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[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 4817 Introduced in Senate (IS)]

<DOC>

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.

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

SECTION 1. SHORT TITLE; PURPOSE.

    (a) Short Title.--This Act may be cited as the ``State-Based 
Universal Health Care Act of 2024''.
    (b) Purpose.--The purpose of this Act is to establish a flexible 
framework under which States can provide comprehensive universal health 
coverage to their residents.

SEC. 2. WAIVER FOR STATE UNIVERSAL HEALTH CARE.

    (a) In General.--Part 4 of subtitle D of title I of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18021 et seq.) is amended 
by adding at the end the following:

``SEC. 1335. WAIVER FOR STATE UNIVERSAL HEALTH CARE.

    ``(a) Application.--
            ``(1) In general.--Subject to paragraph (6), a State may 
        apply to the Secretary (as defined in subsection (i)(3)) for 
        the waiver of so much of the requirements described in 
        paragraph (2) with respect to health benefits coverage within 
        the State for plan years beginning on or after January 1, 2025, 
        as is necessary to implement a comprehensive State universal 
        health care plan in the State under this section. Such 
        application shall--
                    ``(A) be filed at such time and in such manner as 
                the Secretary may require;
                    ``(B) contain such information as the Secretary may 
                require, including--
                            ``(i) a comprehensive description of the 
                        State legislation, or other State legal 
                        authority as applicable, and program to 
                        implement a plan meeting the requirements for a 
                        waiver under this section;
                            ``(ii) a plan for how the State will 
                        achieve in 5 years health coverage for at least 
                        95 percent of residents of the State; and
                            ``(iii) a 10-fiscal-year budget plan for 
                        such plan that is budget neutral for the 
                        Federal Government; and
                    ``(C) provide an assurance that the State has legal 
                authority to implement such plan or has enacted the law 
                described in subsection (b)(2).
            ``(2) Requirements.--The requirements described in this 
        paragraph with respect to health benefits coverage within the 
        State for plan years beginning on or after January 1, 2025, are 
        as follows:
                    ``(A) Sections 1301 through 1324.
                    ``(B) Section 1402.
                    ``(C) Sections 36B and 4980H of the Internal 
                Revenue Code of 1986.
                    ``(D) Title XI of the Social Security Act.
                    ``(E) Title XVIII of the Social Security Act.
                    ``(F) Title XIX of the Social Security Act.
                    ``(G) Title XXI of the Social Security Act.
                    ``(H) Chapter 89 of title 5, United States Code.
                    ``(I) Chapter 55 of title 10, United States Code, 
                including coverage under the TRICARE program.
                    ``(J) Section 514 of the Employee Retirement Income 
                Security Act of 1974.
            ``(3) Passthrough of funding.--With respect to a State 
        waiver under paragraph (1), under which the State assumes 
        responsibility for health coverage under one or more of the 
        specified Federal health programs, including under each of the 
        Federal health care or subsidy programs specified in 
        subparagraphs (A), (B), (C), (E), (F), (G), (H), and (I) of 
        paragraph (2), the Secretary shall not spend Federal health or 
        related administrative funds that would otherwise have been 
        spent for such a program, as applicable, for the time periods 
        covered under the waiver and shall provide for an alternative 
        means by which the aggregate amount of such funds (determined 
        by the Secretary in coordination with the State), including 
        caseload growth, adjusted for inflation in health care costs 
        within the State, shall be paid to the State for purposes of 
        implementing the State plan under the waiver. Any savings in 
        health care spending, including administrative savings, shall 
        be available to the State for reinvestment in health care 
        services under the State plan. Such amount shall be determined 
        annually by the Secretary, taking into account the amount that 
        would otherwise have been spent under each such Federal health 
        program, including for administrative activities and caseload 
        growth, with respect to residents of such State, for those time 
        periods covered under the waiver, adjusted for inflation in 
        health care costs, if such waiver did not apply. Such amount 
        shall include funds equal to the aggregate amount of premium 
        tax credits, cost-sharing reductions, or small-business 
        credits, to the extent applicable to an approved waiver, under 
        sections 36B and 45R of the Internal Revenue Code of 1986 or 
        under section 1402 that would have been available to 
        individuals and businesses in the State for those time periods 
        covered under the waiver, including caseload growth, adjusted 
        for inflation in health care costs, if such waiver did not 
        apply.
            ``(4) Waiver consideration and transparency.--
                    ``(A) In general.--An application for a waiver 
                under this section shall be considered by the 
                Secretary, after taking into account recommendations of 
                the Panel under subsection (g), in accordance with the 
                regulations described in subparagraph (B).
                    ``(B) Regulations.--Not later than 180 days after 
                the date of the enactment of the State-Based Universal 
                Health Care Act of 2024, the Secretary shall promulgate 
                regulations relating to waivers under this section that 
                provide--
                            ``(i) a process for public notice and 
                        comment in accordance with the public notice 
                        and comment requirements applicable under 
                        regulations used for Medicaid waivers pursuant 
                        to section 1115 of the Social Security Act;
                            ``(ii) a process for the submission of an 
                        application that ensures the disclosure of--
                                    ``(I) the provisions of law that 
                                the State involved seeks to waive; and
                                    ``(II) the specific plans of the 
                                State to ensure that the waiver will be 
                                in compliance with subsection (b);
                            ``(iii) a process for providing public 
                        notice and comment after the application is 
                        received by the Secretary that is sufficient to 
                        ensure a meaningful level of public input and 
                        that does not impose requirements that are in 
                        addition to, or duplicative of, requirements 
                        imposed under chapter 5 of title 5, United 
                        States Code (commonly referred to as the 
                        Administrative Procedure Act), or requirements 
                        that are unreasonable or unnecessarily 
                        burdensome with respect to State compliance;
                            ``(iv) a process for the submission to the 
                        Secretary of periodic reports by the State 
                        concerning the implementation of the program 
                        under the waiver;
                            ``(v) a process for the periodic evaluation 
                        by the Secretary with respect to waivers 
                        granted under this section; and
                            ``(vi) a process for providing technical 
                        assistance on--
                                    ``(I) how to develop an application 
                                to any State seeking to submit an 
                                application for a waiver relating to 
                                developing a program of providing 
                                health care for all residents for such 
                                State; and
                                    ``(II) how to improve such a 
                                program for purposes of a State seeking 
                                assistance pursuant to subsection 
                                (e)(2).
                    ``(C) Report.--The Secretary shall annually report 
                to Congress concerning actions taken by the Secretary 
                with respect to applications for waivers under this 
                section and programs conducted pursuant to such waivers 
                that are approved.
            ``(5) Regional waiver request and plan.--Nothing in this 
        section shall be construed to prevent 2 or more States in a 
        region from submitting a single application under this section 
        for a waiver that establishes a plan that is applicable to all 
        of the States included in such application. In the case of such 
        an application and plan, the requirements of this section shall 
        continue to be applicable with respect to each State included 
        in such application.
            ``(6) Coordination with 1332 waivers.--A State may not 
        apply for a waiver under this section with respect to a plan 
        year if such State has in effect, with respect to such plan 
        year, a waiver under section 1332.
            ``(7) Authorization of appropriations.--There is authorized 
        to be appropriated such sums as may be necessary for providing 
        funds to States with a waiver under this section for purposes 
        of carrying out activities described in subsection (b)(1)(E).
    ``(b) Granting of Waivers.--
            ``(1) In general.--The Secretary shall grant a request for 
        a waiver under subsection (a)(1) if the Secretary determines 
        that the State plan--
                    ``(A) will provide, in accordance with subparagraph 
                (B), health benefits coverage to applicable State 
                residents that is at least as comprehensive as the 
                health benefits coverage that such residents would have 
                received under one or more of the specified Federal 
                health programs (as defined in subsection (i)(4)), as 
                applicable, for which such residents would have been 
                eligible, absent such waiver;
                    ``(B) will provide, in the case of such a waiver 
                under subsection (a)(1) for the State to waive any of 
                the requirements described in subsection (a)(2)(F), as 
                applicable, health benefits coverage to applicable 
                State residents who would have otherwise received 
                health benefits coverage in the form of medical 
                assistance under the State Federal health program 
                described in subsection (i)(4)(B) (regardless of 
                whether the State provides for such assistance through 
                a State Medicaid plan under title XIX of the Social 
                Security Act or a waiver of such State Medicaid plan) 
                that includes at least the mandatory benefits under 
                title XIX of the Social Security Act that are required 
                of a State without a waiver of a State Medicaid plan 
                under such title, including benefits for early and 
                periodic screening, diagnostic, and treatment, benefits 
                for non-emergency transportation, and retroactive 
                coverage;
                    ``(C) will provide coverage and cost-sharing 
                protections against excessive out-of-pocket spending to 
                State residents that are at least as affordable as the 
                coverage and cost-sharing protections under the 
                specified Federal health program (as defined in 
                subsection (i)(4)) for which such residents would have 
                been eligible, absent such waiver;
                    ``(D) will provide coverage to all residents of the 
                State, including those otherwise covered under one or 
                more of the Federal health care or subsidy programs 
                specified in subparagraphs (B), (C), (E), (F), (G), and 
                (H) of subsection (a)(2), except individuals who are 
                eligible for benefits through the Indian Health Service 
                or for benefits and services under title 38, United 
                States Code;
                    ``(E) will provide for public education activities 
                to raise awareness of the availability of such coverage 
                and the facilitation of enrollment in such coverage, 
                and to raise awareness regarding restrictions on the 
                sale of duplicative or supplemental private insurance 
                (and, if the State chooses to continue to offer 
                qualified health plans through an Exchange, public 
                education activities will raise awareness of the 
                availability of and the facilitation of enrollment in 
                such plans in a manner similar to an entity that serves 
                as a navigator under a grant under section 1311(i));
                    ``(F) will be publicly administered by an agency or 
                multiple agencies of the State, or an independent 
                public entity within the government of the State;
                    ``(G) will not preclude the purchase of insurance 
                that offers coverage for benefits that are not offered 
                under the State plan;
                    ``(H) will provide systems for complaints, appeals, 
                independent review, and other procedures for accessing 
                and maintaining benefits that are at least as 
                accessible to applicable State residents as those of 
                one or more of the specified Federal health programs 
                (as defined in subsection (i)(4)) for which such 
                residents would have otherwise been eligible without 
                application of such waiver under subsection (a)(1); and
                    ``(I) will provide coverage for reproductive health 
                care services, including abortion, contraception, and 
                gender-affirming care.
        Subparagraph (D) shall not be construed as limiting a State 
        from contracting with one or more private entities to 
        administer the State plan.
            ``(2) Requirement to enact a law.--
                    ``(A) In general.--A law described in this 
                paragraph is a State law (including an executive order 
                by a State governor) that provides for State actions 
                under a waiver under this section, including the 
                implementation of the State plan under subsection 
                (a)(1)(B).
                    ``(B) Termination of opt out.--A State may repeal a 
                law described in subparagraph (A) and terminate the 
                authority provided under the waiver with respect to the 
                State.
    ``(c) Scope of Waiver.--
            ``(1) In general.--The Secretary shall determine the scope 
        of a waiver of a requirement described in subsection (a)(2) 
        granted to a State under subsection (a)(1).
            ``(2) Limitation.--Under this section, the Secretary may 
        not waive any Federal law or requirement that is not listed in 
        subsection (a)(2).
    ``(d) Determinations by Secretary.--
            ``(1) Time for determination.--The Secretary shall, with 
        respect to an application from a State under this section and 
        after taking into account recommendations of the Panel under 
        subsection (g) for such application, make a determination under 
        subsection (a)(1) not later than 90 days after the receipt of 
        such recommendations.
            ``(2) Effect of determination.--
                    ``(A) Granting of waivers.--If the Secretary 
                determines to grant a waiver under subsection (a)(1), 
                the Secretary shall notify the State involved of such 
                determination and the terms and effectiveness of such 
                waiver.
                    ``(B) Denial of waiver.--If the Secretary 
                determines a waiver should not be granted under 
                subsection (a)(1), the Secretary shall notify the State 
                involved and the appropriate committees of Congress of 
                such determination and the reasons therefor.
    ``(e) Required Reports; 5-Year Review.--
            ``(1) In general.--As a condition of receipt of a waiver 
        under this section, after each 5-year period of such waiver, a 
        State shall submit to the Secretary a report that is carried 
        out by an independent, non-partisan entity, with respect to 
        such 5-year period and after a process for public notice and 
        comment at the State level, including public hearings, 
        sufficient to ensure a meaningful level of public input, on the 
        following:
                    ``(A) How waiver funds have been spent by the 
                State.
                    ``(B) The number of residents of the State without 
                health insurance and a description of how the State 
                plans to provide health insurance coverage within the 
                subsequent 5 years to residents of the State without 
                health insurance.
                    ``(C) How affordability in the State for health 
                care has changed over the period.
                    ``(D) Whether the State has achieved health 
                coverage for at least 95 percent of the residents of 
                the State.
                    ``(E) Measurable changes in quality and access.
                    ``(F) Any additional information specified by the 
                Secretary for purposes of determining the successes and 
                challenges of the waiver.
            ``(2) 5-year review.--In the case a State, based on the 
        report submitted under paragraph (1) for a 5-year period--
                    ``(A) has been determined by the Secretary to have 
                not achieved health coverage for at least 95 percent of 
                the residents of the State--
                            ``(i) the State shall have access to 
                        technical assistance described in subsection 
                        (a)(4)(B)(vii) to improve the health insurance 
                        program of the State implemented through the 
                        waiver under this section;
                            ``(ii) the State shall have a grace period 
                        of 12 months after such determination to 
                        achieve health coverage for at least 95 percent 
                        of residents of the State; and
                            ``(iii) if after such 12 months, the State 
                        has not achieved such health coverage, the 
                        waiver under this section may be terminated at 
                        the discretion of the Secretary; and
                    ``(B) has been determined by the Secretary to have 
                achieved health coverage for at least 95 percent of 
                residents of the State, the State, as a condition of 
                continuing such waiver, shall submit to the Secretary a 
                plan for achieving health coverage for the remainder of 
                the residents of the State.
    ``(f) Assuring Coordination.--
            ``(1) In general.--Not later than 180 days after the date 
        of the enactment of the State-Based Universal Health Care Act 
        of 2024, the Secretary of Health and Human Services, the 
        Secretary of the Treasury, the Secretary of Defense, the 
        Secretary of Labor, and the Director of the Office of Personnel 
        Management, shall, through the execution of an interagency 
        memorandum of understanding among such Secretaries and 
        Director--
                    ``(A) develop a process for coordinating and 
                consolidating the State waiver processes applicable 
                under the provisions of this section, and the existing 
                waiver processes applicable under--
                            ``(i) titles XI, XVIII, XIX, and XXI of the 
                        Social Security Act; and
                            ``(ii) any other Federal law relating to 
                        the provision of health care items or services; 
                        and
                    ``(B) ensure that--
                            ``(i) regulations (including regulations 
                        required under subsection (a)(4)(B)), rulings, 
                        and interpretations issued by such Secretaries 
                        and Director relating to the same matter over 
                        which two or more such Secretaries or Director 
                        have responsibility under this section are 
                        administered so as to have the same effect at 
                        all times; and
                            ``(ii) coordination of policies relating to 
                        the granting, implementation, and continuation 
                        of waivers through such Secretaries and 
                        Director in order to have a coordinated 
                        strategy that avoids duplication of effort by 
                        the States or Secretaries and Director and 
                        ensures clarity about waiver application status 
                        and approval.
            ``(2) Single application.--The process under paragraph 
        (1)(A) shall permit a State to submit a single application for 
        a waiver under all of the provisions of this section and the 
        provisions of law listed under clauses (i) and (ii) of such 
        paragraph.
            ``(3) Submission of conforming amendments.--The Secretary 
        of Health and Human Services, in coordination with the other 
        Secretaries listed in paragraph (1) (including the Director of 
        the Office of Personnel Management), shall submit to Congress 
        such recommendations for such technical and conforming 
        amendments to law as may be appropriate to assist in the 
        implementation of this section.
    ``(g) Independent Assessment Panel for Comprehensive Health Care.--
            ``(1) Establishment.--There is established a committee to 
        be known as the `Independent Assessment Panel for Comprehensive 
        Health Care' (in this section referred to as the `Panel').
            ``(2) Consideration of submissions.--The Secretary shall 
        forward a copy of each waiver application submitted under this 
        section to the Panel for consideration under this subsection.
            ``(3) Duties.--The Panel shall--
                    ``(A) review any waiver application by a State 
                forwarded under paragraph (2) and any report submitted 
                under paragraph (1) of subsection (e) for purposes of 
                the review under paragraph (2) of such subsection;
                    ``(B) not later than 90 days after submission of 
                such application (or report) by the State, provide to 
                the State and to the Secretary the recommendations of 
                the Panel regarding the approval or disapproval of such 
                waiver application (or regarding the status of the 
                waiver for continuation pursuant to subsection (e)(2)) 
                and, if applicable, possible improvements to such 
                application (or for purposes of subsection (e)(2)); and
                    ``(C) submit to Congress an annual report on waiver 
                applications (and waiver reports under subsection (e)) 
                reviewed by the Panel during the applicable year, 
                including the number of applications (and reports) 
                received and the number of applications recommended for 
                approval (and of reports with respect to which 
                recommendations for continuation were provided).
            ``(4) Membership.--
                    ``(A) Number and appointment.--The Panel shall 
                consist of 11 members appointed by the Secretary of 
                Health and Human Services, of whom--
                            ``(i) 1 shall be appointed on the 
                        recommendation of the Speaker of the House of 
                        Representatives;
                            ``(ii) 1 shall be appointed on the 
                        recommendation of the minority leader of the 
                        House of Representatives;
                            ``(iii) 1 shall be appointed on the 
                        recommendation of the majority leader of the 
                        Senate;
                            ``(iv) 1 shall be appointed on the 
                        recommendation of the minority leader of the 
                        Senate;
                            ``(v) 1 shall be appointed on the 
                        recommendation of the Republican Governors 
                        Association;
                            ``(vi) 1 shall be appointed on the 
                        recommendation of the Democratic Governors 
                        Association;
                            ``(vii) 1 shall be a representative from 
                        the patient advocacy community;
                            ``(viii) 2 shall be representatives of a 
                        labor organization representing health care 
                        professionals who provide direct patient care, 
                        including at least one labor organization that 
                        primarily represents registered nurses;
                            ``(ix) 1 shall be a representative of 
                        primary care physicians; and
                            ``(x) 1 shall be a representative of health 
                        care professionals practicing in rural or 
                        underserved areas.
                    ``(B) Term of service.--
                            ``(i) In general.--Each member of the Panel 
                        shall serve a 3-year term. A member may serve 
                        after the expiration of that member's term 
                        until a successor has been appointed pursuant 
                        to subparagraph (A).
                            ``(ii) Vacancy.--Any member appointed to 
                        fill a vacancy occurring before the expiration 
                        of the term for which the member's predecessor 
                        was appointed shall be appointed only for the 
                        remainder of that term. A vacancy in the 
                        Commission shall be filled in the manner in 
                        which the original appointment was made.
                    ``(C) Pay.--Members of the Panel shall serve 
                without pay.
                    ``(D) Chairperson; vice chairperson.--
                            ``(i) Chairperson.--The Secretary of Health 
                        and Human Services, or a designee of the 
                        Secretary, shall serve on the Panel as the 
                        Chairperson of the Panel.
                            ``(ii) Vice chairperson.--The Administrator 
                        of the Federal Emergency Management Agency, or 
                        a designee of the Administrator, shall serve on 
                        the Panel as the Vice Chairperson of the Panel.
            ``(5) Staff, experts, and consultants.--The Panel may--
                    ``(A) appoint such staff as the Panel considers to 
                be appropriate, without regard to the provisions of 
                title 5, United States Code, governing appointments in 
                the competitive service;
                    ``(B) fix the pay of such staff, without regard to 
                the provisions of chapter 51 and subchapter III of 
                chapter 53 of such title relating to classification and 
                General Schedule pay rates; and
                    ``(C) procure the services of experts and 
                consultants in accordance with the provisions of 
                section 3109(b) of such title.
            ``(6) Detail of federal personnel.--Upon request of the 
        Panel, the head of any Federal agency may detail, on a 
        reimbursable basis, any of the personnel of the agency to the 
        Panel to assist it in carrying out the duties under paragraph 
        (3).
            ``(7) Federal advisory committee act.--The Federal Advisory 
        Committee Act (5 U.S.C. App.) shall apply to the Panel.
            ``(8) Authorization of appropriations.--There is authorized 
        to be appropriated such sums as may be necessary to the Panel 
        for carrying out the duties of the panel for each of fiscal 
        years 2025 through 2030.
    ``(h) Guidance Relating to American Indians and Alaska Natives.--
            ``(1) In general.--The Secretary shall issue guidance with 
        respect to applying the provisions of this section in a manner 
        consistent with the following:
                    ``(A) To further the goal that Federal health 
                services to maintain and improve the health of Indians 
                are consonant with and required by the Federal 
                Government's historical and unique legal relationship 
                with, and resulting responsibility to, Indians.
                    ``(B) No enrollment fee, premium, or similar 
                charge, and no deduction, copayment, cost sharing, or 
                similar charge, is to be imposed against an Indian who 
                is furnished an item or service through a waiver under 
                this section. All costs incurred in waiving such 
                charges shall be borne by the Federal Government in 
                fulfillment of the trust responsibility.
                    ``(C) A State may not require the enrollment of an 
                individual who is an Indian in health insurance offered 
                through a waiver under this section.
                    ``(D) Health insurance issuers offering coverage 
                pursuant to a waiver under this section must make good 
                faith efforts to contract with Indian health care 
                providers operating within the area served by the 
                issuers.
                    ``(E) Health insurance issuers offering coverage 
                pursuant to a waiver under this section shall pay 
                Indian health care providers, whether such providers 
                are participating or nonparticipating providers with 
                respect to the coverage, for covered services provided 
                to those Indian enrollees who are eligible to receive 
                services from such providers at a rate equal to the 
                rate negotiated between such entity and the provider 
                involved or, if such a rate has not been negotiated, at 
                a rate that is not less than the level and amount of 
                payment which the entity would make for the services if 
                the services were furnished by a participating provider 
                which is not an Indian health care provider.
                    ``(F) Health insurance issuers offering coverage 
                pursuant to a waiver under this section will include a 
                standard contract addendum when contracting with Indian 
                health care providers. The contract addendum will be 
                developed in consultation with Tribes and in conference 
                with urban Indian health programs operating within the 
                service area of the State.
                    ``(G) The treatment of Indians under this section 
                does not constitute invidious racial discrimination in 
                violation of the due process clause of the Fifth or 
                Fourteenth Amendments, but is reasonable and rationally 
                designed to further the health of Indians.
                    ``(H) In the case of any State in which 1 or more 
                Indian health care programs furnishes health care 
                services, the State will provide for a process under 
                which the State seeks advice on a regular, ongoing 
                basis from designees of such Indian health care 
                programs and urban Indian organizations on matters 
                relating to the application of a waiver under this 
                section that are likely to have a direct effect on such 
                Indian health programs and that--
                            ``(i) shall include solicitation of advice 
                        prior to submission of any plan amendments, 
                        waiver requests, and proposals for 
                        demonstration projects likely to have a direct 
                        effect on Indians or Indian health care 
                        programs; and
                            ``(ii) may include appointment of an 
                        advisory committee and of a designee of such 
                        Indian health care programs to the medical care 
                        advisory committee advising the State on its 
                        waiver under this section.
            ``(2) Definitions.--For purposes of this subsection:
                    ``(A) The term `Indian' has the meaning given such 
                term in section 447.50 of title 42, Code of Federal 
                Regulations (as in effect on July 1, 2010).
                    ``(B) The term `Indian health care provider' has 
                the meaning given such term in section 438.14(a) of 
                title 42, Code of Federal Regulations.
    ``(i) Definitions.--In this section:
            ``(1) Health benefits coverage.--The term `health benefits 
        coverage'--
                    ``(A) means--
                            ``(i) health insurance coverage, as such 
                        term is defined in section 2791(b) of the 
                        Public Health Service Act (42 U.S.C. 300gg-
                        (b)); and
                            ``(ii) coverage under a group health plan, 
                        as such term is defined in section 2791(a) of 
                        the Public Health Service Act (42 U.S.C. 300gg-
                        (a)); and
                    ``(B) includes any medical coverage or health 
                benefits provided under one or more of the specified 
                Federal health program described in subparagraphs (A) 
                through (E) of paragraph (4), as applicable to a waiver 
                under subsection (a)(1).
            ``(2) Resident.--With respect to a State, the term 
        `resident' means an individual--
                    ``(A) who is--
                            ``(i) a citizen or national of the United 
                        States; or
                            ``(ii) an alien lawfully residing in the 
                        State (including an alien who is granted 
                        deferred action or who is otherwise authorized 
                        to remain in the United States); and
                    ``(B) whose primary residence (as defined by the 
                State) is located in the State.
            ``(3) Secretary.--The term `Secretary' means--
                    ``(A) the Secretary of Health and Human Services 
                with respect to waivers relating to the provisions 
                described in subparagraphs (A), (B), and (D) through 
                (G) of paragraph (2) of subsection (a);
                    ``(B) the Secretary of the Treasury with respect to 
                waivers relating to the provisions described in 
                subparagraph (C) of such paragraph;
                    ``(C) the Director of the Office of Personnel 
                Management with respect to waivers relating to the 
                provisions described in subparagraph (H) of such 
                paragraph;
                    ``(D) the Secretary of Defense with respect to 
                waivers relating to the provisions described in 
                subparagraph (I) of such paragraph; and
                    ``(E) the Secretary of Labor with respect to 
                waivers relating to the provisions described in 
                subparagraph (J) of such paragraph.
            ``(4) Specified federal health program.--The term 
        `specified Federal health program' means one or more of the 
        following programs, as applicable to a waiver under subsection 
        (a)(1):
                    ``(A) The Medicare program under title XVIII of the 
                Social Security Act.
                    ``(B) The Medicaid program under title XIX of the 
                Social Security Act.
                    ``(C) The Children's Health Insurance Program under 
                title XXI of the Social Security Act.
                    ``(D) The Federal Employees Health Benefits Plan 
                under chapter 89 of title 5, United States Code.
                    ``(E) Medical coverage under chapter 55 of title 
                10, United States Code, including coverage under the 
                TRICARE program.
                    ``(F) An Exchange established under this subtitle.
                    ``(G) Subsidies under section 1402.
                    ``(H) Tax credits under sections 36B and 45R of the 
                Internal Revenue Code of 1986.''.
    (b) Clerical Amendment.--The table of contents in section 1(b) of 
the Patient Protection and Affordable Care Act (42 U.S.C. 18001 note) 
is amended by inserting after the item relating to section 1334 the 
following new item:

``1335. Waiver for State universal health care.''.
                                 <all>
```