II 

116TH CONGRESS 

1ST SESSION S. 470 

To amend title XVIII of the Social Security Act to provide for an option 

for any citizen or permanent resident of the United States age 50 

to 64 to buy into Medicare. 

IN THE SENATE OF THE UNITED STATES 

FEBRUARY 13, 2019 

Ms. STABENOW (for herself, Mr. BROWN, Ms. BALDWIN, Mr. BLUMENTHAL, 

Mr. BOOKER, Mr. CARDIN, Ms. DUCKWORTH, Mr. DURBIN, Ms. HARRIS, 

Ms. KLOBUCHAR, Mr. LEAHY, Mr. MARKEY, Mr. MERKLEY, Mr. 

PETERS, Mr. REED, Mrs. SHAHEEN, Ms. SMITH, Mr. WHITEHOUSE, Mrs. 

GILLIBRAND, and Mr. HEINRICH) introduced the following bill; which was 

read twice and referred to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to provide 

for an option for any citizen or permanent resident of 

the United States age 50 to 64 to buy into Medicare. 

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. 

4 This Act may be cited as the ‘‘Medicare at 50 Act’’. 


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1 SEC. 2. MEDICARE BUY-IN OPTION FOR INDIVIDUALS 50 TO 

2 64 YEARS OF AGE. 

3 (a) IN GENERAL.—Title XVIII of the Social Security 

4 Act (42 U.S.C. 1395c et seq.) is amended by adding at 

5 the end the following new section: 

6 ‘‘MEDICARE BUY-IN OPTION FOR INDIVIDUALS 50 TO 64

7 YEARS OF AGE

8 ‘‘SEC. 1899C. (a) OPTION.— 

9 ‘‘(1) IN GENERAL.—Every individual who meets 

10 the requirements described in paragraph (3) shall be 

11 eligible to enroll under this section. 

12 ‘‘(2) PART A, B, AND D BENEFITS AND PROTEC13 TIONS.—An individual enrolled under this section is 

14 entitled to the same benefits (and shall receive the 

15 same protections) under this title as an individual 

16 who is entitled to benefits under part A and enrolled 

17 under parts B and D, including the ability to enroll 

18 in a Medicare Advantage plan that provides qualified 

19 prescription drug coverage (an MA–PD plan) and 

20 including access to the Medicare Beneficiary Om21 budsman under section 1808(c). 

22 ‘‘(3) REQUIREMENTS FOR ELIGIBILITY.—The 

23 requirements described in this paragraph are the fol24 lowing: 


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1 ‘‘(A) AGE.—The individual has attained 50 

2 years of age, but has not attained 65 years of 

3 age. 

4 ‘‘(B) MEDICARE ELIGIBILITY (BUT FOR

5 AGE).—The individual is not otherwise entitled 

6 to benefits under part A or eligible to enroll 

7 under part A or part B but would be eligible for 

8 benefits under part A or part B if the indi9 vidual were 65 years of age. 

10 ‘‘(b) ENROLLMENT AND COVERAGE PERIODS.— 

11 ‘‘(1) IN GENERAL.—The Secretary shall estab12 lish enrollment and coverage periods for individuals 

13 who enroll under this section. 

14 ‘‘(2) COORDINATION.—Such periods shall be es15 tablished in coordination with the enrollment and 

16 coverage periods for plans offered under an Ex17 change established under title I of the Patient Pro18 tection and Affordable Care Act and plans under 

19 parts C and D. If the Secretary determines appro20 priate, the Secretary may expand such enrollment 

21 periods beyond the enrollment periods under such an 

22 Exchange or under parts C and D. 

23 ‘‘(3) BEGINNING OF COVERAGE AND SPECIAL

24 ENROLLMENT PERIODS.—The Secretary shall estab25 lish such periods so that coverage under this section 


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1 shall first begin on January 1 of the first year be2 ginning at least one year after the date of the enact3 ment of this section and shall include special enroll4 ment periods, in accordance with section 155.420 of 

5 title 45 of the Code of Federal Regulations, that are 

6 applicable to qualified health plans offered through 

7 an Exchange. 

8 ‘‘(c) PREMIUM.— 

9 ‘‘(1) AMOUNT OF MONTHLY PREMIUMS.—The 

10 Secretary shall (beginning for the first year that be11 gins more than 1 year after the date of the enact12 ment of this section), during September of the pre13 ceding year, determine a monthly premium for all 

14 individuals enrolled under this section. Such monthly 

premium shall be equal to 1 15 ⁄12 of the annual pre16 mium computed under paragraph (2)(B), which 

17 shall apply with respect to coverage provided under 

18 this section for any month in the succeeding year. 

19 ‘‘(2) ANNUAL PREMIUM.— 

20 ‘‘(A) COMBINED PER CAPITA AVERAGE FOR

21 ALL MEDICARE BENEFITS.—The Secretary shall 

22 estimate the average, annual per capita amount 

23 for benefits and administrative expenses that 

24 will be payable under parts A, B, and D (inVerDate Sep 11 2014 03:48 Feb 22, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S470.IS S470

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1 cluding, as applicable, under part C) in the year 

2 for all individuals enrolled under this section. 

3 ‘‘(B) ANNUAL PREMIUM.—The annual pre4 mium under this subsection for months in a 

5 year is equal to the average, annual per capita 

6 amount estimated under subparagraph (A) for 

7 the year. 

8 ‘‘(3) INCREASED PREMIUM FOR CERTAIN PART

9 C AND D PLANS.—Nothing in this section shall pre10 clude an individual from choosing a Medicare Advan11 tage plan or a prescription drug plan that requires 

12 the individual to pay an additional amount (because 

13 of supplemental benefits or because it is a more ex14 pensive plan). In such case the individual would be 

15 responsible for the increased monthly premium. 

16 ‘‘(d) PAYMENT OF PREMIUMS.— 

17 ‘‘(1) IN GENERAL.—Premiums for enrollment 

18 under this section shall be paid to the Secretary at 

19 such times, and in such manner, as the Secretary 

20 determines appropriate. 

21 ‘‘(2) DEPOSIT INTO MEDICARE BUY-IN TRUST

22 FUND.—Amounts collected by the Secretary under 

23 this section shall be deposited in the Medicare Buy24 In Trust Fund established under paragraph (3). 

25 ‘‘(3) MEDICARE BUY-IN TRUST FUND.— 


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1 ‘‘(A) IN GENERAL.—There is hereby cre2 ated on the books of the Treasury of the United 

3 States a trust fund to be known as the ‘Medi4 care Buy-In Trust Fund’ (in this paragraph re5 ferred to as the ‘Trust Fund’). The Trust Fund 

6 shall consist of such gifts and bequests as may 

7 be made as provided in section 201(i)(1) and 

8 such amounts as may be deposited in, or appro9 priated to, such fund as provided in this title. 

10 ‘‘(B) INCORPORATION OF PROVISIONS.— 

11 Subsections (b) through (i) of section 1841 

12 shall apply with respect to the Trust Fund and 

13 this title in the same manner as they apply with 

14 respect to the Federal Supplementary Medical 

15 Insurance Trust Fund and part B, respectively, 

16 except that in applying such section 1841, any 

17 reference in such section to ‘this part’ shall be 

18 construed to be a reference to this section and 

19 any reference in section 1841(h) to section 

20 1840(d) and in section 1841(i) to sections 

21 1840(b)(1) and 1842(g) are deemed to be ref22 erences to comparable authority exercised under 

23 this section. 

24 ‘‘(e) NOT ELIGIBLE FOR MEDICARE COST-SHARING

25 ASSISTANCE.—An individual enrolled under this section 


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1 shall not be treated as enrolled under any part of this title 

2 for purposes of obtaining medical assistance for Medicare 

3 cost-sharing or otherwise under title XIX. 

4 ‘‘(f) ELIGIBILITY FOR FINANCIAL ASSISTANCE.— 

5 ‘‘(1) IN GENERAL.—Individuals enrolled in cov6 erage under this section shall, from amounts trans7 ferred under paragraph (2), receive financial assist8 ance for such coverage that is substantially similar 

9 to the assistance the individual would have received 

10 if the individual were enrolled in a qualified health 

11 plan through an Exchange. 

12 ‘‘(2) TRANSFER OF FUNDS TO MEDICARE BUY13 IN TRUST FUND.— 

14 ‘‘(A) IN GENERAL.—The Secretary shall 

15 transfer to the Medicare Buy-In Trust Fund 

16 under subsection (d)(3) for each plan year the 

17 amount determined under paragraph (C) for 

18 such year. 

19 ‘‘(B) USE OF FUNDS.—The amounts 

20 transferred to the Medicare Buy-In Trust Fund 

21 under subparagraph (A) shall only be used to 

22 reduce the premiums and cost-sharing for cov23 erage under this section of individuals enrolled 

24 under such coverage who would be eligible for 

25 cost-sharing reductions under section 1402 of 


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1 the Patient Protection and Affordable Care Act 

2 and premium assistance under section 36B of 

3 the Internal Revenue Code of 1986 if such indi4 vidual were enrolled in a qualified health plan. 

5 ‘‘(C) AMOUNT OF TRANSFER.— 

6 ‘‘(i) IN GENERAL.—The amount de7 termined under this subparagraph for any 

8 plan year is the aggregate amount the Sec9 retary determines is equal to 100 percent 

10 of the premium tax credits under section 

11 36B of the Internal Revenue Code of 

12 1986, and 100 percent of the cost-sharing 

13 reductions under section 1402 of the Pa14 tient Protection and Affordable Care Act, 

15 that would have been provided for the plan 

16 year to eligible individuals who meet speci17 fied income criteria and are enrolled for 

18 such plan year in coverage provided 

19 through enrollment under this section if 

20 such individuals were enrolled for such 

21 year in a qualified health plan through an 

22 Exchange. 

23 ‘‘(ii) SPECIFIC REQUIREMENTS.—The 

24 Secretary shall make the determination 

25 under clause (i) on a per enrollee basis and 


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1 shall take into account all relevant factors 

2 necessary to determine the value of the 

3 premium tax credits and cost-sharing re4 ductions that would have been provided to 

5 eligible individuals described in section 

6 1331 of the Patient Protection and Afford7 able Care Act, including the age and in8 come of the enrollee, geographic differences 

9 in average spending for health care across 

10 rating areas, the health status of the en11 rollee for purposes of determining risk ad12 justment payments and reinsurance pay13 ments that would have been made if the 

14 enrollee had enrolled in a qualified health 

15 plan through an Exchange, and whether 

16 any reconciliation of the credit or cost17 sharing reductions would have occurred if 

18 the enrollee had been so enrolled. This de19 termination shall take into consideration 

20 the experience of other States with respect 

21 to participation in an Exchange and such 

22 credits and reductions provided to resi23 dents of the other States, with a special 

24 focus on enrollees with income below 200 

25 percent of poverty. 


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1 ‘‘(D) CERTIFICATION.— 

2 ‘‘(i) IN GENERAL.—The Chief Actuary 

3 of the Centers for Medicare & Medicaid 

4 Services, in consultation with the Office of 

5 Tax Analysis of the Department of the 

6 Treasury, shall certify whether the method7 ology used to make determinations under 

8 subparagraph (C), and such determina9 tions, meet the requirements of this para10 graph. 

11 ‘‘(ii) CORRECTIONS.—The Secretary 

12 shall adjust the payment to the Trust 

13 Fund for any plan year to reflect any error 

14 in the determinations under subparagraph 

15 (C) for any preceding plan year. 

16 ‘‘(iii) APPLICATION.—Coverage pro17 vided through enrollment under this part 

18 and parts B and D pursuant to this sec19 tion shall be treated as coverage under a 

20 qualified health plan in the silver level of 

21 coverage in the individual market offered 

22 through an Exchange and the Secretary 

23 shall be treated as the issuer of such plan. 

24 ‘‘(g) TREATMENT IN RELATION TO THE AFFORD25 ABLE CARE ACT.— 


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1 ‘‘(1) SATISFACTION OF INDIVIDUAL MAN2 DATE.—For purposes of applying section 5000A of 

3 the Internal Revenue Code of 1986, the coverage 

4 provided under this section constitutes minimum es5 sential coverage under subsection (f)(1)(A)(i) of 

6 such section 5000A. 

7 ‘‘(2) ELIGIBILITY FOR PREMIUM ASSISTANCE.— 

8 Coverage provided under this section— 

9 ‘‘(A) shall be treated as coverage under a 

10 qualified health plan in the individual market 

11 enrolled in through the Exchange where the in12 dividual resides for all purposes of section 36B 

13 of the Internal Revenue Code of 1986 other 

14 than subsection (c)(2)(B) thereof; and 

15 ‘‘(B) shall not be treated as eligibility for 

16 other minimum essential coverage for purposes 

17 of subsection (c)(2)(B) of such section 36B. 

18 The Secretary shall determine the applicable second 

19 lowest cost silver plan which shall apply to coverage 

20 under this section for purposes of determining the 

21 premium assistance amount under section 36B(b)(2) 

22 of such Code. Notwithstanding the preceding sen23 tences, in determining the applicable second lowest 

24 cost silver plan with respect to any taxpayer under 

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1 vided under this section shall not be taken into ac2 count as a silver plan of the individual market. 

3 ‘‘(3) ELIGIBILITY FOR COST-SHARING REDUC4 TIONS.—For purposes of applying section 1402 of 

5 the Patient Protection and Affordable Care Act (42 

6 U.S.C. 18071)— 

7 ‘‘(A) coverage provided under this section 

8 shall be treated as coverage under a qualified 

9 health plan in the silver level of coverage in the 

10 individual market offered through an Exchange; 

11 and 

12 ‘‘(B) the Secretary shall be treated as the 

13 issuer of such plan. 

14 ‘‘(4) MEDICAID MANAGED CARE.—States are 

15 prohibited from buying their Medicaid beneficiaries 

16 ages 50 to 64 into Medicare under this section, and 

17 individuals otherwise eligible for enrollment under a 

18 State plan under title XIX are prohibited from cov19 erage under this title pursuant to enrollment under 

20 this section. The preceding sentence shall not apply 

21 to Medicaid beneficiaries whose Medicaid coverage or 

22 eligibility does not meet the definition of minimum 

23 essential coverage under a government-sponsored 

24 program under section 1.5000A–2 of title 26, Code 

25 of Federal Regulations (or any successor regulation). 


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1 ‘‘(h) GUARANTEED ISSUE OF MEDIGAP POLICIES

2 UPON FIRST ENROLLMENT AND EACH SUBSEQUENT EN3 ROLLMENT.—In the case of an individual who enrolls 

4 under this section (including an individual who was pre5 viously enrolled under this section), paragraphs (2)(A), 

6 (2)(D), (3)(B)(ii), and (3)(B)(vi) of section 1882(s)— 

7 ‘‘(1) shall be applied by substituting ‘50’ for 

8 ‘65’; 

9 ‘‘(2) if the individual was enrolled under this 

10 section and subsequently disenrolls, shall apply each 

11 time the individual subsequently reenrolls under this 

12 section as if the individual had attained 50 years of 

13 age on the date of such reenrollment (and as if the 

14 individual had never previously enrolled in a Medi15 care supplemental policy); and 

16 ‘‘(3) shall be applied as if this section had not 

17 been enacted (and as if the individual had never pre18 viously enrolled in a Medicare supplemental policy) 

19 when the individual attains 65 years of age. 

20 ‘‘(i) OVERSIGHT.—There is established an advisory 

21 committee to be known as the ‘Medicare Buy In Oversight 

22 Board’ to monitor and oversee the implementation of this 

23 section, including the experience of the individuals enroll24 ing under this section. The Medicare Buy In Oversight 

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1 tinual improvement of the implementation of this section 

2 as well as the relationship of enrollment under this section 

3 to other health care programs. 

4 ‘‘(j) OUTREACH AND ENROLLMENT.— 

5 ‘‘(1) IN GENERAL.—During the period that be6 gins on January 1, 2019, and ends on December 31, 

7 2021, the Secretary shall award grants to eligible 

8 entities for the following purposes: 

9 ‘‘(A) OUTREACH AND ENROLLMENT.—To 

10 carry out outreach, public education activities, 

11 and enrollment activities to raise awareness of 

12 the availability of, and encourage, enrollment 

13 under this section. 

14 ‘‘(B) ASSISTING INDIVIDUALS’ TRANSITION

15 UNDER THIS SECTION.—To provide assistance 

16 to individuals to enroll under this section. 

17 ‘‘(C) RAISING AWARENESS OF PREMIUM

18 ASSISTANCE AND COST-SHARING REDUC19 TIONS.—To distribute fair and impartial infor20 mation concerning enrollment under this section 

21 and the availability of premium assistance tax 

22 credits under section 36B of the Internal Rev23 enue Code of 1986 and cost-sharing reductions 

24 under section 1402 of the Patient Protection 

25 and Affordable Care Act, and to assist eligible 


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1 individuals in applying for such tax credits and 

2 cost-sharing reductions. 

3 ‘‘(2) ELIGIBLE ENTITIES.— 

4 ‘‘(A) IN GENERAL.—In this subsection, the 

5 term ‘eligible entity’ means— 

6 ‘‘(i) a State; or 

7 ‘‘(ii) a nonprofit community-based or8 ganization. 

9 ‘‘(B) ENROLLMENT AGENTS.—Such term 

10 includes a licensed independent insurance agent 

11 or broker that has an arrangement with a State 

12 or nonprofit community-based organization to 

13 enroll eligible individuals under this section. 

14 ‘‘(C) EXCLUSIONS.—Such term does not 

15 include an entity that— 

16 ‘‘(i) is a health insurance issuer; or 

17 ‘‘(ii) receives any consideration, either 

18 directly or indirectly, from any health in19 surance issuer in connection with the en20 rollment of any individuals under this sec21 tion. 

22 ‘‘(3) PRIORITY.—In awarding grants under this 

23 subsection, the Secretary shall give priority to 

24 awarding grants to States or eligible entities in 

25 States that have geographic rating areas at risk of 


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1 having no qualified health plans in the individual 

2 market. 

3 ‘‘(4) FUNDING.—For purposes of carrying out 

4 this subsection, there is appropriated to the Sec5 retary, out of any moneys in the Treasury not other6 wise appropriated, $500,000,000 for calendar year 

7 2019 and for each subsequent calendar year. 

8 ‘‘(k) NO EFFECT ON BENEFITS FOR INDIVIDUALS

9 OTHERWISE ELIGIBLE OR ON TRUST FUNDS.—The Sec10 retary shall implement the provisions of this section in 

11 such a manner to ensure that such provisions— 

12 ‘‘(1) have no effect on the benefits under this 

13 title for individuals who are entitled to, or enrolled 

14 for, such benefits other than through this section; 

15 and 

16 ‘‘(2) have no negative impact on the Federal 

17 Hospital Insurance Trust Fund or the Federal Sup18 plementary Medical Insurance Trust Fund (includ19 ing the Medicare Prescription Drug Account within 

20 such Trust Fund). 

21 ‘‘(l) CONSULTATION.—In promulgating regulations 

22 to implement this section, the Secretary shall consult with 

23 interested parties, including groups representing bene24 ficiaries, health care providers, employers, and insurance 

25 companies.’’. 


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1 SEC. 3. AUTHORITY TO NEGOTIATE FAIR PRICES FOR MEDI2 CARE PRESCRIPTION DRUGS. 

3 (a) IN GENERAL.—Section 1860D–11 of the Social 

4 Security Act (42 U.S.C. 1395w–111) is amended by strik5 ing subsection (i). 

6 (b) EFFECTIVE DATE.—The amendment made by 

7 this section shall take effect on the date of the enactment 

8 of this Act. 

Æ 


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