

7 (2) shall establish and maintain an advisory 

8 group and a stakeholder group for purposes of seek9 ing such assistance. 

10 (e) INITIAL MEETING.—The Board shall hold its ini11 tial meeting not later than 90 days after the date of the 

12 enactment of this Act. 

13 SEC. 303. REPORTING REQUIREMENTS. 

14 (a) REPORTING BY MANUFACTURERS.—The Board 

15 shall require each manufacturer of a prescription drug or 

16 medical device that is sold in the United States to submit 

17 to the Board on a periodic basis, at a level of specificity 

18 determined by the Board to be necessary to make a deter19 mination under section 304, the following information 

20 with respect to the reporting period: 

21 (1) Each type of prescription drug and medical 

22 device that is sold by the manufacturer or an affil23 iate of the manufacturer— 

24 (A) in the United States; or 


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1 (B) in a country that is a member of the 

2 Organization for Economic Co-operation and 

3 Development. 

4 (2) The price charged by the manufacturer and 

5 the affiliate for the prescription drug or medical de6 vice in the United States and in any such country, 

7 as applicable. 

8 (3) The costs of the manufacturer and the affil9 iate to produce and market the prescription drug or 

10 medical device for sale in the United States and in 

11 any such country, as applicable. 

12 (b) REPORTING BY CBO.—The Director of the Con13 gressional Budget Office shall submit an annual report to 

14 the Board on trends in the prices charged for prescription 

15 drugs and medical devices. 

16 SEC. 304. PROHIBITION AGAINST EXCESSIVE PRICE. 

17 (a) PROHIBITION.—Beginning on the effective date 

18 of the regulation required by subsection (b), the manufac19 turer of a prescription drug or medical device shall not 

20 charge an excessive price, as determined pursuant to such 

21 regulation, for such drug or device. 

22 (b) FORMULA.—The Board shall by regulation pre23 scribe a formula for determining whether the average 

24 manufacturer price of such drug or device over an annual 

25 quarter is an excessive price. 


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1 (c) DETERMINATION OF EXCESSIVE PRICE.—If the 

2 Board determines, on its own initiative or in response to 

3 a petition submitted under subsection (d), that the manu4 facturer of a prescription drug or medical device charges 

5 an excessive price for such drug or device in violation of 

6 subsection (a)— 

7 (1) the Board shall give the manufacturer— 

8 (A) notice of such violation; and 

9 (B) subject to subsection (d), a period to 

10 correct such violation; and 

11 (2) if the manufacturer fails to correct the vio12 lation by the end of such period, the manufacturer 

13 shall be subject to section 305, section 

14 1927(c)(2)(E) of the Social Security Act (as added 

15 by subsection (c) of section 305), and section 4192 

16 of the Internal Revenue Code of 1986, as added by 

17 subsection (d) of section 305. 

18 (d) PETITIONS.—Any person may petition the Board 

19 to make a determination under subsection (c) regarding 

20 the pricing of a prescription drug or medical device. Not 

21 later than 90 days after the date of receipt of such a peti22 tion, the Board shall— 

23 (1) make a determination under subsection (c) 

24 regarding such pricing; or 

25 (2) decline to make such a determination. 


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1 (e) CONTINUING VIOLATION.—The Board shall not 

2 be required to give a manufacturer an opportunity to cor3 rect a violation, as described in subsection (c)(1)(B), be4 fore the manufacturer becomes subject to the provisions 

5 described in subsection (c)(2) for such violation, if— 

6 (1) the Board has already provided such an op7 portunity to correct to the manufacturer; and 

8 (2) the Board finds that the violation of sub9 section (a) is a continuation of an earlier violation 

10 with respect to which such an opportunity was pro11 vided. 

12 (f) CONSIDERATIONS.—The formula required by sub13 section (a) shall at a minimum take into consideration— 

14 (1) the average manufacturer price of the pre15 scription drug or medical device over the respective 

16 annual quarter or quarters; 

17 (2) the average manufacturer price of other 

18 prescription drugs or medical devices in the same 

19 therapeutic class over the same quarter or quarters; 

20 (3) the average price at which the prescription 

21 drug or medical device and other prescription drugs 

22 and medical devices in the same therapeutic class 

23 have been sold by manufacturers in countries other 

24 than the United States; 


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1 (4) the costs associated with producing and 

2 marketing the prescription drug or medical device, 

3 the value of the drug or device to patients where suf4 ficient data is available to determine such value, the 

5 total Federal investment in the development of the 

6 drug or device, the size of the patient population re7 ceiving the drug or device, and other factors deter8 minative as to the true cost of production; and 

9 (5) whether the price of the prescription drug 

10 or medical device increased during any annual quar11 ter by a percentage that is more than 2 percent 

12 greater than the CPI increase percentage (as defined 

13 in section 215(i) of the Social Security Act (42 

14 U.S.C. 415)) for the respective annual quarter. 

15 SEC. 305. ENFORCEMENT PROVISIONS. 

16 (a) REDUCED PATENT TERM.—If the Board finds 

17 that the manufacturer of a prescription drug or medical 

18 device, who is also an owner of a patent for such drug 

19 or device, charged an excessive price for such drug or de20 vice in violation of section 304(a), the Board may— 

21 (1) reduce the term, by not more than 5 years, 

22 of any patent issued under title 35, United States 

23 Code, relating to such drug or device; or 

24 (2) if the term of each patent for such drug or 

25 device has expired, reduce the term, by not more 


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1 than 5 years, of another patent owned by the patent 

2 owner relating to a prescription drug or medical de3 vice. 

4 (b) CIVIL PENALTIES.—If the Board determines 

5 under section 304(c) that a manufacturer of a prescription 

6 drug or medical device charged an excessive price for a 

7 prescription drug or medical device in violation of section 

8 304(a), the Board may impose a civil penalty on the man9 ufacturer of not more than 10 percent of the manufactur10 er’s gross sales of the drug or device during the period 

11 beginning on the date on which an excessive price is first 

12 charged and ending on the date on which the manufac13 turer ceases to charge an excessive price. 

14 (c) ENFORCEMENT THROUGH INCREASED MEDICAID

15 REBATES.— 

16 (1) IN GENERAL.—Section 1927(c)(2) of the 

17 Social Security Act (42 U.S.C. 1396r–8(c)(2)) is 

18 amended— 

19 (A) in subparagraph (A), by inserting ‘‘, 

20 subject to subparagraph (E),’’ after ‘‘increased 

21 by’’; and 

22 (B) by adding at the end the following new 

23 subparagraph: 

24 ‘‘(E) DISCOURAGING EXCESSIVE PRICES.— 


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1 ‘‘(i) IN GENERAL.—In the case of a 

2 manufacturer of a single source drug or an 

3 innovator multiple source drug with a re4 bate agreement under this section, if the 

5 Prescription Drug and Medical Device 

6 Price Review Board established under sec7 tion 301 of the Medicare for America Act 

8 determines under section 304(a) of such 

9 Act that such manufacturer charged, with 

10 respect to a 30-day period, an excessive 

11 price for such drug, and the Board deter12 mines under clause (ii) to apply an in13 creased amount described in such clause 

14 with respect to such manufacturer and 

15 drug, the amount of the rebate determined 

16 under subparagraph (A) for such manufac17 turer and drug shall be, subject to sub18 paragraph (D), increased by such amount 

19 for the 4 rebate periods following such 30- 

20 day period. 

21 ‘‘(ii) INCREASED AMOUNT DETER22 MINATION.—For purposes of clause (i), if 

23 the Board described in such clause makes 

24 such a determination under such section 

25 304(a), with respect to a manufacturer 


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1 and drug described in such clause, the 

2 Board may determine an increased amount 

3 to apply with respect to such manufacturer 

4 and drug and rebate period described in 

5 such clause. Such increased amount may 

6 not exceed the rebate amount that would 

7 otherwise be applied to such manufacturer 

8 and drug under this section for such rebate 

9 period, without regard to this subpara10 graph.’’. 

11 (2) EFFECTIVE DATE.—This subsection and the 

12 amendments made by this subsection shall apply 

13 with respect to rebate agreements entered into after 

14 the date that is 60 days after the date of the enact15 ment of this Act. 

16 (d) TAX ON EXCESS PRESCRIPTION DRUG AND MED17 ICAL DEVICE PROFITS.— 

18 (1) DETERMINATION OF AMOUNT.—If the 

19 Board determines under section 304(a) that a man20 ufacturer, producer, or importer of a prescription 

21 drug or medical device charged an excessive price for 

22 such prescription drug or medical device during a 

23 taxable year, the Board may determine under this 

24 paragraph a reasonable price for such drug or device 

25 for such taxable year. 


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1 (2) IMPOSITION OF TAX.— 

2 (A) IN GENERAL.—The Internal Revenue 

3 Code of 1986 is amended by inserting after sec4 tion 4191 the following new section: 

5 ‘‘SEC. 4192. EXCESSIVE PRESCRIPTION DRUG AND MEDICAL 

6 DEVICE PRICE. 

7 ‘‘(a) IN GENERAL.—There is hereby imposed on the 

8 sale of any prescription drug or medical device by the 

9 manufacturer, producer, or importer a tax equal to the 

10 difference between the price at which such drug or device 

11 is so sold and the reasonable price determined by the Pre12 scription Drug and Medical Device Price Review Board 

13 under section 305(d)(1) of the Medicare for America Act 

14 for such drug or device for the taxable year for sales after 

15 the determination. 

16 ‘‘(b) PRESCRIPTION DRUG OR MEDICAL DEVICE.— 

17 For purposes of this section, the term ‘prescription drug 

18 or medical device’ means any prescription drug (as defined 

19 in section 9008 of the Patient Protection and Affordable 

20 Care Act) or device (as defined in section 201(h) of the 

21 Federal Food, Drug, and Cosmetic Act) intended for hu22 mans.’’. 

23 (B) CLERICAL AMENDMENT.—The table of 

24 parts for chapter 32 of such Code is amended— 


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1 (i) in the item relating to subchapter 

2 E, by striking ‘‘Medical’’ and inserting 

3 ‘‘Drugs and medical’’, and 

4 (ii) by inserting after the item relating 

5 to section 4191 the following new item: 

6 ‘‘SEC. 4192. EXCESSIVE PRESCRIPTION DRUG AND MEDICAL 

7 DEVICE PRICE.’’. 

8 (3) EFFECTIVE DATE.—This subsection and the 

9 amendments made by this subsection shall apply 

10 with respect to sales after December 31, 2018. 

11 SEC. 306. AUTHORITY. 

12 (a) OBTAINING OFFICIAL DATA.—The chairperson of 

13 the Board may secure directly from any Federal agency 

14 information necessary to enable the Board to carry out 

15 its duties. Upon request of the chairperson, the head of 

16 the agency shall furnish such information to the Board 

17 to the extent such information is not prohibited from dis18 closure by law. 

19 (b) MAILS.—The Board may use the United States 

20 mails in the same manner and under the same conditions 

21 as other Federal agencies. 

22 (c) ADMINISTRATIVE SUPPORT SERVICES.—Upon the 

23 request of the chairperson of the Board, the Administrator 

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1 bursable basis, the administrative support services nec2 essary for the Board to carry out its duties. 

3 (d) CONTRACT AUTHORITY.—The Board may con4 tract with and compensate government and private agen5 cies or persons for the purpose of conducting research, 

6 surveys, and other services necessary to enable the Board 

7 to carry out its duties. 

8 (e) INVESTIGATIONS.—The Board may make such in9 vestigations as it considers necessary to determine whether 

10 there is or may be a violation of any regulation promul11 gated under this Act and may require or permit any per12 son to file with it a statement in writing, under oath or 

13 otherwise as the Board shall determine, as to all the facts 

14 and circumstances concerning the matter to be inves15 tigated. 

16 (f) SUBPOENA POWER.— 

17 (1) IN GENERAL.—The Board may issue sub18 poenas requiring the attendance and testimony of 

19 witnesses and the production of any evidence relat20 ing to any matter under investigation by the Board. 

21 The attendance of witnesses and the production of 

22 evidence may be required from any place within the 

23 United States at any designated place of hearing 

24 within the United States. 


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1 (2) FAILURE TO OBEY A SUBPOENA.—If a per2 son refuses to obey a subpoena issued under para3 graph (1), the Board may apply to a United States 

4 district court for an order requiring that person to 

5 appear before the Board to give testimony, produce 

6 evidence, or both, relating to the matter under inves7 tigation. The application may be made within the ju8 dicial district where the hearing is conducted or 

9 where that person is found, resides, or transacts 

10 business. Any failure to obey the order of the court 

11 may be punished by the court as civil contempt. 

12 (3) SERVICE OF SUBPOENAS.—The subpoenas 

13 of the Board shall be served in the manner provided 

14 for subpoenas issued by a United States district 

15 court under the Federal Rules of Civil Procedure for 

16 the United States district courts. 

17 (4) SERVICE OF PROCESS.—All process of any 

18 court to which application is made under paragraph 

19 (2) may be served in the judicial district in which 

20 the person required to be served resides or may be 

21 found. 

22 (5) NOTICE.—Upon issuing any subpoena 

23 under this subsection, the Board shall give notice of 

24 such issuance to the appropriate committees of Con25 gress, including the Committee on Appropriations of 


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1 the House of Representatives and the Committee on 

2 Appropriations of the Senate. 

3 (g) CONFIDENTIALITY.—Nothing in this title shall be 

4 construed as authorizing the Board to disclose any infor5 mation that is a trade secret or confidential information 

6 subject to section 552(b)(4) of title 5, United States Code, 

7 or section 1905 of title 18, United States Code. 

8 SEC. 307. REGULATIONS. 

9 (a) IN GENERAL.—Not later than 1 year after the 

10 date of the initial meeting held under section 302(e), the 

11 Board shall issue final regulations to carry out this Act. 

12 (b) NOTICE AND COMMENT REQUIREMENT.—The 

13 regulations developed under subsection (a) shall be issued 

14 in accordance with the notice and comment procedures es15 tablished under section 553 of title 5, United States Code. 

16 SEC. 308. REPORT TO FEDERAL AGENCIES. 

17 Not later than 1 year after the effective date of the 

18 regulations under section 307 and annually thereafter, the 

19 Board shall submit to each Federal agency that dispenses 

20 or makes payments for the dispensing of prescription 

21 drugs or medical devices a report containing— 

22 (1) a list of each prescription drug and medical 

23 device for which an excessive price was charged dur24 ing the preceding calendar year, as determined by 

25 the Board under section 304; 


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1 (2) recommendations to the Federal agency 

2 against dispensing or making payments for the dis3 pensing of the prescription drug or medical device; 

4 and 

5 (3) recommendations to the Federal agency to 

6 substitute, in place of any drug or device listed pur7 suant to paragraph (1), a similar prescription drug 

8 or medical device that is not sold at an excessive 

9 price. 

10 SEC. 309. DEFINITIONS. 

11 In this title: 

12 (1) The term ‘‘affiliate’’ means, with respect to 

13 a manufacturer, any entity that controls, is con14 trolled by, or is under common control with such 

15 manufacturer. 

16 (2) The term ‘‘average manufacturer price’’ 

17 means the average price charged by the manufac18 turer of a prescription drug or medical device, as ap19 plicable, for sales of the drug or device by the manu20 facturer in the United States over the respective an21 nual quarter. 

22 (3) The term ‘‘medical device’’ means a device 

23 (as defined in section 201 of the Federal Food, 

24 Drug, and Cosmetic Act (21 U.S.C. 321)). 


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1 (4) The term ‘‘prescription drug’’ means a drug 

2 (as defined in section 201 of the Federal Food, 

3 Drug, and Cosmetic Act (21 U.S.C. 321)) that is 

4 subject to section 503(b)(1) of such Act (21 U.S.C. 

5 353(b)(1)). 

6 SEC. 310. MORATORIUM ON DIRECT-TO-CONSUMER DRUG 

7 ADVERTISING. 

8 The Federal Food, Drug, and Cosmetic Act (21 

9 U.S.C. 301 et seq.) is amended— 

10 (1) in section 301 (21 U.S.C. 331), by adding 

11 at the end the following: 

12 ‘‘(eee) The conduct of direct-to-consumer advertising 

13 of a drug in violation of section 506J.’’; and 

14 (2) in chapter V, by inserting after section 506I 

15 (21 U.S.C. 356f) the following: 

16 ‘‘SEC. 506J. DIRECT-TO-CONSUMER DRUG ADVERTISING. 

17 ‘‘(a) PROHIBITIONS.— 

18 ‘‘(1) FIRST THREE YEARS.— 

19 ‘‘(A) IN GENERAL.—Subject to subpara20 graph (B), no person shall conduct direct-to21 consumer advertising of a drug for which an 

22 application is submitted under section 505(b) 

23 before the end of the 3-year period beginning 

24 on the date of the approval of such application. 


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1 ‘‘(B) WAIVER.—The Secretary may waive 

2 the application of subparagraph (A) to a drug 

3 during the third year of the 3-year period de4 scribed in such subparagraph if— 

5 ‘‘(i) the sponsor of the drug submits 

6 an application to the Secretary pursuant to 

7 subparagraph (C); and 

8 ‘‘(ii) the Secretary, after considering 

9 the application and any accompanying ma10 terials, determines that direct-to-consumer 

11 advertising of the drug would have an af12 firmative value to public health. 

13 ‘‘(C) APPLICATION FOR WAIVER.—To seek 

14 a waiver under subparagraph (B), the sponsor 

15 of a drug shall submit an application to the 

16 Secretary at such time, in such manner, and 

17 containing such information as the Secretary 

18 may require. 

19 ‘‘(2) SUBSEQUENT YEARS.—The Secretary may 

20 prohibit direct-to-consumer advertising of a drug 

21 during the period beginning at the end of the 3-year 

22 period described in paragraph (1)(A) if the Sec23 retary determines that the drug has significant ad24 verse health effects based on post-approval studies, 

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1 entific literature, any clinical or observational stud2 ies, or any other appropriate resource. 

3 ‘‘(b) REGULATIONS.—Not later than 1 year after the 

4 date of the enactment of this section, the Secretary shall 

5 revise the regulations promulgated under this Act gov6 erning drug advertisements to the extent necessary to im7 plement this section. 

8 ‘‘(c) RULE OF CONSTRUCTION.—This section shall 

9 not be construed to diminish the authority of the Secretary 

10 to prohibit or regulate direct-to-consumer advertising of 

11 drugs under other provisions of law.’’. 

12 SEC. 311. REPORTING ON JUSTIFICATION FOR DRUG PRICE 

13 INCREASES. 

14 Title III of the Public Health Service Act (42 U.S.C. 

15 241 et seq.) is amended by adding at the end the fol16 lowing: 

17 ‘‘PART W—DRUG PRICE REPORTING; DRUG 

18 VALUE FUND 

19 ‘‘SEC. 399OO. REPORTING ON JUSTIFICATION FOR DRUG 

20 PRICE INCREASES. 

21 ‘‘(a) DEFINITIONS.—In this section: 

22 ‘‘(1) MANUFACTURER.—The term ‘manufac23 turer’ means the person— 

24 ‘‘(A) that holds the application for a drug 

25 approved under section 505 of the Federal 


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1 Food, Drug, and Cosmetic Act or the license 

2 issued under section 351 of the Public Health 

3 Service Act; or 

4 ‘‘(B) who is responsible for setting the 

5 price for the drug. 

6 ‘‘(2) QUALIFYING DRUG.—The term ‘qualifying 

7 drug’ means any drug that is approved under sub8 section (c) or (j) of section 505 of the Federal Food, 

9 Drug, and Cosmetic Act or licensed under subsection 

10 (a) or (k) of section 351 of this Act— 

11 ‘‘(A) that has a wholesale acquisition cost 

12 of $100 or more per month supply or per a 

13 course of treatment that lasts less than a 

14 month and is— 

15 ‘‘(i)(I) subject to section 503(b)(1) of 

16 the Federal Food, Drug, and Cosmetic 

17 Act; or 

18 ‘‘(II) commonly administered by hos19 pitals (as determined by the Secretary); 

20 ‘‘(ii) not designated as a drug for a 

21 rare disease or condition under section 526 

22 of the Federal Food, Drug, and Cosmetic 

23 Act; and 

24 ‘‘(iii) not designated by the Secretary 

25 as a vaccine; and 


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1 ‘‘(B) for which, during the previous cal2 endar year, at least 1 dollar of the total amount 

3 of sales were for individuals enrolled under the 

4 Medicare program under title XVIII of the So5 cial Security Act (42 U.S.C. 1395 et seq.) or 

6 under a State Medicaid plan under title XIX of 

7 such Act (42 U.S.C. 1396 et seq.) or under a 

8 waiver of such plan. 

9 ‘‘(3) WHOLESALE ACQUISITION COST.—The 

10 term ‘wholesale acquisition cost’ has the meaning 

11 given that term in section 1847A(c)(6)(B) of the So12 cial Security Act (42 U.S.C. 1395w–3a(c)(6)(B)). 

13 ‘‘(b) REPORT.— 

14 ‘‘(1) REPORT REQUIRED.—The manufacturer of 

15 a qualifying drug shall submit a report to the Sec16 retary for each price increase of a qualifying drug 

17 that will result in an increase in the wholesale acqui18 sition cost of that drug that is equal to— 

19 ‘‘(A) 10 percent or more over a 12-month 

20 period; or 

21 ‘‘(B) 25 percent or more over a 36-month 

22 period. 

23 ‘‘(2) REPORT DEADLINE.—Each report de24 scribed in paragraph (1) shall be submitted to the 


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1 Secretary not later than 30 days prior to the 

2 planned effective date of such price increase. 

3 ‘‘(c) CONTENTS.—A report under subsection (b) 

4 shall, at a minimum, include— 

5 ‘‘(1) with respect to the qualifying drug— 

6 ‘‘(A) the percentage by which the manufac7 turer will raise the wholesale acquisition cost of 

8 the drug on the planned effective date of such 

9 price increase; 

10 ‘‘(B) a justification for, and description of, 

11 each manufacturer’s price increase that oc12 curred during the 12-month period described in 

13 subsection (b)(1)(A) or the 36-month period de14 scribed in subsection (b)(1)(B), as applicable; 

15 ‘‘(C) the identity of the initial developer of 

16 the drug; 

17 ‘‘(D) a description of the history of the 

18 manufacturer’s price increases for the drug 

19 since the approval of the application for the 

20 drug under section 505 of the Federal Food, 

21 Drug, and Cosmetic Act or the issuance of the 

22 license for the drug under section 351, or since 

23 the manufacturer acquired such approved appli24 cation or license; 

25 ‘‘(E) the current list price of the drug; 


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1 ‘‘(F) the total expenditures of the manu2 facturer on— 

3 ‘‘(i) materials and manufacturing for 

4 such drug; and 

5 ‘‘(ii) acquiring patents and licensing 

6 for such drug; 

7 ‘‘(G) the percentage of total expenditures 

8 of the manufacturer on research and develop9 ment for such drug that was derived from Fed10 eral funds; 

11 ‘‘(H) the total expenditures of the manu12 facturer on research and development for such 

13 drug that is used for— 

14 ‘‘(i) basic and preclinical research; 

15 ‘‘(ii) clinical research; 

16 ‘‘(iii) new drug development; 

17 ‘‘(iv) pursuing new or expanded indi18 cations for such drug through supple19 mental applications under section 505 of 

20 the Federal Food, Drug, and Cosmetic 

21 Act; and 

22 ‘‘(v) carrying out postmarket require23 ments related to such drug, including those 

24 under section 505(o)(3) of such Act; 


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1 ‘‘(I) the total revenue and the net profit 

2 generated from the qualifying drug for each cal3 endar year since the approval of the application 

4 for the drug under section 505 of the Federal 

5 Food, Drug, and Cosmetic Act or the issuance 

6 of the license for the drug under section 351, 

7 or since the manufacturer acquired such ap8 proved application or license; and 

9 ‘‘(J) the total costs associated with mar10 keting and advertising for the qualifying drug; 

11 ‘‘(2) with respect to the manufacturer— 

12 ‘‘(A) the total revenue and the net profit 

13 of the manufacturer for the 12-month period 

14 described in subsection (b)(1)(A) or the 36- 

15 month period described in subsection (b)(1)(B), 

16 as applicable; 

17 ‘‘(B) all stock-based performance metrics 

18 used by the manufacturer to determine execu19 tive compensation for the 12-month period de20 scribed in subsection (b)(1)(A) or the 36-month 

21 period described in subsection (b)(1)(B), as ap22 plicable; and 

23 ‘‘(C) any additional information the manu24 facturer chooses to provide related to drug pric25 ing decisions, such as total expenditures on— 


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1 ‘‘(i) drug research and development; 

2 or 

3 ‘‘(ii) clinical trials on drugs that failed 

4 to receive approval by the Food and Drug 

5 Administration; and 

6 ‘‘(3) such other related information as the Sec7 retary considers appropriate. 

8 ‘‘(d) CIVIL PENALTY.—Any manufacturer of a quali9 fying drug that fails to submit a report for the drug as 

10 required by this section shall be subject to a civil penalty 

11 of $100,000 for each day on which the violation continues. 

12 ‘‘(e) PUBLIC POSTING.— 

13 ‘‘(1) IN GENERAL.—Subject to paragraph (3), 

14 not later than 30 days after the submission of a re15 port under subsection (b), the Secretary shall post 

16 the report on the public website of the Department 

17 of Health and Human Services. 

18 ‘‘(2) FORMAT.—In developing the format of 

19 such report for public posting, the Secretary shall 

20 consult stakeholders, including beneficiary groups, 

21 and shall seek feedback on the content and format 

22 from consumer advocates and readability experts to 

23 ensure such public reports are user-friendly to the 

24 public and are written in plain language that con25 sumers can readily understand. 


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1 ‘‘(3) TRADE SECRETS AND CONFIDENTIAL IN2 FORMATION.—In carrying out this section, the Sec3 retary shall enforce applicable law concerning the 

4 protection of confidential commercial information 

5 and trade secrets. 

6 ‘‘SEC. 399OO–1. USE OF CIVIL PENALTY AMOUNTS. 

7 ‘‘The Secretary shall collect the civil penalties under 

8 section 399OO, in addition to any other amounts avail9 able, and without further appropriation, and shall use 

10 such funds to carry out activities described in this part 

11 and to improve consumer and provider information about 

12 drug value and drug price transparency. 

13 ‘‘SEC. 399OO–2. ANNUAL REPORT TO CONGRESS. 

14 ‘‘(a) IN GENERAL.—Subject to subsection (b), the 

15 Secretary shall submit to Congress, and post on the public 

16 website of the Department of Health and Human Services 

17 in a way that is easy to use and understand, an annual 

18 report— 

19 ‘‘(1) summarizing the information reported pur20 suant to section 399OO; and 

21 ‘‘(2) including copies of the reports and sup22 porting detailed economic analyses submitted pursu23 ant to such section. 

24 ‘‘(b) TRADE SECRETS AND CONFIDENTIAL INFORMA25 TION.—In carrying out this section, the Secretary shall 


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1 enforce applicable law concerning the protection of con2 fidential commercial information and trade secrets.’’. 

Æ 


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