II 

118TH CONGRESS 

2D SESSION S. 4817 

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

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

universal health care systems that provide comprehensive health benefits 

to State residents, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JULY 25, 2024 

Mr. MARKEY (for himself, Ms. WARREN, and Mr. MERKLEY) introduced the 

following bill; which was read twice and referred to the Committee on Finance 

A BILL 

To amend title I of the Patient Protection and Affordable 

Care Act to authorize the establishment of, and provide 

support for, State-based universal health care systems 

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

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

3 SECTION 1. SHORT TITLE; PURPOSE. 

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

5 ‘‘State-Based Universal Health Care Act of 2024’’. 


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1 (b) PURPOSE.—The purpose of this Act is to estab2 lish a flexible framework under which States can provide 

3 comprehensive universal health coverage to their residents. 

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

5 (a) IN GENERAL.—Part 4 of subtitle D of title I of 

6 the Patient Protection and Affordable Care Act (42 

7 U.S.C. 18021 et seq.) is amended by adding at the end 

8 the following: 

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

10 ‘‘(a) APPLICATION.— 

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

12 State may apply to the Secretary (as defined in sub13 section (i)(3)) for the waiver of so much of the re14 quirements described in paragraph (2) with respect 

15 to health benefits coverage within the State for plan 

16 years beginning on or after January 1, 2025, as is 

17 necessary to implement a comprehensive State uni18 versal health care plan in the State under this sec19 tion. Such application shall— 

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

21 manner as the Secretary may require; 

22 ‘‘(B) contain such information as the Sec23 retary may require, including— 

24 ‘‘(i) a comprehensive description of 

25 the State legislation, or other State legal 


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1 authority as applicable, and program to 

2 implement a plan meeting the require3 ments for a waiver under this section; 

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

5 achieve in 5 years health coverage for at 

6 least 95 percent of residents of the State; 

7 and 

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

9 such plan that is budget neutral for the 

10 Federal Government; and 

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

12 has legal authority to implement such plan or 

13 has enacted the law described in subsection 

14 (b)(2). 

15 ‘‘(2) REQUIREMENTS.—The requirements de16 scribed in this paragraph with respect to health ben17 efits coverage within the State for plan years begin18 ning on or after January 1, 2025, are as follows: 

19 ‘‘(A) Sections 1301 through 1324. 

20 ‘‘(B) Section 1402. 

21 ‘‘(C) Sections 36B and 4980H of the In22 ternal Revenue Code of 1986. 

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

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

25 Act. 


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

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

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

4 Code. 

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

6 Code, including coverage under the TRICARE 

7 program. 

8 ‘‘(J) Section 514 of the Employee Retire9 ment Income Security Act of 1974. 

10 ‘‘(3) PASSTHROUGH OF FUNDING.—With re11 spect to a State waiver under paragraph (1), under 

12 which the State assumes responsibility for health 

13 coverage under one or more of the specified Federal 

14 health programs, including under each of the Fed15 eral health care or subsidy programs specified in 

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

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

18 Federal health or related administrative funds that 

19 would otherwise have been spent for such a pro20 gram, as applicable, for the time periods covered 

21 under the waiver and shall provide for an alternative 

22 means by which the aggregate amount of such funds 

23 (determined by the Secretary in coordination with 

24 the State), including caseload growth, adjusted for 

25 inflation in health care costs within the State, shall 


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1 be paid to the State for purposes of implementing 

2 the State plan under the waiver. Any savings in 

3 health care spending, including administrative sav4 ings, shall be available to the State for reinvestment 

5 in health care services under the State plan. Such 

6 amount shall be determined annually by the Sec7 retary, taking into account the amount that would 

8 otherwise have been spent under each such Federal 

9 health program, including for administrative activi10 ties and caseload growth, with respect to residents 

11 of such State, for those time periods covered under 

12 the waiver, adjusted for inflation in health care 

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

14 shall include funds equal to the aggregate amount of 

15 premium tax credits, cost-sharing reductions, or 

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

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

18 Internal Revenue Code of 1986 or under section 

19 1402 that would have been available to individuals 

20 and businesses in the State for those time periods 

21 covered under the waiver, including caseload growth, 

22 adjusted for inflation in health care costs, if such 

23 waiver did not apply. 

24 ‘‘(4) WAIVER CONSIDERATION AND TRANS25 PARENCY.— 


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

2 waiver under this section shall be considered by 

3 the Secretary, after taking into account rec4 ommendations of the Panel under subsection 

5 (g), in accordance with the regulations de6 scribed in subparagraph (B). 

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

8 days after the date of the enactment of the 

9 State-Based Universal Health Care Act of 

10 2024, the Secretary shall promulgate regula11 tions relating to waivers under this section that 

12 provide— 

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

14 comment in accordance with the public no15 tice and comment requirements applicable 

16 under regulations used for Medicaid waiv17 ers pursuant to section 1115 of the Social 

18 Security Act; 

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

20 an application that ensures the disclosure 

21 of— 

22 ‘‘(I) the provisions of law that 

23 the State involved seeks to waive; and 


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1 ‘‘(II) the specific plans of the 

2 State to ensure that the waiver will be 

3 in compliance with subsection (b); 

4 ‘‘(iii) a process for providing public 

5 notice and comment after the application is 

6 received by the Secretary that is sufficient 

7 to ensure a meaningful level of public 

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

13 Procedure Act), or requirements that are 

14 unreasonable or unnecessarily burdensome 

15 with respect to State compliance; 

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

17 the Secretary of periodic reports by the 

18 State concerning the implementation of the 

19 program under the waiver; 

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

23 ‘‘(vi) a process for providing technical 

24 assistance on— 


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

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

5 health care for all residents for such 

6 State; and 

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

9 assistance pursuant to subsection 

10 (e)(2). 

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

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

16 are approved. 

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

18 Nothing in this section shall be construed to prevent 

19 2 or more States in a region from submitting a sin20 gle application under this section for a waiver that 

21 establishes a plan that is applicable to all of the 

22 States included in such application. In the case of 

23 such an application and plan, the requirements of 

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


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

2 State may not apply for a waiver under this section 

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

5 section 1332. 

6 ‘‘(7) AUTHORIZATION OF APPROPRIATIONS.— 

7 There is authorized to be appropriated such sums as 

8 may be necessary for providing funds to States with 

9 a waiver under this section for purposes of carrying 

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

11 ‘‘(b) GRANTING OF WAIVERS.— 

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

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

14 Secretary determines that the State plan— 

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

19 such residents would have received under one or 

20 more of the specified Federal health programs 

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

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

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

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


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

3 coverage to applicable State residents who 

4 would have otherwise received health benefits 

5 coverage in the form of medical assistance 

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

8 whether the State provides for such assistance 

9 through a State Medicaid plan under title XIX 

10 of the Social Security Act or a waiver of such 

11 State Medicaid plan) that includes at least the 

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

14 without a waiver of a State Medicaid plan 

15 under such title, including benefits for early 

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

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

20 protections against excessive out-of-pocket 

21 spending to State residents that are at least as 

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


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1 such residents would have been eligible, absent 

2 such waiver; 

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

4 of the State, including those otherwise covered 

5 under one or more of the Federal health care 

6 or subsidy programs specified in subparagraphs 

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

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

9 benefits through the Indian Health Service or 

10 for benefits and services under title 38, United 

11 States Code; 

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

14 such coverage and the facilitation of enrollment 

15 in such coverage, and to raise awareness re16 garding restrictions on the sale of duplicative or 

17 supplemental private insurance (and, if the 

18 State chooses to continue to offer qualified 

19 health plans through an Exchange, public edu20 cation activities will raise awareness of the 

21 availability of and the facilitation of enrollment 

22 in such plans in a manner similar to an entity 

23 that serves as a navigator under a grant under 

24 section 1311(i)); 


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

2 agency or multiple agencies of the State, or an 

3 independent public entity within the govern4 ment of the State; 

5 ‘‘(G) will not preclude the purchase of in6 surance that offers coverage for benefits that 

7 are not offered under the State plan; 

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

9 appeals, independent review, and other proce10 dures for accessing and maintaining benefits 

11 that are at least as accessible to applicable 

12 State residents as those of one or more of the 

13 specified Federal health programs (as defined 

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

15 would have otherwise been eligible without ap16 plication of such waiver under subsection 

17 (a)(1); and 

18 ‘‘(I) will provide coverage for reproductive 

19 health care services, including abortion, contra20 ception, and gender-affirming care. 

21 Subparagraph (D) shall not be construed as limiting 

22 a State from contracting with one or more private 

23 entities to administer the State plan. 

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


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

2 this paragraph is a State law (including an ex3 ecutive order by a State governor) that provides 

4 for State actions under a waiver under this sec5 tion, including the implementation of the State 

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

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

8 may repeal a law described in subparagraph (A) 

9 and terminate the authority provided under the 

10 waiver with respect to the State. 

11 ‘‘(c) SCOPE OF WAIVER.— 

12 ‘‘(1) IN GENERAL.—The Secretary shall deter13 mine the scope of a waiver of a requirement de14 scribed in subsection (a)(2) granted to a State under 

15 subsection (a)(1). 

16 ‘‘(2) LIMITATION.—Under this section, the Sec17 retary may not waive any Federal law or require18 ment that is not listed in subsection (a)(2). 

19 ‘‘(d) DETERMINATIONS BY SECRETARY.— 

20 ‘‘(1) TIME FOR DETERMINATION.—The Sec21 retary shall, with respect to an application from a 

22 State under this section and after taking into ac23 count recommendations of the Panel under sub24 section (g) for such application, make a determinaVerDate Sep 11 2014 22:25 Aug 22, 2024 Jkt 049200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\S4817.IS S4817

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1 tion under subsection (a)(1) not later than 90 days 

2 after the receipt of such recommendations. 

3 ‘‘(2) EFFECT OF DETERMINATION.— 

4 ‘‘(A) GRANTING OF WAIVERS.—If the Sec5 retary determines to grant a waiver under sub6 section (a)(1), the Secretary shall notify the 

7 State involved of such determination and the 

8 terms and effectiveness of such waiver. 

9 ‘‘(B) DENIAL OF WAIVER.—If the Sec10 retary determines a waiver should not be grant11 ed under subsection (a)(1), the Secretary shall 

12 notify the State involved and the appropriate 

13 committees of Congress of such determination 

14 and the reasons therefor. 

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

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

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

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

19 a report that is carried out by an independent, non20 partisan entity, with respect to such 5-year period 

21 and after a process for public notice and comment 

22 at the State level, including public hearings, suffi23 cient to ensure a meaningful level of public input, on 

24 the following: 


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

2 the State. 

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

4 without health insurance and a description of 

5 how the State plans to provide health insurance 

6 coverage within the subsequent 5 years to resi7 dents of the State without health insurance. 

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

9 health care has changed over the period. 

10 ‘‘(D) Whether the State has achieved 

11 health coverage for at least 95 percent of the 

12 residents of the State. 

13 ‘‘(E) Measurable changes in quality and 

14 access. 

15 ‘‘(F) Any additional information specified 

16 by the Secretary for purposes of determining 

17 the successes and challenges of the waiver. 

18 ‘‘(2) 5-YEAR REVIEW.—In the case a State, 

19 based on the report submitted under paragraph (1) 

20 for a 5-year period— 

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

22 to have not achieved health coverage for at least 

23 95 percent of the residents of the State— 

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

25 technical assistance described in subsection 


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1 (a)(4)(B)(vii) to improve the health insur2 ance program of the State implemented 

3 through the waiver under this section; 

4 ‘‘(ii) the State shall have a grace pe5 riod of 12 months after such determination 

6 to achieve health coverage for at least 95 

7 percent of residents of the State; and 

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

9 State has not achieved such health cov10 erage, the waiver under this section may be 

11 terminated at the discretion of the Sec12 retary; and 

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

14 to have achieved health coverage for at least 95 

15 percent of residents of the State, the State, as 

16 a condition of continuing such waiver, shall sub17 mit to the Secretary a plan for achieving health 

18 coverage for the remainder of the residents of 

19 the State. 

20 ‘‘(f) ASSURING COORDINATION.— 

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

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

23 Universal Health Care Act of 2024, the Secretary of 

24 Health and Human Services, the Secretary of the 

25 Treasury, the Secretary of Defense, the Secretary of 


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1 Labor, and the Director of the Office of Personnel 

2 Management, shall, through the execution of an 

3 interagency memorandum of understanding among 

4 such Secretaries and Director— 

5 ‘‘(A) develop a process for coordinating 

6 and consolidating the State waiver processes 

7 applicable under the provisions of this section, 

8 and the existing waiver processes applicable 

9 under— 

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

11 of the Social Security Act; and 

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

13 the provision of health care items or serv14 ices; and 

15 ‘‘(B) ensure that— 

16 ‘‘(i) regulations (including regulations 

17 required under subsection (a)(4)(B)), rul18 ings, and interpretations issued by such 

19 Secretaries and Director relating to the 

20 same matter over which two or more such 

21 Secretaries or Director have responsibility 

22 under this section are administered so as 

23 to have the same effect at all times; and 

24 ‘‘(ii) coordination of policies relating 

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1 tinuation of waivers through such Secre2 taries and Director in order to have a co3 ordinated strategy that avoids duplication 

4 of effort by the States or Secretaries and 

5 Director and ensures clarity about waiver 

6 application status and approval. 

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

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

9 single application for a waiver under all of the provi10 sions of this section and the provisions of law listed 

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

12 ‘‘(3) SUBMISSION OF CONFORMING AMEND13 MENTS.—The Secretary of Health and Human Serv14 ices, in coordination with the other Secretaries listed 

15 in paragraph (1) (including the Director of the Of16 fice of Personnel Management), shall submit to Con17 gress such recommendations for such technical and 

18 conforming amendments to law as may be appro19 priate to assist in the implementation of this section. 

20 ‘‘(g) INDEPENDENT ASSESSMENT PANEL FOR COM21 PREHENSIVE HEALTH CARE.— 

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

23 committee to be known as the ‘Independent Assess24 ment Panel for Comprehensive Health Care’ (in this 

25 section referred to as the ‘Panel’). 


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

2 Secretary shall forward a copy of each waiver appli3 cation submitted under this section to the Panel for 

4 consideration under this subsection. 

5 ‘‘(3) DUTIES.—The Panel shall— 

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

7 State forwarded under paragraph (2) and any 

8 report submitted under paragraph (1) of sub9 section (e) for purposes of the review under 

10 paragraph (2) of such subsection; 

11 ‘‘(B) not later than 90 days after submis12 sion of such application (or report) by the 

13 State, provide to the State and to the Secretary 

14 the recommendations of the Panel regarding 

15 the approval or disapproval of such waiver ap16 plication (or regarding the status of the waiver 

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

18 and, if applicable, possible improvements to 

19 such application (or for purposes of subsection 

20 (e)(2)); and 

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

22 on waiver applications (and waiver reports 

23 under subsection (e)) reviewed by the Panel 

24 during the applicable year, including the num25 ber of applications (and reports) received and 


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1 the number of applications recommended for 

2 approval (and of reports with respect to which 

3 recommendations for continuation were pro4 vided). 

5 ‘‘(4) MEMBERSHIP.— 

6 ‘‘(A) NUMBER AND APPOINTMENT.—The 

7 Panel shall consist of 11 members appointed by 

8 the Secretary of Health and Human Services, 

9 of whom— 

10 ‘‘(i) 1 shall be appointed on the rec11 ommendation of the Speaker of the House 

12 of Representatives; 

13 ‘‘(ii) 1 shall be appointed on the rec14 ommendation of the minority leader of the 

15 House of Representatives; 

16 ‘‘(iii) 1 shall be appointed on the rec17 ommendation of the majority leader of the 

18 Senate; 

19 ‘‘(iv) 1 shall be appointed on the rec20 ommendation of the minority leader of the 

21 Senate; 

22 ‘‘(v) 1 shall be appointed on the rec23 ommendation of the Republican Governors 

24 Association; 


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1 ‘‘(vi) 1 shall be appointed on the rec2 ommendation of the Democratic Governors 

3 Association; 

4 ‘‘(vii) 1 shall be a representative from 

5 the patient advocacy community; 

6 ‘‘(viii) 2 shall be representatives of a 

7 labor organization representing health care 

8 professionals who provide direct patient 

9 care, including at least one labor organiza10 tion that primarily represents registered 

11 nurses; 

12 ‘‘(ix) 1 shall be a representative of 

13 primary care physicians; and 

14 ‘‘(x) 1 shall be a representative of 

15 health care professionals practicing in 

16 rural or underserved areas. 

17 ‘‘(B) TERM OF SERVICE.— 

18 ‘‘(i) IN GENERAL.—Each member of 

19 the Panel shall serve a 3-year term. A 

20 member may serve after the expiration of 

21 that member’s term until a successor has 

22 been appointed pursuant to subparagraph 

23 (A). 

24 ‘‘(ii) VACANCY.—Any member ap25 pointed to fill a vacancy occurring before 


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1 the expiration of the term for which the 

2 member’s predecessor was appointed shall 

3 be appointed only for the remainder of that 

4 term. A vacancy in the Commission shall 

5 be filled in the manner in which the origi6 nal appointment was made. 

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

8 serve without pay. 

9 ‘‘(D) CHAIRPERSON; VICE CHAIR10 PERSON.— 

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

12 Health and Human Services, or a designee 

13 of the Secretary, shall serve on the Panel 

14 as the Chairperson of the Panel. 

15 ‘‘(ii) VICE CHAIRPERSON.—The Ad16 ministrator of the Federal Emergency 

17 Management Agency, or a designee of the 

18 Administrator, shall serve on the Panel as 

19 the Vice Chairperson of the Panel. 

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

21 The Panel may— 

22 ‘‘(A) appoint such staff as the Panel con23 siders to be appropriate, without regard to the 

24 provisions of title 5, United States Code, gov25 erning appointments in the competitive service; 


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1 ‘‘(B) fix the pay of such staff, without re2 gard to the provisions of chapter 51 and sub3 chapter III of chapter 53 of such title relating 

4 to classification and General Schedule pay 

5 rates; and 

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

7 consultants in accordance with the provisions of 

8 section 3109(b) of such title. 

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

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

11 may detail, on a reimbursable basis, any of the per12 sonnel of the agency to the Panel to assist it in car13 rying out the duties under paragraph (3). 

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

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

16 App.) shall apply to the Panel. 

17 ‘‘(8) AUTHORIZATION OF APPROPRIATIONS.— 

18 There is authorized to be appropriated such sums as 

19 may be necessary to the Panel for carrying out the 

20 duties of the panel for each of fiscal years 2025 

21 through 2030. 

22 ‘‘(h) GUIDANCE RELATING TO AMERICAN INDIANS

23 AND ALASKA NATIVES.— 

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

25 guidance with respect to applying the provisions of 


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1 this section in a manner consistent with the fol2 lowing: 

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

4 health services to maintain and improve the 

5 health of Indians are consonant with and re6 quired by the Federal Government’s historical 

7 and unique legal relationship with, and result8 ing responsibility to, Indians. 

9 ‘‘(B) No enrollment fee, premium, or simi10 lar charge, and no deduction, copayment, cost 

11 sharing, or similar charge, is to be imposed 

12 against an Indian who is furnished an item or 

13 service through a waiver under this section. All 

14 costs incurred in waiving such charges shall be 

15 borne by the Federal Government in fulfillment 

16 of the trust responsibility. 

17 ‘‘(C) A State may not require the enroll18 ment of an individual who is an Indian in 

19 health insurance offered through a waiver under 

20 this section. 

21 ‘‘(D) Health insurance issuers offering cov22 erage pursuant to a waiver under this section 

23 must make good faith efforts to contract with 

24 Indian health care providers operating within 

25 the area served by the issuers. 


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1 ‘‘(E) Health insurance issuers offering cov2 erage pursuant to a waiver under this section 

3 shall pay Indian health care providers, whether 

4 such providers are participating or nonpartici5 pating providers with respect to the coverage, 

6 for covered services provided to those Indian 

7 enrollees who are eligible to receive services 

8 from such providers at a rate equal to the rate 

9 negotiated between such entity and the provider 

10 involved or, if such a rate has not been nego11 tiated, at a rate that is not less than the level 

12 and amount of payment which the entity would 

13 make for the services if the services were fur14 nished by a participating provider which is not 

15 an Indian health care provider. 

16 ‘‘(F) Health insurance issuers offering cov17 erage pursuant to a waiver under this section 

18 will include a standard contract addendum 

19 when contracting with Indian health care pro20 viders. The contract addendum will be devel21 oped in consultation with Tribes and in con22 ference with urban Indian health programs op23 erating within the service area of the State. 

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

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1 crimination in violation of the due process 

2 clause of the Fifth or Fourteenth Amendments, 

3 but is reasonable and rationally designed to fur4 ther the health of Indians. 

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

6 or more Indian health care programs furnishes 

7 health care services, the State will provide for 

8 a process under which the State seeks advice on 

9 a regular, ongoing basis from designees of such 

10 Indian health care programs and urban Indian 

11 organizations on matters relating to the appli12 cation of a waiver under this section that are 

13 likely to have a direct effect on such Indian 

14 health programs and that— 

15 ‘‘(i) shall include solicitation of advice 

16 prior to submission of any plan amend17 ments, waiver requests, and proposals for 

18 demonstration projects likely to have a di19 rect effect on Indians or Indian health care 

20 programs; and 

21 ‘‘(ii) may include appointment of an 

22 advisory committee and of a designee of 

23 such Indian health care programs to the 

24 medical care advisory committee advising 

25 the State on its waiver under this section. 


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1 ‘‘(2) DEFINITIONS.—For purposes of this sub2 section: 

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

4 given such term in section 447.50 of title 42, 

5 Code of Federal Regulations (as in effect on 

6 July 1, 2010). 

7 ‘‘(B) The term ‘Indian health care pro8 vider’ has the meaning given such term in sec9 tion 438.14(a) of title 42, Code of Federal Reg10 ulations. 

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

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

13 ‘health benefits coverage’— 

14 ‘‘(A) means— 

15 ‘‘(i) health insurance coverage, as 

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

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

18 300gg–(b)); and 

19 ‘‘(ii) coverage under a group health 

20 plan, as such term is defined in section 

21 2791(a) of the Public Health Service Act 

22 (42 U.S.C. 300gg–(a)); and 

23 ‘‘(B) includes any medical coverage or 

24 health benefits provided under one or more of 

25 the specified Federal health program described 


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•S 4817 IS

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

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

3 (a)(1). 

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

5 term ‘resident’ means an individual— 

6 ‘‘(A) who is— 

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

8 States; or 

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

10 State (including an alien who is granted 

11 deferred action or who is otherwise author12 ized to remain in the United States); and 

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

14 by the State) is located in the State. 

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

16 means— 

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

18 Services with respect to waivers relating to the 

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

20 and (D) through (G) of paragraph (2) of sub21 section (a); 

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

23 respect to waivers relating to the provisions de24 scribed in subparagraph (C) of such paragraph; 


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•S 4817 IS

1 ‘‘(C) the Director of the Office of Per2 sonnel Management with respect to waivers re3 lating to the provisions described in subpara4 graph (H) of such paragraph; 

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

6 to waivers relating to the provisions described 

7 in subparagraph (I) of such paragraph; and 

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

9 to waivers relating to the provisions described 

10 in subparagraph (J) of such paragraph. 

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

12 The term ‘specified Federal health program’ means 

13 one or more of the following programs, as applicable 

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

15 ‘‘(A) The Medicare program under title 

16 XVIII of the Social Security Act. 

17 ‘‘(B) The Medicaid program under title 

18 XIX of the Social Security Act. 

19 ‘‘(C) The Children’s Health Insurance Pro20 gram under title XXI of the Social Security 

21 Act. 

22 ‘‘(D) The Federal Employees Health Bene23 fits Plan under chapter 89 of title 5, United 

24 States Code. 


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

2 title 10, United States Code, including coverage 

3 under the TRICARE program. 

4 ‘‘(F) An Exchange established under this 

5 subtitle. 

6 ‘‘(G) Subsidies under section 1402. 

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

8 45R of the Internal Revenue Code of 1986.’’. 

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

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

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

12 after the item relating to section 1334 the following new 

13 item: 

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

Æ 


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