I 

117TH CONGRESS 

1ST SESSION H. R. 1976 

To establish an improved Medicare for All national health insurance program. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 17, 2021 

Ms. JAYAPAL (for herself, Ms. ADAMS, Ms. BARRAGA ́N, Ms. BASS, Mr. 

BEYER, Mr. BLUMENAUER, Ms. BONAMICI, Mr. BOWMAN, Mr. BRENDAN

F. BOYLE of Pennsylvania, Mr. BROWN, Ms. BUSH, Mr. CARBAJAL, Mr. 

CA ́RDENAS, Mr. CARSON, Mr. CARTWRIGHT, Ms. CHU, Mr. CICILLINE, 

Ms. CLARK of Massachusetts, Ms. CLARKE of New York, Mr. CLEAVER, 

Mr. COHEN, Mr. DEUTCH, Mr. DANNY K. DAVIS of Illinois, Mr. DEFAZIO, Ms. DEGETTE, Mr. DESAULNIER, Mrs. DINGELL, Mr. DOGGETT, 

Mr. MICHAEL F. DOYLE of Pennsylvania, Ms. ESCOBAR, Mr. ESPAILLAT, 

Ms. LOIS FRANKEL of Florida, Mr. GALLEGO, Mr. GARCI ́A of Illinois, 

Mr. GOMEZ, Mr. GREEN of Texas, Mr. GRIJALVA, Mr. HARDER of California, Mr. HASTINGS, Mrs. HAYES, Mr. HIGGINS of New York, Mr. 

HUFFMAN, Ms. JACKSON LEE, Ms. JACOBS of California, Mr. JEFFRIES, 

Mr. JOHNSON of Georgia, Mr. JONES, Mr. KAHELE, Mr. KEATING, Ms. 

KELLY of Illinois, Mr. KHANNA, Mr. KILDEE, Mrs. KIRKPATRICK, Mr. 

LANGEVIN, Mrs. LAWRENCE, Ms. LEE of California, Ms. LEGER

FERNANDEZ, Mr. LEVIN of Michigan, Mr. LEVIN of California, Mr. LIEU, 

Mr. LOWENTHAL, Mrs. CAROLYN B. MALONEY of New York, Mr. 

MCGOVERN, Mr. MCNERNEY, Mr. MEEKS, Ms. MENG, Mr. NADLER, 

Mrs. NAPOLITANO, Mr. NEGUSE, Ms. NEWMAN, Ms. NORTON, Ms. 

OCASIO-CORTEZ, Ms. OMAR, Mr. PANETTA, Mr. PAYNE, Mr. PERLMUTTER, Ms. PINGREE, Mr. POCAN, Ms. PORTER, Ms. PRESSLEY, Mr. 

RASKIN, Ms. ROYBAL-ALLARD, Mr. RUSH, Mr. SABLAN, Ms. SA ́NCHEZ, 

Mr. SARBANES, Ms. SCHAKOWSKY, Mr. SCHIFF, Mr. SCOTT of Virginia, 

Mr. SHERMAN, Mr. SMITH of Washington, Ms. SPEIER, Mr. SWALWELL, 

Mr. TAKANO, Mr. THOMPSON of Mississippi, Mr. THOMPSON of California, Ms. TITUS, Ms. TLAIB, Mr. TONKO, Mr. TORRES of New York, 

Mrs. TRAHAN, Mr. VARGAS, Mr. VEASEY, Ms. VELA ́ZQUEZ, Ms. WATERS, 

Mrs. WATSON COLEMAN, Mr. WELCH, Ms. WILD, Ms. WILLIAMS of Georgia, Ms. WILSON of Florida, Mr. YARMUTH, Mr. PALLONE, and Mr. 

PRICE of North Carolina) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to 

the Committees on Ways and Means, Education and Labor, Rules, Oversight and Reform, Armed Services, and the Judiciary, for a period to be 

subsequently determined by the Speaker, in each case for consideration 


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of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To establish an improved Medicare for All national health 

insurance program. 

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

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘Medicare for All Act of 2021’’. 

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

7 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—ESTABLISHMENT OF THE MEDICARE FOR ALL 

PROGRAM; UNIVERSAL COVERAGE; ENROLLMENT 

Sec. 101. Establishment of the Medicare for All Program. 

Sec. 102. Universal coverage. 

Sec. 103. Freedom of choice. 

Sec. 104. Non-discrimination. 

Sec. 105. Enrollment. 

Sec. 106. Effective date of benefits. 

Sec. 107. Prohibition against duplicating coverage. 

TITLE II—COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE 

BENEFITS AND BENEFITS FOR LONG-TERM CARE 

Sec. 201. Comprehensive benefits. 

Sec. 202. No cost-sharing; other limitations. 

Sec. 203. Exclusions and limitations. 

Sec. 204. Coverage of long-term care services. 

TITLE III—PROVIDER PARTICIPATION 

Sec. 301. Provider participation and standards; whistleblower protections. 

Sec. 302. Qualifications for providers. 

Sec. 303. Use of private contracts. 

TITLE IV—ADMINISTRATION 


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Subtitle A—General Administration Provisions 

Sec. 401. Administration. 

Sec. 402. Consultation. 

Sec. 403. Regional administration. 

Sec. 404. Beneficiary ombudsman. 

Sec. 405. Conduct of related health programs. 

Subtitle B—Control Over Fraud and Abuse 

Sec. 411. Application of Federal sanctions to all fraud and abuse under the 

Medicare for All Program. 

TITLE V—QUALITY ASSESSMENT 

Sec. 501. Quality standards. 

Sec. 502. Addressing health care disparities. 

TITLE VI—HEALTH BUDGET; PAYMENTS; COST CONTAINMENT 

MEASURES 

Subtitle A—Budgeting 

Sec. 601. National health budget. 

Subtitle B—Payments to Providers 

Sec. 611. Payments to institutional providers based on global budgets. 

Sec. 612. Payment to individual providers through fee-for-service. 

Sec. 613. Ensuring accurate valuation of services under the Medicare physician 

fee schedule. 

Sec. 614. Payment prohibitions; capital expenditures; special projects. 

Sec. 615. Office of Health Equity. 

Sec. 616. Office of Primary Care. 

Sec. 617. Payments for prescription drugs and approved devices and equipment. 

TITLE VII—UNIVERSAL MEDICARE TRUST FUND 

Sec. 701. Universal Medicare Trust Fund. 

TITLE VIII—CONFORMING AMENDMENTS TO THE EMPLOYEE 

RETIREMENT INCOME SECURITY ACT OF 1974 

Sec. 801. Prohibition of employee benefits duplicative of benefits under the 

Medicare for All Program; coordination in case of workers’ 

compensation. 

Sec. 802. Application of continuation coverage requirements under ERISA and 

certain other requirements relating to group health plans. 

Sec. 803. Effective date of title. 

TITLE IX—ADDITIONAL CONFORMING AMENDMENTS 

Sec. 901. Relationship to existing Federal health programs. 

Sec. 902. Sunset of provisions related to the State Exchanges. 

Sec. 903. Sunset of provisions related to pay for performance programs. 

TITLE X—TRANSITION 


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Subtitle A—Medicare for All Transition Over 2 Years and Transitional BuyIn Option 

Sec. 1001. Medicare for all transition over two years. 

Sec. 1002. Establishment of the Medicare transition buy-in. 

Subtitle B—Transitional Medicare Reforms 

Sec. 1011. Eliminating the 24-month waiting period for Medicare coverage for 

individuals with disabilities. 

Sec. 1012. Ensuring continuity of care. 

TITLE XI—MISCELLANEOUS 

Sec. 1101. Definitions. 

Sec. 1102. Rules of construction. 

Sec. 1103. No use of resources for law enforcement of certain registration requirements. 

1 TITLE I—ESTABLISHMENT OF 

2 THE MEDICARE FOR ALL PRO3 GRAM; UNIVERSAL COV4 ERAGE; ENROLLMENT 

5 SEC. 101. ESTABLISHMENT OF THE MEDICARE FOR ALL 

6 PROGRAM. 

7 There is hereby established a national health insur8 ance program to provide comprehensive protection against 

9 the costs of health care and health-related services, in ac10 cordance with the standards specified in, or established 

11 under, this Act. 

12 SEC. 102. UNIVERSAL COVERAGE. 

13 (a) IN GENERAL.—Every individual who is a resident 

14 of the United States is entitled to benefits for health care 

15 services under this Act. The Secretary shall promulgate 

16 a rule that provides criteria for determining residency for 

17 eligibility purposes under this Act. 


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1 (b) TREATMENT OF OTHER INDIVIDUALS.—The Sec2 retary may make eligible for benefits for health care serv3 ices under this Act other individuals not described in sub4 section (a), and regulate the eligibility of such individuals, 

5 to ensure that every person in the United States has ac6 cess to health care. In regulating such eligibility, the Sec7 retary shall ensure that individuals are not allowed to 

8 travel to the United States for the sole purpose of obtain9 ing health care items and services provided under the pro10 gram established under this Act. 

11 SEC. 103. FREEDOM OF CHOICE. 

12 Any individual entitled to benefits under this Act may 

13 obtain health services from any institution, agency, or in14 dividual qualified to participate under this Act. 

15 SEC. 104. NON-DISCRIMINATION. 

16 (a) IN GENERAL.—No person shall, on the basis of 

17 race, color, national origin, age, disability, marital status, 

18 citizenship status, primary language use, genetic condi19 tions, previous or existing medical conditions, religion, or 

20 sex, including sex stereotyping, gender identity, sexual ori21 entation, and pregnancy and related medical conditions 

22 (including termination of pregnancy), be excluded from 

23 participation in or be denied the benefits of the program 

24 established under this Act (except as expressly authorized 

25 by this Act for purposes of enforcing eligibility standards 


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1 described in section 102), or be subject to any reduction 

2 of benefits or other discrimination by any participating 

3 provider (as defined in section 301), or any entity con4 ducting, administering, or funding a health program or 

5 activity, including contracts of insurance, pursuant to this 

6 Act. 

7 (b) CLAIMS OF DISCRIMINATION.— 

8 (1) IN GENERAL.—The Secretary shall establish 

9 a procedure for adjudication of administrative com10 plaints alleging a violation of subsection (a). 

11 (2) JURISDICTION.—Any person aggrieved by a 

12 violation of subsection (a) by a covered entity may 

13 file suit in any district court of the United States 

14 having jurisdiction of the parties. A person may 

15 bring an action under this paragraph concurrently 

16 as such administrative remedies as established in 

17 paragraph (1). 

18 (3) DAMAGES.—If the court finds a violation of 

19 subsection (a), the court may grant compensatory 

20 and punitive damages, declaratory relief, injunctive 

21 relief, attorneys’ fees and costs, or other relief as ap22 propriate. 

23 (c) CONTINUED APPLICATION OF LAWS.—Nothing in 

24 this title (or an amendment made by this title) shall be 

25 construed to invalidate or otherwise limit any of the rights, 


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1 remedies, procedures, or legal standards available to indi2 viduals aggrieved under section 1557 of the Patient Pro3 tection and Affordable Care Act (42 U.S.C. 18116), title 

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

5 seq.), title VII of the Civil Rights Act of 1964 (42 U.S.C. 

6 2000e et seq.), title IX of the Education Amendments of 

7 1972 (20 U.S.C. 1681 et seq.), section 504 of the Reha8 bilitation Act of 1973 (29 U.S.C. 794), or the Age Dis9 crimination Act of 1975 (42 U.S.C. 611 et seq.). Nothing 

10 in this title (or an amendment to this title) shall be con11 strued to supersede State laws that provide additional pro12 tections against discrimination on any basis described in 

13 subsection (a). 

14 SEC. 105. ENROLLMENT. 

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

16 mechanism for the enrollment of individuals eligible for 

17 benefits under this Act. The mechanism shall— 

18 (1) include a process for the automatic enroll19 ment of individuals at the time of birth in the 

20 United States (or upon establishment of residency in 

21 the United States); 

22 (2) provide for the enrollment, as of the dates 

23 described in section 106, of all individuals who are 

24 eligible to be enrolled as of such dates, as applicable; 

25 and 


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1 (3) include a process for the enrollment of indi2 viduals made eligible for health care services under 

3 section 102(b). 

4 (b) ISSUANCE OF UNIVERSAL MEDICARE CARDS.— 

5 In conjunction with an individual’s enrollment for benefits 

6 under this Act, the Secretary shall provide for the issuance 

7 of a Universal Medicare card that shall be used for pur8 poses of identification and processing of claims for bene9 fits under this program. The card shall not include an in10 dividual’s Social Security number. 

11 SEC. 106. EFFECTIVE DATE OF BENEFITS. 

12 (a) IN GENERAL.—Except as provided in subsection 

13 (b), benefits shall first be available under this Act for 

14 items and services furnished 2 years after the date of the 

15 enactment of this Act. 

16 (b) COVERAGE FOR CERTAIN INDIVIDUALS.— 

17 (1) IN GENERAL.—For any eligible individual 

18 who— 

19 (A) has not yet attained the age of 19 as 

20 of the date that is 1 year after the date of the 

21 enactment of this Act; or 

22 (B) has attained the age of 55 as of the 

23 date that is 1 year after the date of the enact24 ment of this Act, 


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1 benefits shall first be available under this Act for 

2 items and services furnished as of such date. 

3 (2) OPTION TO CONTINUE IN OTHER COVERAGE

4 DURING TRANSITION PERIOD.—Any person who is 

5 eligible to receive benefits as described in paragraph 

6 (1) may opt to maintain any coverage described in 

7 section 901, private health insurance coverage, or 

8 coverage offered pursuant to subtitle A of title X 

9 (including the amendments made by such subtitle) 

10 until the date described in subsection (a). 

11 SEC. 107. PROHIBITION AGAINST DUPLICATING COVERAGE. 

12 (a) IN GENERAL.—Beginning on the effective date 

13 described in section 106(a), it shall be unlawful for— 

14 (1) a private health insurer to sell health insur15 ance coverage that duplicates the benefits provided 

16 under this Act; or 

17 (2) an employer to provide benefits for an em18 ployee, former employee, or the dependents of an 

19 employee or former employee that duplicate the ben20 efits provided under this Act. 

21 (b) CONSTRUCTION.—Nothing in this Act shall be 

22 construed as prohibiting the sale of health insurance cov23 erage for any additional benefits not covered by this Act, 

24 including additional benefits that an employer may provide 


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1 to employees or their dependents, or to former employees 

2 or their dependents. 

3 TITLE II—COMPREHENSIVE BEN4 EFITS, INCLUDING PREVEN5 TIVE BENEFITS AND BENE6 FITS FOR LONG-TERM CARE 

7 SEC. 201. COMPREHENSIVE BENEFITS. 

8 (a) IN GENERAL.—Subject to the other provisions of 

9 this title and titles IV through IX, individuals enrolled for 

10 benefits under this Act are entitled to have payment made 

11 by the Secretary to an eligible provider for the following 

12 items and services if medically necessary or appropriate 

13 for the maintenance of health or for the diagnosis, treat14 ment, or rehabilitation of a health condition: 

15 (1) Hospital services, including inpatient and 

16 outpatient hospital care, including 24-hour-a-day 

17 emergency services and inpatient prescription drugs. 

18 (2) Ambulatory patient services. 

19 (3) Primary and preventive services, including 

20 chronic disease management. 

21 (4) Prescription drugs and medical devices, in22 cluding outpatient prescription drugs, medical de23 vices, and biological products. 

24 (5) Mental health and substance use treatment 

25 services, including inpatient care. 


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1 (6) Laboratory and diagnostic services. 

2 (7) Comprehensive reproductive, maternity, and 

3 newborn care. 

4 (8) Oral health, audiology, and vision services. 

5 (9) Rehabilitative and habilitative services and 

6 devices. 

7 (10) Emergency services and transportation. 

8 (11) Early and periodic screening, diagnostic, 

9 and treatment services, as described in sections 

10 1902(a)(10)(A), 1902(a)(43), 1905(a)(4)(B), and 

11 1905(r) of the Social Security Act (42 U.S.C. 

12 1396a(a)(10)(A); 1396a(a)(43); 1396d(a)(4)(B); 

13 1396d(r)). 

14 (12) Necessary transportation to receive health 

15 care services for persons with disabilities, older indi16 viduals with functional limitations, or low-income in17 dividuals (as determined by the Secretary). 

18 (13) Long-term care services and support (as 

19 described in section 204). 

20 (14) Hospice care. 

21 (15) Services provided by a licensed marriage 

22 and family therapist or a licensed mental health 

23 counselor. 

24 (b) REVISION.—The Secretary shall, at least annu25 ally, and on a regular basis, evaluate whether the benefits 


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1 package should be improved to promote the health of bene2 ficiaries, account for changes in medical practice or new 

3 information from medical research, or respond to other 

4 relevant developments in health science, and shall make 

5 recommendations to Congress regarding any such im6 provements. Such recommendations may not include a rec7 ommendation to eliminate any benefit. 

8 (c) HEARINGS.— 

9 (1) IN GENERAL.—The Committee on Energy 

10 and Commerce and the Committee on Ways and 

11 Means of the House of Representatives shall, not 

12 less frequently than annually, hold a hearing on the 

13 recommendations submitted by the Secretary under 

14 subsection (b). 

15 (2) EXERCISE OF RULEMAKING AUTHORITY.— 

16 Paragraph (1) is enacted— 

17 (A) as an exercise of rulemaking power of 

18 the House of Representatives, and, as such, 

19 shall be considered as part of the rules of the 

20 House, and such rules shall supersede any other 

21 rule of the House only to the extent that rule 

22 is inconsistent therewith; and 

23 (B) with full recognition of the constitu24 tional right of either House to change such 

25 rules (so far as relating to the procedure in 


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1 such House) at any time, in the same manner, 

2 and to the same extent as in the case of any 

3 other rule of the House. 

4 (d) COMPLEMENTARY AND INTEGRATIVE MEDI5 CINE.— 

6 (1) IN GENERAL.—In carrying out subsection 

7 (b), the Secretary shall consult with the persons de8 scribed in paragraph (2) with respect to— 

9 (A) identifying specific complementary and 

10 integrative medicine practices that are appro11 priate to include in the benefits package; and 

12 (B) identifying barriers to the effective 

13 provision and integration of such practices into 

14 the delivery of health care, and identifying 

15 mechanisms for overcoming such barriers. 

16 (2) CONSULTATION.—In accordance with para17 graph (1), the Secretary shall consult with— 

18 (A) the Director of the National Center for 

19 Complementary and Integrative Health; 

20 (B) the Commissioner of Food and Drugs; 

21 (C) institutions of higher education, pri22 vate research institutes, and individual re23 searchers with extensive experience in com24 plementary and alternative medicine and the inVerDate Sep 11 2014 23:21 May 17, 2021 Jkt 019200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\H1976.IH H1976

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1 tegration of such practices into the delivery of 

2 health care; 

3 (D) nationally recognized providers of com4 plementary and integrative medicine; and 

5 (E) such other officials, entities, and indi6 viduals with expertise on complementary and 

7 integrative medicine as the Secretary deter8 mines appropriate. 

9 (e) STATES MAY PROVIDE ADDITIONAL BENE10 FITS.—Individual States may provide additional benefits 

11 for the residents of such States, as determined by such 

12 State, and may provide benefits to individuals not eligible 

13 for benefits under this Act, at the expense of the State, 

14 subject to the requirements specified in section 1102. 

15 SEC. 202. NO COST-SHARING; OTHER LIMITATIONS. 

16 (a) IN GENERAL.—The Secretary shall ensure that 

17 no cost-sharing, including deductibles, coinsurance, copay18 ments, or similar charges, is imposed on an individual for 

19 any benefits provided under this Act. 

20 (b) NO BALANCE BILLING.—No provider may impose 

21 a charge to an enrolled individual for covered services for 

22 which benefits are provided under this Act. 

23 (c) NO PRIOR AUTHORIZATION.—Benefits provided 

24 under this Act shall be covered without any need for any 


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1 prior authorization determination and without any limita2 tion applied through the use of step therapy protocols. 

3 SEC. 203. EXCLUSIONS AND LIMITATIONS. 

4 (a) IN GENERAL.—Benefits for items and services 

5 are not available under this Act unless the items and serv6 ices meet the standards developed by the Secretary pursu7 ant to section 201(a). 

8 (b) TREATMENT OF EXPERIMENTAL ITEMS AND

9 SERVICES AND DRUGS.— 

10 (1) IN GENERAL.—In applying subsection (a), 

11 the Secretary shall make national coverage deter12 minations with respect to items and services that are 

13 experimental in nature. Such determinations shall be 

14 consistent with the national coverage determination 

15 process as defined in section 1869(f)(1)(B) of the 

16 Social Security Act (42 U.S.C. 1395ff(f)(1)(B)). 

17 (2) APPEALS PROCESS.—The Secretary shall 

18 establish a process by which individuals can appeal 

19 coverage decisions. The process shall, as much as is 

20 feasible, follow the process for appeals under the 

21 Medicare program described in section 1869 of the 

22 Social Security Act (42 U.S.C. 1395ff). 

23 (c) APPLICATION OF PRACTICE GUIDELINES.— 

24 (1) IN GENERAL.—In the case of items and 

25 services for which the Department of Health and 


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1 Human Services has recognized a national practice 

2 guideline, such items and services shall be deemed to 

3 meet the standards specified in section 201(a) if 

4 they have been provided in accordance with such 

5 guideline. For purposes of this subsection, an item 

6 or service not provided in accordance with a practice 

7 guideline shall be deemed to have been provided in 

8 accordance with the guideline if the health care pro9 vider providing the item or service— 

10 (A) exercised appropriate professional 

11 judgment in accordance with the laws and re12 quirements of the State in which such item or 

13 service is furnished in deviating from the guide14 line; 

15 (B) acted in the best interest of the indi16 vidual receiving the item or service; and 

17 (C) acted in a manner consistent with the 

18 individual’s wishes. 

19 (2) OVERRIDE OF STANDARDS.— 

20 (A) IN GENERAL.—An individual’s treating 

21 physician or other health care professional au22 thorized to exercise independent professional 

23 judgment in implementing a patient’s medical 

24 or nursing care plan in accordance with the 

25 scope of practice, licensure, and other law of 


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1 the State where items and services are to be 

2 furnished may override practice standards es3 tablished pursuant to section 201(a) or practice 

4 guidelines described in paragraph (1), including 

5 such standards and guidelines that are imple6 mented by a provider through the use of health 

7 information technology, such as electronic 

8 health record technology, clinical decision sup9 port technology, and computerized order entry 

10 programs. 

11 (B) LIMITATION.—An override described 

12 in subparagraph (A) shall, in the professional 

13 judgment of such physician, nurse, or health 

14 care professional, be— 

15 (i) consistent with such physician’s, 

16 nurse’s, or health care professional’s deter17 mination of medical necessity and appro18 priateness or nursing assessment; 

19 (ii) in the best interests of the indi20 vidual; and 

21 (iii) consistent with the individual’s 

22 wishes. 

23 SEC. 204. COVERAGE OF LONG-TERM CARE SERVICES. 

24 (a) IN GENERAL.—Subject to the other provisions of 

25 this Act, individuals enrolled for benefits under this Act 


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1 are entitled to the following long-term services and sup2 ports and to have payment made by the Secretary to an 

3 eligible provider for such services and supports if medically 

4 necessary and appropriate and in accordance with the 

5 standards established in this Act, for maintenance of 

6 health or for care, services, diagnosis, treatment, or reha7 bilitation that is related to a medically determinable condi8 tion, whether physical or mental, of health, injury, or age 

9 that— 

10 (1) causes a functional limitation in performing 

11 one or more activities of daily living; or 

12 (2) requires a similar need of assistance in per13 forming instrumental activities of daily living. 

14 (b) ELIGIBILITY.—An individual shall be eligible for 

15 services and supports described in this section if such indi16 vidual has one or more medically determinable conditions 

17 described in subsection (a). 

18 (c) SERVICES AND SUPPORTS.—Long-term services 

19 and supports under this section shall be tailored to an in20 dividual’s needs, as determined through assessment, and 

21 shall be defined by the Secretary to— 

22 (1) include any long-term nursing services for 

23 the enrollee, whether provided in an institution or in 

24 a home and community-based setting; 


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1 (2) provide coverage for a broad spectrum of 

2 long-term services and supports, including for home 

3 and community-based services and other care pro4 vided through non-institutional settings; 

5 (3) provide coverage that meets the physical, 

6 mental, and social needs of recipients while allowing 

7 recipients their maximum possible autonomy and 

8 their maximum possible civic, social, and economic 

9 participation; 

10 (4) prioritize delivery of long-term services and 

11 supports through home and community-based serv12 ices over institutionalization; 

13 (5) unless an individual elects otherwise, ensure 

14 that recipients will receive home and community 

15 based long-term services and supports (as defined in 

16 subsection (f)(4)), regardless of the individuals’s 

17 type or level of disability, service need, or age; 

18 (6) be provided with the goal of enabling per19 sons with disabilities to receive services in the least 

20 restrictive and most integrated setting appropriate 

21 to the individual’s needs; 

22 (7) be provided in such a manner that allows 

23 persons with disabilities to maintain their independ24 ence, self-determination, and dignity; 


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1 (8) provide long-term services and supports 

2 that are of equal quality and equally accessible 

3 across geographic regions; and 

4 (9) ensure that long-term services and supports 

5 provide recipient’s the option of self-direction of 

6 services from either the recipient or care coordina7 tors of the recipient’s choosing. 

8 (d) PUBLIC CONSULTATION.—In developing regula9 tions to implement this section, the Secretary shall consult 

10 with an advisory commission on long-term services and 

11 supports that includes— 

12 (1) people with disabilities who use long-term 

13 services and supports and older adults who use long14 term services and supports; 

15 (2) representatives of people with disabilities 

16 and representatives of older adults; 

17 (3) groups that represent the diversity of the 

18 population of people living with disabilities, including 

19 racial, ethnic, national origin, primary language use, 

20 age, sex, including gender identity and sexual ori21 entation, geographical, and socioeconomic diversity; 

22 (4) providers of long-term services and sup23 ports, including family attendants and family care24 givers, and members of organized labor; 

25 (5) disability rights organizations; and 


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1 (6) relevant academic institutions and research2 ers. 

3 (e) BUDGETING AND PAYMENTS.—Budgeting and 

4 payments for long-term services and supports provided 

5 under this section shall be made in accordance with the 

6 provisions under title VI. 

7 (f) DEFINITIONS.—In this section: 

8 (1) The term ‘‘long-term services and supports’’ 

9 means long-term care, treatment, maintenance, or 

10 services needed to support the activities of daily liv11 ing and instrumental activities of daily living, includ12 ing home and community-based services and any ad13 ditional services and supports identified by the Sec14 retary to support people with disabilities to live, 

15 work, and participate in their communities. 

16 (2) The term ‘‘activities of daily living’’ means 

17 basic personal everyday activities, including tasks 

18 such as eating, toileting, grooming, dressing, bath19 ing, and transferring. 

20 (3) The term ‘‘instrumental activities of daily 

21 living’’ means activities related to living independ22 ently in the community, including but not limited to, 

23 meal planning and preparation, managing finances, 

24 shopping for food, clothing, and other essential 

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1 municating by phone or other media, and traveling 

2 around and participating in the community. 

3 (4) The term ‘‘home and community-based 

4 services’’ means the home and community-based 

5 services that are coverable under subsections (c), 

6 (d), (i), and (k) of section 1915 of the Social Secu7 rity Act (42 U.S.C. 1396n), and as defined by the 

8 Secretary, including as defined in the home and 

9 community-based services settings rule in sections 

10 441.530 and 441.710 of title 42, Code of Federal 

11 Regulations (or a successor regulation). 

12 TITLE III—PROVIDER 

13 PARTICIPATION 

14 SEC. 301. PROVIDER PARTICIPATION AND STANDARDS; 

15 WHISTLEBLOWER PROTECTIONS. 

16 (a) IN GENERAL.—An individual or other entity fur17 nishing any covered item or service under this Act is not 

18 a qualified provider unless the individual or entity— 

19 (1) is a qualified provider of the items or serv20 ices under section 302; 

21 (2) has filed with the Secretary a participation 

22 agreement described in subsection (b); and 

23 (3) meets, as applicable, such other qualifica24 tions and conditions with respect to a provider of 

25 services under title XVIII of the Social Security Act 


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1 as described in section 1866 of the Social Security 

2 Act (42 U.S.C. 1395cc). 

3 (b) REQUIREMENTS IN PARTICIPATION AGREE4 MENT.— 

5 (1) IN GENERAL.—A participation agreement 

6 described in this subsection between the Secretary 

7 and a provider shall provide at least for the fol8 lowing: 

9 (A) Items and services to eligible persons 

10 shall be furnished by the provider without dis11 crimination, in accordance with section 104(a). 

12 Nothing in this subparagraph shall be con13 strued as requiring the provision of a type or 

14 class of items or services that are outside the 

15 scope of the provider’s normal practice. 

16 (B) No charge will be made to any enrolled 

17 individual for any covered items or services 

18 other than for payment authorized by this Act. 

19 (C) The provider agrees to furnish such in20 formation as may be reasonably required by the 

21 Secretary, in accordance with uniform reporting 

22 standards established under section 401(b)(1), 

23 for— 

24 (i) quality review by designated enti25 ties; 


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1 (ii) making payments under this Act, 

2 including the examination of records as 

3 may be necessary for the verification of in4 formation on which such payments are 

5 based; 

6 (iii) statistical or other studies re7 quired for the implementation of this Act; 

8 and 

9 (iv) such other purposes as the Sec10 retary may specify. 

11 (D) In the case of a provider that is not 

12 an individual, the provider agrees not to employ 

13 or use for the provision of health services any 

14 individual or other provider that has had a par15 ticipation agreement under this subsection ter16 minated for cause. The Secretary may authorize 

17 such employment or use on a case-by-case 

18 basis. 

19 (E) In the case of a provider paid under 

20 a fee-for-service basis for items and services 

21 furnished under this Act, the provider agrees to 

22 submit bills and any required supporting docu23 mentation relating to the provision of covered 

24 items and services within 30 days after the date 

25 of providing such items and services. 


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1 (F) In the case of an institutional provider 

2 paid pursuant to section 611, the provider 

3 agrees to submit information and any other re4 quired supporting documentation as may be 

5 reasonably required by the Secretary within 30 

6 days after the date of providing such items and 

7 services and in accordance with the uniform re8 porting standards established under section 

9 401(b)(1), including information on a quarterly 

10 basis that— 

11 (i) relates to the provision of covered 

12 items and services; and 

13 (ii) describes items and services fur14 nished with respect to specific individuals. 

15 (G) In the case of a provider that receives 

16 payment for items and services furnished under 

17 this Act based on diagnosis-related coding, pro18 cedure coding, or other coding system or data, 

19 the provider agrees— 

20 (i) to disclose to the Secretary any 

21 system or index of coding or classifying pa22 tient symptoms, diagnoses, clinical inter23 ventions, episodes, or procedures that such 

24 provider utilizes for global budget negotia25 tions under title VI or for meeting any 


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1 other payment, documentation, or data col2 lection requirements under this Act; and 

3 (ii) not to use any such system or 

4 index to establish financial incentives or 

5 disincentives for health care professionals, 

6 or that is proprietary, interferes with the 

7 medical or nursing process, or is designed 

8 to increase the amount or number of pay9 ments. 

10 (H) The provider complies with the duty of 

11 provider ethics and reporting requirements de12 scribed in paragraph (2). 

13 (I) In the case of a provider that is not an 

14 individual, the provider agrees that no board 

15 member, executive, or administrator of such 

16 provider receives compensation from, owns 

17 stock or has other financial investments in, or 

18 serves as a board member of any entity that 

19 contracts with or provides items or services, in20 cluding pharmaceutical products and medical 

21 devices or equipment, to such provider. 

22 (2) PROVIDER DUTY OF ETHICS.—Each health 

23 care provider, including institutional providers, has a 

24 duty to advocate for and to act in the exclusive in25 terest of each individual under the care of such proVerDate Sep 11 2014 23:21 May 17, 2021 Jkt 019200 PO 00000 Frm 00026 Fmt 6652 Sfmt 6201 E:\BILLS\H1976.IH H1976

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1 vider according to the applicable legal standard of 

2 care, such that no financial interest or relationship 

3 impairs any health care provider’s ability to furnish 

4 necessary and appropriate care to such individual. 

5 To implement the duty established in this para6 graph, the Secretary shall— 

7 (A) promulgate reasonable reporting rules 

8 to evaluate participating provider compliance 

9 with this paragraph; 

10 (B) prohibit participating providers, 

11 spouses, and immediate family members of par12 ticipating providers, from accepting or entering 

13 into any arrangement for any bonus, incentive 

14 payment, profit-sharing, or compensation based 

15 on patient utilization or based on financial out16 comes of any other provider or entity; and 

17 (C) prohibit participating providers or any 

18 board member or representative of such pro19 vider from serving as board members for or re20 ceiving any compensation, stock, or other finan21 cial investment in an entity that contracts with 

22 or provides items or services (including pharma23 ceutical products and medical devices or equip24 ment) to such provider. 


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1 (3) TERMINATION OF PARTICIPATION AGREE2 MENT.— 

3 (A) IN GENERAL.—Participation agree4 ments may be terminated, with appropriate no5 tice— 

6 (i) by the Secretary for failure to meet 

7 the requirements of this Act; 

8 (ii) in accordance with the provisions 

9 described in section 411; or 

10 (iii) by a provider. 

11 (B) TERMINATION PROCESS.—Providers 

12 shall be provided notice and a reasonable oppor13 tunity to correct deficiencies before the Sec14 retary terminates an agreement unless a more 

15 immediate termination is required for public 

16 safety or similar reasons. 

17 (C) PROVIDER PROTECTIONS.— 

18 (i) PROHIBITION.—The Secretary may 

19 not terminate a participation agreement or 

20 in any other way discriminate against, or 

21 cause to be discriminated against, any cov22 ered provider or authorized representative 

23 of the provider, on account of such pro24 vider or representative— 


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1 (I) providing, causing to be pro2 vided, or being about to provide or 

3 cause to be provided to the provider, 

4 the Federal Government, or the attor5 ney general of a State information re6 lating to any violation of, or any act 

7 or omission the provider or represent8 ative reasonably believes to be a viola9 tion of, any provision of this title (or 

10 an amendment made by this title); 

11 (II) testifying or being about to 

12 testify in a proceeding concerning 

13 such violation; 

14 (III) assisting or participating, or 

15 being about to assist or participate, in 

16 such a proceeding; or 

17 (IV) objecting to, or refusing to 

18 participate in, any activity, policy, 

19 practice, or assigned task that the 

20 provider or representative reasonably 

21 believes to be in violation of any provi22 sion of this Act (including any amend23 ment made by this Act), or any order, 

24 rule, regulation, standard, or ban 


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1 under this Act (including any amend2 ment made by this Act). 

3 (ii) COMPLAINT PROCEDURE.—A pro4 vider or representative who believes that he 

5 or she has been discriminated against in 

6 violation of this section may seek relief in 

7 accordance with the procedures, notifica8 tions, burdens of proof, remedies, and stat9 utes of limitation set forth in section 

10 2087(b) of title 15, United States Code. 

11 (c) WHISTLEBLOWER PROTECTIONS.— 

12 (1) RETALIATION PROHIBITED.—No person 

13 may discharge or otherwise discriminate against any 

14 employee because the employee or any person acting 

15 pursuant to a request of the employee— 

16 (A) notified the Secretary or the employ17 ee’s employer of any alleged violation of this 

18 title, including communications related to car19 rying out the employee’s job duties; 

20 (B) refused to engage in any practice made 

21 unlawful by this title, if the employee has iden22 tified the alleged illegality to the employer; 

23 (C) testified before or otherwise provided 

24 information relevant for Congress or for any 


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1 Federal or State proceeding regarding any pro2 vision (or proposed provision) of this title; 

3 (D) commenced, caused to be commenced, 

4 or is about to commence or cause to be com5 menced a proceeding under this title; 

6 (E) testified or is about to testify in any 

7 such proceeding; or 

8 (F) assisted or participated or is about to 

9 assist or participate in any manner in such a 

10 proceeding or in any other manner in such a 

11 proceeding or in any other action to carry out 

12 the purposes of this title. 

13 (2) ENFORCEMENT ACTION.—Any employee 

14 covered by this section who alleges discrimination by 

15 an employer in violation of paragraph (1) may bring 

16 an action, subject to the statute of limitations in the 

17 anti-retaliation provisions of the False Claims Act 

18 and the rules and procedures, legal burdens of proof, 

19 and remedies applicable under the employee protec20 tions provisions of the Surface Transportation As21 sistance Act. 

22 (3) APPLICATION.— 

23 (A) Nothing in this subsection shall be 

24 construed to diminish the rights, privileges, or 

25 remedies of any employee under any Federal or 


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1 State law or regulation, including the rights 

2 and remedies against retaliatory action under 

3 the False Claims Act (31 U.S.C. 3730(h)), or 

4 under any collective bargaining agreement. The 

5 rights and remedies in this section may not be 

6 waived by any agreement, policy, form, or con7 dition of employment. 

8 (B) Nothing in this subsection shall be 

9 construed to preempt or diminish any other 

10 Federal or State law or regulation against dis11 crimination, demotion, discharge, suspension, 

12 threats, harassment, reprimand, retaliation, or 

13 any other manner of discrimination, including 

14 the rights and remedies against retaliatory ac15 tion under the False Claims Act (31 U.S.C. 

16 3730(h)). 

17 (4) DEFINITIONS.—In this subsection: 

18 (A) EMPLOYER.—The term ‘‘employer’’ 

19 means any person engaged in profit or non20 profit business or industry, including one or 

21 more individuals, partnerships, associations, 

22 corporations, trusts, professional membership 

23 organization including a certification, discipli24 nary, or other professional body, unincorporated 

25 organizations, nongovernmental organizations, 


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1 or trustees, and subject to liability for violating 

2 the provisions of this Act. 

3 (B) EMPLOYEE.—The term ‘‘employee’’ 

4 means any individual performing activities 

5 under this Act on behalf of an employer. 

6 SEC. 302. QUALIFICATIONS FOR PROVIDERS. 

7 (a) IN GENERAL.—A health care provider is consid8 ered to be qualified to furnish covered items and services 

9 under this Act if the provider is licensed or certified to 

10 furnish such items and services in the State in which the 

11 individual receiving such items or services is located and 

12 meets— 

13 (1) the requirements of such State’s law to fur14 nish such items and services; and 

15 (2) applicable requirements of Federal law to 

16 furnish such items and services. 

17 (b) LIMITATION.—An entity or provider shall not be 

18 qualified to furnish covered items and services under this 

19 Act if the entity or provider provides no items and services 

20 directly to individuals, including— 

21 (1) entities or providers that contract with 

22 other entities or providers to provide such items and 

23 services; and 

24 (2) entities that are currently approved to co25 ordinate care plans under the Medicare Advantage 


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1 program established in part C of title XVIII of the 

2 Social Security Act (42 U.S.C. 1851 et seq.) but do 

3 not directly provide items and services of such care 

4 plans. 

5 (c) MINIMUM PROVIDER STANDARDS.— 

6 (1) IN GENERAL.—The Secretary shall estab7 lish, evaluate, and update national minimum stand8 ards to ensure the quality of items and services pro9 vided under this Act and to monitor efforts by 

10 States to ensure the quality of such items and serv11 ices. A State may establish additional minimum 

12 standards which providers shall meet with respect to 

13 items and services provided in such State. 

14 (2) NATIONAL MINIMUM STANDARDS.—The 

15 Secretary shall establish national minimum stand16 ards under paragraph (1) for institutional providers 

17 of services and individual health care practitioners. 

18 Except as the Secretary may specify in order to 

19 carry out this Act, a hospital, skilled nursing facility, 

20 or other institutional provider of services shall meet 

21 standards applicable to such a provider under the 

22 Medicare program under title XVIII of the Social 

23 Security Act (42 U.S.C. 1395 et seq.). Such stand24 ards also may include, where appropriate, elements 

25 relating to— 


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1 (A) adequacy and quality of facilities; 

2 (B) mandatory minimum safe registered 

3 nurse-to-patient staffing ratios and optimal 

4 staffing levels for physicians and other health 

5 care practitioners; 

6 (C) training and competence of personnel 

7 (including requirements related to the number 

8 of or type of required continuing education 

9 hours); 

10 (D) comprehensiveness of service; 

11 (E) continuity of service; 

12 (F) patient waiting time, access to serv13 ices, and preferences; and 

14 (G) performance standards, including orga15 nization, facilities, structure of services, effi16 ciency of operation, and outcome in palliation, 

17 improvement of health, stabilization, cure, or 

18 rehabilitation. 

19 (3) TRANSITION IN APPLICATION.—If the Sec20 retary provides for additional requirements for pro21 viders under this subsection, any such additional re22 quirement shall be implemented in a manner that 

23 provides for a reasonable period during which a pre24 viously qualified provider is permitted to meet such 

25 an additional requirement. 


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1 (4) ABILITY TO PROVIDE SERVICES.—With re2 spect to any entity or provider certified to provide 

3 items and services described in section 201(a)(7), 

4 the Secretary may not prohibit such entity or pro5 vider from participating for reasons other than such 

6 entity’s or provider’s ability to provide such items 

7 and services. 

8 (d) FEDERAL PROVIDERS.—Any provider qualified to 

9 provide health care items and services through the Depart10 ment of Veterans Affairs, the Indian Health Service, or 

11 the uniformed services (with respect to the direct care 

12 component of the TRICARE Program) is a qualifying pro13 vider under this section with respect to any individual who 

14 qualifies for such items and services under applicable Fed15 eral law. 

16 SEC. 303. USE OF PRIVATE CONTRACTS. 

17 (a) IN GENERAL.—This section shall apply beginning 

18 2 years after the date of the enactment of this Act. 

19 (b) PARTICIPATING PROVIDERS.— 

20 (1) PRIVATE CONTRACTS FOR COVERED ITEMS

21 AND SERVICES FOR ELIGIBLE INDIVIDUALS.—An in22 stitutional or individual provider with an agreement 

23 in effect under section 301 may not bill or enter into 

24 any private contract with any individual eligible for 


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1 benefits under the Act for any item or service that 

2 is a benefit under this Act. 

3 (2) PRIVATE CONTRACTS FOR NONCOVERED

4 ITEMS AND SERVICES FOR ELIGIBLE INDIVIDUALS.— 

5 An institutional or individual provider with an agree6 ment in effect under section 301 may bill or enter 

7 into a private contract with an individual eligible for 

8 benefits under the Act for any item or service that 

9 is not a benefit under this Act only if— 

10 (A) the contract and provider meet the re11 quirements specified in paragraphs (3) and (4), 

12 respectively; 

13 (B) such item or service is not payable or 

14 available under this Act; and 

15 (C) the provider receives— 

16 (i) no reimbursement under this Act 

17 directly or indirectly for such item or serv18 ice, and 

19 (ii) receives no amount for such item 

20 or service from an organization which re21 ceives reimbursement for such items or 

22 service under this Act directly or indirectly. 

23 (3) CONTRACT REQUIREMENTS.—Any contract 

24 to provide items and services described in paragraph 

25 (2) shall— 


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1 (A) be in writing and signed by the indi2 vidual (or authorized representative of the indi3 vidual) receiving the item or service before the 

4 item or service is furnished pursuant to the 

5 contract; 

6 (B) not be entered into at a time when the 

7 individual is facing an emergency health care 

8 situation; and 

9 (C) clearly indicate to the individual receiv10 ing such items and services that by signing 

11 such a contract the individual— 

12 (i) agrees not to submit a claim (or to 

13 request that the provider submit a claim) 

14 under this Act for such items or services; 

15 (ii) agrees to be responsible for pay16 ment of such items or services and under17 stands that no reimbursement will be pro18 vided under this Act for such items or 

19 services; 

20 (iii) acknowledges that no limits under 

21 this Act apply to amounts that may be 

22 charged for such items or services; and 

23 (iv) acknowledges that the provider is 

24 providing services outside the scope of the 

25 program under this Act. 


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1 (4) AFFIDAVIT.—A participating provider who 

2 enters into a contract described in paragraph (2) 

3 shall have in effect during the period any item or 

4 service is to be provided pursuant to the contract an 

5 affidavit that shall— 

6 (A) identify the provider who is to furnish 

7 such noncovered item or service, and be signed 

8 by such provider; 

9 (B) state that the provider will not submit 

10 any claim under this Act for any noncovered 

11 item or service provided to any individual en12 rolled under this Act; and 

13 (C) be filed with the Secretary no later 

14 than 10 days after the first contract to which 

15 such affidavit applies is entered into. 

16 (5) ENFORCEMENT.—If a provider signing an 

17 affidavit described in paragraph (4) knowingly and 

18 willfully submits a claim under this title for any item 

19 or service provided or receives any reimbursement or 

20 amount for any such item or service provided pursu21 ant to a private contract described in paragraph (2) 

22 with respect to such affidavit— 

23 (A) any contract described in paragraph 

24 (2) shall be null and void; 


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1 (B) no payment shall be made under this 

2 title for any item or service furnished by the 

3 provider during the 2-year period beginning on 

4 the date the affidavit was signed; and 

5 (C) any payment received under this title 

6 for any item or service furnished during such 

7 period shall be remitted. 

8 (6) PRIVATE CONTRACTS FOR INELIGIBLE INDI9 VIDUALS.—An institutional or individual provider 

10 with an agreement in effect under section 301 may 

11 bill or enter into a private contract with any indi12 vidual ineligible for benefits under the Act for any 

13 item or service. 

14 (c) NONPARTICIPATING PROVIDERS.— 

15 (1) PRIVATE CONTRACTS FOR COVERED ITEMS

16 AND SERVICES FOR ELIGIBLE INDIVIDUALS.—An in17 stitutional or individual provider with no agreement 

18 in effect under section 301 may bill or enter into 

19 any private contract with any individual eligible for 

20 benefits under the Act for any item or service that 

21 is a benefit under this Act described in title II only 

22 if the contract and provider meet the requirements 

23 specified in paragraphs (2) and (3), respectively. 


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1 (2) ITEMS REQUIRED TO BE INCLUDED IN CON2 TRACT.—Any contract to provide items and services 

3 described in paragraph (1) shall— 

4 (A) be in writing and signed by the indi5 vidual (or authorized representative of the indi6 vidual) receiving the item or service before the 

7 item or service is furnished pursuant to the 

8 contract; 

9 (B) not be entered into at a time when the 

10 individual is facing an emergency health care 

11 situation; and 

12 (C) clearly indicate to the individual receiv13 ing such items and services that by signing 

14 such a contract the individual— 

15 (i) acknowledges that the individual 

16 has the right to have such items or services 

17 provided by other providers for whom pay18 ment would be made under this Act; 

19 (ii) agrees not to submit a claim (or 

20 to request that the provider submit a 

21 claim) under this Act for such items or 

22 services even if such items or services are 

23 otherwise covered by this Act; 

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1 stands that no reimbursement will be pro2 vided under this Act for such items or 

3 services; 

4 (iv) acknowledges that no limits under 

5 this Act apply to amounts that may be 

6 charged for such items or services; and 

7 (v) acknowledges that the provider is 

8 providing services outside the scope of the 

9 program under this Act. 

10 (3) AFFIDAVIT.—A provider who enters into a 

11 contract described in paragraph (1) shall have in ef12 fect during the period any item or service is to be 

13 provided pursuant to the contract an affidavit that 

14 shall— 

15 (A) identify the provider who is to furnish 

16 such covered item or service, and be signed by 

17 such provider; 

18 (B) state that the provider will not submit 

19 any claim under this Act for any covered item 

20 or service provided to any individual enrolled 

21 under this Act during the 2-year period begin22 ning on the date the affidavit is signed; and 

23 (C) be filed with the Secretary no later 

24 than 10 days after the first contract to which 

25 such affidavit applies is entered into. 


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1 (4) ENFORCEMENT.—If a provider signing an 

2 affidavit described in paragraph (3) knowingly and 

3 willfully submits a claim under this title for any item 

4 or service provided or receives any reimbursement or 

5 amount for any such item or service provided pursu6 ant to a private contract described in paragraph (1) 

7 with respect to such affidavit— 

8 (A) any contract described in paragraph 

9 (1) shall be null and void; and 

10 (B) no payment shall be made under this 

11 title for any item or service furnished by the 

12 provider during the 2-year period beginning on 

13 the date the affidavit was signed. 

14 (5) PRIVATE CONTRACTS FOR NONCOVERED

15 ITEMS AND SERVICES FOR ANY INDIVIDUAL.—An in16 stitutional or individual provider with no agreement 

17 in effect under section 301 may bill or enter into a 

18 private contract with any individual for a item or 

19 service that is not a benefit under this Act. 


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1 TITLE IV—ADMINISTRATION 

2 Subtitle A—General 

3 Administration Provisions 

4 SEC. 401. ADMINISTRATION. 

5 (a) GENERAL DUTIES OF THE SECRETARY.— 

6 (1) IN GENERAL.—The Secretary shall develop 

7 policies, procedures, guidelines, and requirements to 

8 carry out this Act, including related to— 

9 (A) eligibility for benefits; 

10 (B) enrollment; 

11 (C) benefits provided; 

12 (D) provider participation standards and 

13 qualifications, as described in title III; 

14 (E) levels of funding; 

15 (F) methods for determining amounts of 

16 payments to providers of covered items and 

17 services, consistent with subtitle B; 

18 (G) a process for appealing or petitioning 

19 for a determination of coverage or noncoverage 

20 of items and services under this Act; 

21 (H) planning for capital expenditures and 

22 service delivery; 

23 (I) planning for health professional edu24 cation funding; 


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1 (J) encouraging States to develop regional 

2 planning mechanisms; and 

3 (K) any other regulations necessary to 

4 carry out the purposes of this Act. 

5 (2) REGULATIONS.—Regulations authorized by 

6 this Act shall be issued by the Secretary in accord7 ance with section 553 of title 5, United States Code. 

8 (3) ACCESSIBILITY.—The Secretary shall have 

9 the obligation to ensure the timely and accessible 

10 provision of items and services that all eligible indi11 viduals are entitled to under this Act. 

12 (b) UNIFORM REPORTING STANDARDS; ANNUAL RE13 PORT; STUDIES.— 

14 (1) UNIFORM REPORTING STANDARDS.— 

15 (A) IN GENERAL.—The Secretary shall es16 tablish uniform State reporting requirements 

17 and national standards to ensure an adequate 

18 national database containing information per19 taining to health services practitioners, ap20 proved providers, the costs of facilities and 

21 practitioners providing items and services, the 

22 quality of such items and services, the outcomes 

23 of such items and services, and the equity of 

24 health among population groups. Such database 

25 shall include, to the maximum extent feasible 


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1 without compromising patient privacy, health 

2 outcome measures used under this Act, and to 

3 the maximum extent feasible without excessively 

4 burdening providers, a description of the stand5 ards and qualifications, levels of finding, and 

6 methods described in subparagraphs (D) 

7 through (F) of subsection (a)(1). 

8 (B) REQUIRED DATA DISCLOSURES.—In 

9 establishing reporting requirements and stand10 ards under subparagraph (A), the Secretary 

11 shall require a provider with an agreement in 

12 effect under section 301 to disclose to the Sec13 retary, in a time and manner specified by the 

14 Secretary, the following (as applicable to the 

15 type of provider): 

16 (i) Any data the provider is required 

17 to report or does report to any State or 

18 local agency, or, as of January 1, 2019, to 

19 the Secretary or any entity that is part of 

20 the Department of Health and Human 

21 Services, except data that are required 

22 under the programs terminated in section 

23 903. 

24 (ii) Annual financial data that in25 cludes information on employees (including 


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1 the number of employees, hours worked, 

2 and wage information) by job title and by 

3 each patient care unit or department with4 in each facility (including outpatient units 

5 or departments); the number of registered 

6 nurses per staffed bed by each such unit or 

7 department; information on the dollar 

8 value and annual spending (including pur9 chases, upgrades, and maintenance) for 

10 health information technology; and risk-ad11 justed and raw patient outcome data (in12 cluding data on medical, surgical, obstet13 ric, and other procedures). 

14 (C) REPORTS.—The Secretary shall regu15 larly analyze information reported to the Sec16 retary and shall define rules and procedures to 

17 allow researchers, scholars, health care pro18 viders, and others to access and analyze data 

19 for purposes consistent with quality and out20 comes research, without compromising patient 

21 privacy. 

22 (2) ANNUAL REPORT.—Beginning 2 years after 

23 the date of the enactment of this Act, the Secretary 

24 shall annually report to Congress on the following: 


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1 (A) The status of implementation of the 

2 Act. 

3 (B) Enrollment under this Act. 

4 (C) Benefits under this Act. 

5 (D) Expenditures and financing under this 

6 Act. 

7 (E) Cost-containment measures and 

8 achievements under this Act. 

9 (F) Quality assurance. 

10 (G) Health care utilization patterns, in11 cluding any changes attributable to the pro12 gram. 

13 (H) Changes in the per-capita costs of 

14 health care. 

15 (I) Differences in the health status of the 

16 populations of the different States, including by 

17 racial, ethnic, national origin, primary language 

18 use, age, disability, sex, including gender iden19 tity and sexual orientation, geographical, and 

20 income characteristics; 

21 (J) Progress on quality and outcome meas22 ures, and long-range plans and goals for 

23 achievements in such areas. 

24 (K) Plans for improving service to medi25 cally underserved populations. 


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1 (L) Transition problems as a result of im2 plementation of this Act. 

3 (M) Opportunities for improvements under 

4 this Act. 

5 (3) STATISTICAL ANALYSES AND OTHER STUD6 IES.—The Secretary may, either directly or by con7 tract— 

8 (A) make statistical and other studies, on 

9 a nationwide, regional, State, or local basis, of 

10 any aspect of the operation of this Act; 

11 (B) develop and test methods of delivery of 

12 items and services as the Secretary may con13 sider necessary or promising for the evaluation, 

14 or for the improvement, of the operation of this 

15 Act; and 

16 (C) develop methodological standards for 

17 policymaking. 

18 (c) AUDITS.— 

19 (1) IN GENERAL.—The Comptroller General of 

20 the United States shall conduct an audit of the De21 partment of Health and Human Services every fifth 

22 fiscal year following the effective date of this Act to 

23 determine the effectiveness of the program in car24 rying out the duties under subsection (a). 


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1 (2) REPORTS.—The Comptroller General of the 

2 United States shall submit a report to Congress con3 cerning the results of each audit conducted under 

4 this subsection. 

5 SEC. 402. CONSULTATION. 

6 The Secretary shall consult with Federal agencies, 

7 Indian tribes and urban Indian health organizations, and 

8 private entities, such as labor organizations representing 

9 health care workers, professional societies, national asso10 ciations, nationally recognized associations of health care 

11 experts, medical schools and academic health centers, con12 sumer groups, and business organizations in the formula13 tion of guidelines, regulations, policy initiatives, and infor14 mation gathering to ensure the broadest and most in15 formed input in the administration of this Act. Nothing 

16 in this Act shall prevent the Secretary from adopting 

17 guidelines, consistent with the provisions of section 203(c), 

18 developed by such a private entity if, in the Secretary’s 

19 judgment, such guidelines are generally accepted as rea20 sonable and prudent and consistent with this Act. 

21 SEC. 403. REGIONAL ADMINISTRATION. 

22 (a) COORDINATION WITH REGIONAL OFFICES.—The 

23 Secretary shall establish and maintain regional offices for 

24 purposes of carrying out the duties specified in subsection 

25 (c) and promoting adequate access to, and efficient use 


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1 of, tertiary care facilities, equipment, and services by indi2 viduals enrolled under this Act. Wherever possible, the 

3 Secretary shall incorporate regional offices of the Centers 

4 for Medicare & Medicaid Services for this purpose. 

5 (b) APPOINTMENT OF REGIONAL DIRECTORS.—In 

6 each such regional office there shall be— 

7 (1) one regional director appointed by the Sec8 retary; 

9 (2) one deputy director appointed by the re10 gional director to represent the Indian and Alaska 

11 Native tribes in the region, if any; and 

12 (3) one deputy direction appointed by the re13 gional director to oversee long-term services and 

14 supports. 

15 (c) REGIONAL OFFICE DUTIES.—Each regional di16 rector shall— 

17 (1) provide an annual health care needs assess18 ment with respect to the region under the director’s 

19 jurisdiction to the Secretary after a thorough exam20 ination of health needs and in consultation with pub21 lic health officials, clinicians, patients, and patient 

22 advocates; 

23 (2) recommend any changes in provider reim24 bursement or payment for delivery of health services 


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1 determined appropriate by the regional director, sub2 ject to the provisions of title VI; and 

3 (3) establish a quality assurance mechanism in 

4 each such region in order to minimize both under5 utilization and overutilization of health care items 

6 and services and to ensure that all providers meet 

7 quality standards established pursuant to this Act. 

8 SEC. 404. BENEFICIARY OMBUDSMAN. 

9 (a) IN GENERAL.—The Secretary shall appoint a 

10 Beneficiary Ombudsman who shall have expertise and ex11 perience in the fields of health care and education of, and 

12 assistance to, individuals enrolled under this Act. 

13 (b) DUTIES.—The Beneficiary Ombudsman shall— 

14 (1) receive complaints, grievances, and requests 

15 for information submitted by individuals enrolled 

16 under this Act or eligible to enroll under this Act 

17 with respect to any aspect of the Medicare for All 

18 Program; 

19 (2) provide assistance with respect to com20 plaints, grievances, and requests referred to in para21 graph (1), including assistance in collecting relevant 

22 information for such individuals, to seek an appeal 

23 of a decision or determination made by a regional of24 fice or the Secretary; and 


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1 (3) submit annual reports to Congress and the 

2 Secretary that describe the activities of the Ombuds3 man and that include such recommendations for im4 provement in the administration of this Act as the 

5 Ombudsman determines appropriate. The Ombuds6 man shall not serve as an advocate for any increases 

7 in payments or new coverage of services, but may 

8 identify issues and problems in payment or coverage 

9 policies. 

10 SEC. 405. CONDUCT OF RELATED HEALTH PROGRAMS. 

11 In performing functions with respect to health per12 sonnel education and training, health research, environ13 mental health, disability insurance, vocational rehabilita14 tion, the regulation of food and drugs, and all other mat15 ters pertaining to health, the Secretary shall direct the ac16 tivities of the Department of Health and Human Services 

17 toward contributions to the health of the people com18 plementary to this Act. 

19 Subtitle B—Control Over Fraud 

20 and Abuse 

21 SEC. 411. APPLICATION OF FEDERAL SANCTIONS TO ALL 

22 FRAUD AND ABUSE UNDER THE MEDICARE 

23 FOR ALL PROGRAM. 

24 The following sections of the Social Security Act shall 

25 apply to this Act in the same manner as they apply to 


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1 title XVIII or State plans under title XIX of the Social 

2 Security Act: 

3 (1) Section 1128 (relating to exclusion of indi4 viduals and entities). 

5 (2) Section 1128A (civil monetary penalties). 

6 (3) Section 1128B (criminal penalties). 

7 (4) Section 1124 (relating to disclosure of own8 ership and related information). 

9 (5) Section 1126 (relating to disclosure of cer10 tain owners). 

11 (6) Section 1877 (relating to physician refer12 rals). 

13 TITLE V—QUALITY ASSESSMENT 

14 SEC. 501. QUALITY STANDARDS. 

15 (a) IN GENERAL.—All standards and quality meas16 ures under this Act shall be implemented and evaluated 

17 by the Center for Clinical Standards and Quality of the 

18 Centers for Medicare & Medicaid Services (referred to in 

19 this title as the ‘‘Center’’) or such other agency deter20 mined appropriate by the Secretary, in coordination with 

21 the Agency for Healthcare Research and Quality and other 

22 offices of the Department of Health and Human Services. 

23 (b) DUTIES OF THE CENTER.—The Center shall per24 form the following duties: 


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1 (1) Review and evaluate each practice guideline 

2 developed under part B of title IX of the Public 

3 Health Service Act. In so reviewing and evaluating, 

4 the Center shall determine whether the guideline 

5 should be recognized as a national practice guideline 

6 in accordance with and subject to the provisions of 

7 section 203(c). 

8 (2) Review and evaluate each standard of qual9 ity, performance measure, and medical review cri10 terion developed under part B of title IX of the Pub11 lic Health Service Act (42 U.S.C. 299 et seq.). In 

12 so reviewing and evaluating, the Center shall deter13 mine whether the standard, measure, or criterion is 

14 appropriate for use in assessing or reviewing the 

15 quality of items and services provided by health care 

16 institutions or health care professionals. The use of 

17 mechanisms that discriminate against people with 

18 disabilities is prohibited for use in any value or cost19 effectiveness assessments. The Center shall consider 

20 the evidentiary basis for the standard, and the valid21 ity, reliability, and feasibility of measuring the 

22 standard. 

23 (3) Adoption of methodologies for profiling the 

24 patterns of practice of health care professionals and 

25 for identifying and notifying outliers. 


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1 (4) Development of minimum criteria for com2 petence for entities that can qualify to conduct ongo3 ing and continuous external quality reviews in the 

4 administrative regions. Such criteria shall require 

5 such an entity to be administratively independent of 

6 the individual or board that administers the region 

7 and shall ensure that such entities do not provide fi8 nancial incentives to reviewers to favor one pattern 

9 of practice over another. The Center shall ensure co10 ordination and reporting by such entities to ensure 

11 national consistency in quality standards. 

12 (5) Submission of a report to the Secretary an13 nually specifically on findings from outcomes re14 search and development of practice guidelines that 

15 may affect the Secretary’s determination of coverage 

16 of services under section 401(a)(1)(G). 

17 SEC. 502. ADDRESSING HEALTH CARE DISPARITIES. 

18 (a) EVALUATING DATA COLLECTION AP19 PROACHES.—The Center shall evaluate approaches for the 

20 collection of data under this Act, to be performed in con21 junction with existing quality reporting requirements and 

22 programs under this Act, that allow for the ongoing, accu23 rate, and timely collection of data on disparities in health 

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1 ability, sex (including gender identity and sexual orienta2 tion), geography, or socioeconomic status. In conducting 

3 such evaluation, the Center shall consider the following ob4 jectives: 

5 (1) Protecting patient privacy. 

6 (2) Minimizing the administrative burdens of 

7 data collection and reporting on providers under this 

8 Act. 

9 (3) Improving data on race, ethnicity, national 

10 origin, primary language use, age, disability, sex (in11 cluding gender identity and sexual orientation), ge12 ography, and socioeconomic status. 

13 (b) REPORTS TO CONGRESS.— 

14 (1) REPORT ON EVALUATION.—Not later than 

15 18 months after the date on which benefits first be16 come available as described in section 106(a), the 

17 Center shall submit to Congress and the Secretary 

18 a report on the evaluation conducted under sub19 section (a). Such report shall, taking into consider20 ation the results of such evaluation— 

21 (A) identify approaches (including defining 

22 methodologies) for identifying and collecting 

23 and evaluating data on health care disparities 

24 on the basis of race, ethnicity, national origin, 

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1 cluding gender identity and sexual orientation), 

2 geography, or socioeconomic status under the 

3 Medicare for All Program; and 

4 (B) include recommendations on the most 

5 effective strategies and approaches to reporting 

6 quality measures, as appropriate, on the basis 

7 of race, ethnicity, national origin, primary lan8 guage use, age, disability, sex (including gender 

9 identity and sexual orientation), geography, or 

10 socioeconomic status. 

11 (2) REPORT ON DATA ANALYSES.—Not later 

12 than 4 years after the submission of the report 

13 under subsection (b)(1), and every 4 years there14 after, the Center shall submit to Congress and the 

15 Secretary a report that includes recommendations 

16 for improving the identification of health care dis17 parities based on the analyses of data collected 

18 under subsection (c). 

19 (c) IMPLEMENTING EFFECTIVE APPROACHES.—Not 

20 later than 2 years after the date on which benefits first 

21 become available as described in section 106(a), the Sec22 retary shall implement the approaches identified in the re23 port submitted under subsection (b)(1) for the ongoing, 

24 accurate, and timely collection and evaluation of data on 

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1 tional origin, primary language use, age, disability, sex 

2 (including gender identity and sexual orientation), geog3 raphy, or socioeconomic status. 

4 TITLE VI—HEALTH BUDGET; 

5 PAYMENTS; COST CONTAIN6 MENT MEASURES 

7 Subtitle A—Budgeting 

8 SEC. 601. NATIONAL HEALTH BUDGET. 

9 (a) NATIONAL HEALTH BUDGET.— 

10 (1) IN GENERAL.—By not later than September 

11 1 of each year, beginning with the year prior to the 

12 date on which benefits first become available as de13 scribed in section 106(a), the Secretary shall estab14 lish a national health budget, which specifies a budg15 et for the total expenditures to be made for covered 

16 health care items and services under this Act. 

17 (2) DIVISION OF BUDGET INTO COMPONENTS.— 

18 The national health budget shall consist of the fol19 lowing components: 

20 (A) An operating budget. 

21 (B) A capital expenditures budget. 

22 (C) A special projects budget. 

23 (D) Quality assessment activities under 

24 title V. 


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1 (E) Health professional education expendi2 tures. 

3 (F) Administrative costs, including costs 

4 related to the operation of regional offices. 

5 (G) A reserve fund. 

6 (H) Prevention and public health activities. 

7 (3) ALLOCATION AMONG COMPONENTS.—The 

8 Secretary shall allocate the funds received for pur9 poses of carrying out this Act among the compo10 nents described in paragraph (2) in a manner that 

11 ensures— 

12 (A) that the operating budget allows for 

13 every participating provider in the Medicare for 

14 All Program to meet the needs of their respec15 tive patient populations; 

16 (B) that the special projects budget is suf17 ficient to meet the health care needs within 

18 areas described in paragraph (2)(C) through 

19 the construction, renovation, and staffing of 

20 health care facilities in a reasonable timeframe; 

21 (C) a fair allocation for quality assessment 

22 activities; and 

23 (D) that the health professional education 

24 expenditure component is sufficient to provide 

25 for the amount of health professional education 


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1 expenditures sufficient to meet the need for cov2 ered health care services. 

3 (4) REGIONAL ALLOCATION.—The Secretary 

4 shall annually provide each regional office with an 

5 allotment the Secretary determines appropriate for 

6 purposes of carrying out this Act in such region, in7 cluding payments to providers in such region, capital 

8 expenditures in such region, special projects in such 

9 region, health professional education in such region, 

10 administrative expenses in such region, and preven11 tion and public health activities in such region. 

12 (5) OPERATING BUDGET.—The operating budg13 et described in paragraph (2)(A) shall be used for— 

14 (A) payments to institutional providers 

15 pursuant to section 611; and 

16 (B) payments to individual providers pur17 suant to section 612. 

18 (6) CAPITAL EXPENDITURES BUDGET.—The 

19 capital expenditures budget described in paragraph 

20 (2)(B) shall be used for— 

21 (A) the construction or renovation of 

22 health care facilities, excluding congregate or 

23 segregated facilities for individuals with disabil24 ities who receive long-term care services and 

25 support; and 


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1 (B) major equipment purchases. 

2 (7) SPECIAL PROJECTS BUDGET.—The special 

3 projects budget described in paragraph (2)(C) shall 

4 be used for the purposes of allocating funds for the 

5 construction of new facilities, major equipment pur6 chases, and staffing in rural or medically under7 served areas (as defined in section 330(b)(3) of the 

8 Public Health Service Act (42 U.S.C. 254b(b)(3))), 

9 including areas designated as health professional 

10 shortage areas (as defined in section 332(a) of the 

11 Public Health Service Act (42 U.S.C. 254e(a))), and 

12 to address health disparities, including racial, ethnic, 

13 national origin, primary language use, age, dis14 ability, sex (including gender identity and sexual ori15 entation), geography, or socioeconomic health dis16 parities. 

17 (8) TEMPORARY WORKER ASSISTANCE.— 

18 (A) IN GENERAL.—For up to 5 years fol19 lowing the date on which benefits first become 

20 available as described in section 106(a), at least 

21 1 percent of the budget shall be allocated to 

22 programs providing assistance to workers who 

23 perform functions in the administration of the 

24 health insurance system, or related functions 

25 within health care institutions or organizations 


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1 who may be affected by the implementation of 

2 this Act and who may experience economic dis3 location as a result of the implementation of 

4 this Act. 

5 (B) CLARIFICATION.—Assistance described 

6 in subparagraph (A) shall include wage replace7 ment, retirement benefits, job training and 

8 placement, preferential hiring, and education 

9 benefits. 

10 (9) RESERVE FUND.—The reserve fund de11 scribed in paragraph (2)(G) shall be used to respond 

12 to the costs of an epidemic, pandemic, natural dis13 aster, or other such health emergency, or market14 shift adjustments related to patient volume. 

15 (10) SUPPLEMENTAL INDIAN HEALTH SERVICE

16 ALLOCATION.—The Secretary shall annually deter17 mine the need to provide an allotment of supple18 mental funds to Indian Health Services, including 

19 payments to providers, capital expenditures, special 

20 projects, health professional education, administra21 tive expenses, and prevention and public health ac22 tivities. 

23 (b) DEFINITIONS.—In this section: 

24 (1) CAPITAL EXPENDITURES.—The term ‘‘cap25 ital expenditures’’ means expenses for the purchase, 


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1 lease, construction, or renovation of capital facilities 

2 and for major equipment. 

3 (2) HEALTH PROFESSIONAL EDUCATION EX4 PENDITURES.—The term ‘‘health professional edu5 cation expenditures’’ means expenditures in hospitals 

6 and other health care facilities to cover costs associ7 ated with teaching and related research activities, in8 cluding the impact of workforce diversity on patient 

9 outcomes. 

10 Subtitle B—Payments to Providers 

11 SEC. 611. PAYMENTS TO INSTITUTIONAL PROVIDERS 

12 BASED ON GLOBAL BUDGETS. 

13 (a) IN GENERAL.—Not later than the beginning of 

14 each fiscal quarter during which an institutional provider 

15 of care (including hospitals, skilled nursing facilities, Fed16 erally qualified health centers, and independent dialysis fa17 cilities) is to furnish items and services under this Act, 

18 the Secretary shall pay to such institutional provider a 

19 lump sum in accordance with the succeeding provisions of 

20 this subsection and consistent with the following: 

21 (1) PAYMENT IN FULL.—Such payment shall be 

22 considered as payment in full for all operating ex23 penses for items and services furnished under this 

24 Act, whether inpatient or outpatient, by such pro25 vider for such quarter, including outpatient or any 


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1 other care provided by the institutional provider or 

2 provided by any health care provider who provided 

3 items and services pursuant to an agreement paid 

4 through the global budget as described in paragraph 

5 (3). 

6 (2) QUARTERLY REVIEW.—The regional direc7 tor, on a quarterly basis, shall review whether re8 quirements of the institutional provider’s participa9 tion agreement and negotiated global budget have 

10 been performed and shall determine whether adjust11 ments to such institutional provider’s payment are 

12 warranted. This review shall include consideration 

13 for additional funding necessary for unanticipated 

14 items and services for individuals with complex med15 ical needs or market-shift adjustments related to pa16 tient volume. The review shall also include an as17 sessment of any adjustments made to ensure that 

18 accuracy and need for adjustment was appropriate. 

19 (3) AGREEMENTS FOR SALARIED PAYMENTS

20 FOR CERTAIN PROVIDERS.—Certain group practices 

21 and other health care providers, as determined by 

22 the Secretary, with agreements to provide items and 

23 services at a specified institutional provider paid a 

24 global budget under this subsection may elect to be 

25 paid through such institutional provider’s global 


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1 budget in lieu of payment under section 612 of this 

2 title. Any— 

3 (A) individual health care professional of 

4 such group practice or other provider receiving 

5 payment through an institutional provider’s 

6 global budget shall be paid on a salaried basis 

7 that is equivalent to salaries or other compensa8 tion rates negotiated for individual health care 

9 professionals of such institutional provider; and 

10 (B) any group practice or other health care 

11 provider that receives payment through an in12 stitutional provider global budget under this 

13 paragraph shall be subject to the same report14 ing and disclosure requirements of the institu15 tional provider. 

16 (4) INTERIM ADJUSTMENTS.—The regional di17 rector shall consider a petition for adjustment of any 

18 payment under this section filed by an institutional 

19 provider at any time based on the following: 

20 (A) Factors that led to increased costs for 

21 the institutional provider that can reasonably be 

22 considered to be unanticipated and out of the 

23 control of the institutional provider, such as— 

24 (i) natural disasters; 


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1 (ii) outbreaks of epidemics or infec2 tious diseases; 

3 (iii) unexpected facility or equipment 

4 repairs or purchases; 

5 (iv) significant and unexpected in6 creases in pharmaceutical or medical device 

7 prices; and 

8 (v) unanticipated increases in complex 

9 or high-cost patients or care needs. 

10 (B) Changes in Federal or State law that 

11 result in a change in costs. 

12 (C) Reasonable increases in labor costs, in13 cluding salaries and benefits, and changes in 

14 collective bargaining agreements, prevailing 

15 wage, or local law. 

16 (b) PAYMENT AMOUNT.— 

17 (1) IN GENERAL.—The amount of each pay18 ment to a provider described in subsection (a) shall 

19 be determined before the start of each fiscal year 

20 through negotiations between the provider and the 

21 regional director with jurisdiction over such pro22 vider. Such amount shall be based on factors speci23 fied in paragraph (2). 


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1 (2) PAYMENT FACTORS.—Payments negotiated 

2 pursuant to paragraph (1) shall take into account, 

3 with respect to a provider— 

4 (A) the historical volume of services pro5 vided for each item and services in the previous 

6 3-year period; 

7 (B) the actual expenditures of such pro8 vider in such provider’s most recent cost report 

9 under title XVIII of the Social Security Act for 

10 each item and service compared to— 

11 (i) such expenditures for other institu12 tional providers in the director’s jurisdic13 tion; and 

14 (ii) normative payment rates estab15 lished under comparative payment rate 

16 systems, including any adjustments, for 

17 such items and services; 

18 (C) projected changes in the volume and 

19 type of items and services to be furnished; 

20 (D) wages for employees, including any 

21 necessary increases mandatory minimum safe 

22 registered nurse-to-patient ratios and optimal 

23 staffing levels for physicians and other health 

24 care workers; 


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1 (E) the provider’s maximum capacity to 

2 provide items and services; 

3 (F) education and prevention programs; 

4 (G) permissible adjustment to the pro5 vider’s operating budget due to factors such 

6 as— 

7 (i) an increase in primary or specialty 

8 care access; 

9 (ii) efforts to decrease health care dis10 parities in rural or medically underserved 

11 areas; 

12 (iii) a response to emergent epidemic 

13 conditions; 

14 (iv) an increase in complex or high15 cost patients or care needs; or 

16 (v) proposed new and innovative pa17 tient care programs at the institutional 

18 level; 

19 (H) whether the provider is located in a 

20 high social vulnerability index community, zip 

21 code, or census track, or is a minority-serving 

22 provider; and 

23 (I) any other factor determined appro24 priate by the Secretary. 


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1 (3) LIMITATION.—Payment amounts negotiated 

2 pursuant to paragraph (1) may not— 

3 (A) take into account capital expenditures 

4 of the provider or any other expenditure not di5 rectly associated with the provision of items and 

6 services by the provider to an individual; 

7 (B) be used by a provider for capital ex8 penditures or such other expenditures; 

9 (C) exceed the provider’s capacity to pro10 vide care under this Act; or 

11 (D) be used to pay or otherwise com12 pensate any board member, executive, or ad13 ministrator of the institutional provider who 

14 has any interest or relationship prohibited 

15 under section 301(b)(2) of this Act or disclosed 

16 under section 301 of this Act. 

17 (4) LIMITATION ON COMPENSATION.—Com18 pensation costs for any employee or any contractor 

19 or any subcontractor employee of an institutional 

20 provider receiving global budgets under this section 

21 shall meet the compensation cap established in sec22 tion 702 of the Bipartisan Budget Act of 2013 (41 

23 U.S.C. 4304(a)(16)) and implementing regulations. 

24 (5) REGIONAL NEGOTIATIONS PERMITTED.— 

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1 tiate changes to an institutional provider’s global 

2 budget, including any adjustments to address un3 foreseen market-shifts related to patient volume. 

4 (c) BASELINE RATES AND ADJUSTMENTS.— 

5 (1) IN GENERAL.—The Secretary shall use ex6 isting prospective payment systems under title 

7 XVIII of the Social Security Act to serve as the 

8 comparative payment rate system in global budget 

9 negotiations described in subsection (b). The Sec10 retary shall update such comparative payment rate 

11 systems annually. 

12 (2) SPECIFICATIONS.—In developing the com13 parative payment rate system, the Secretary shall 

14 use only the operating base payment rates under 

15 each such prospective payment systems with applica16 ble adjustments. 

17 (3) LIMITATION.—The comparative rate system 

18 established under this subsection shall not include 

19 the value-based payment adjustments and the cap20 ital expenses base payment rates that may be in21 cluded in such a prospective payment system. 

22 (4) INITIAL YEAR.—In the first year that global 

23 budget payments under this Act are available to in24 stitutional providers and for purposes of selecting a 

25 comparative payment rate system used during initial 


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1 global budget negotiations for each institutional pro2 vider, the Secretary shall take into account the ap3 propriate prospective payment system from the most 

4 recent year under title XVIII of the Social Security 

5 Act to determine what operating base payment the 

6 institutional provider would have been paid for cov7 ered items and services furnished the preceding year 

8 with applicable adjustments, excluding value-based 

9 payment adjustments, based on such prospective 

10 payment system. 

11 (d) OPERATING EXPENSES.—For purposes of this 

12 title, ‘‘operating expenses’’ of a provider include the fol13 lowing: 

14 (1) The cost of all items and services associated 

15 with the provision of inpatient care and outpatient 

16 care, including the following: 

17 (A) Wages and salary costs for physicians, 

18 nurses, and other health care practitioners em19 ployed by an institutional provider, including 

20 mandatory minimum safe registered nurse-to21 patient staffing ratios and optimal staffing lev22 els for physicians and other healthcare workers. 

23 (B) Wages and salary costs for all ancil24 lary staff and services. 


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1 (C) Costs of all pharmaceutical products 

2 administered by health care clinicians at the in3 stitutional provider’s facilities or through serv4 ices provided in accordance with State licensing 

5 laws or regulations under which the institu6 tional provider operates. 

7 (D) Costs for infectious disease response 

8 preparedness, including maintenance of a 1- 

9 year or 365-day stockpile of personal protective 

10 equipment, occupational testing and surveil11 lance, medical services for occupational infec12 tious disease exposure, and contact tracing. 

13 (E) Purchasing and maintenance of med14 ical devices, supplies, and other health care 

15 technologies, including diagnostic testing equip16 ment. 

17 (F) Costs of all incidental services nec18 essary for safe patient care and handling. 

19 (G) Costs of patient care, education, and 

20 prevention programs, including occupational 

21 health and safety programs, public health pro22 grams, and necessary staff to implement such 

23 programs, for the continued education and 

24 health and safety of clinicians and other indi25 viduals employed by the institutional provider. 


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1 (2) Administrative costs for the institutional 

2 provider. 

3 SEC. 612. PAYMENT TO INDIVIDUAL PROVIDERS THROUGH 

4 FEE-FOR-SERVICE. 

5 (a) IN GENERAL.—In the case of a provider not de6 scribed in section 611(a) (including those in group prac7 tices who are not receiving payment on a salaried basis 

8 described in section 611(a)(3) and providers of home and 

9 community-based services), payment for items and serv10 ices furnished under this Act for which payment is not 

11 otherwise made under section 611 shall be made by the 

12 Secretary in amounts determined under the fee schedule 

13 established pursuant to subsection (b). Such payment 

14 shall be considered to be payment in full for such items 

15 and services, and a provider receiving such payment may 

16 not charge the individual receiving such item or service 

17 in any amount. 

18 (b) FEE SCHEDULE.— 

19 (1) ESTABLISHMENT.—Not later than 1 year 

20 after the date of the enactment of this Act, and in 

21 consultation with providers and regional office direc22 tors, the Secretary shall establish a national fee 

23 schedule for items and services payable under this 

24 Act. The Secretary shall evaluate the effectiveness of 


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1 the fee-for-service structure and update such fee 

2 schedule annually. 

3 (2) AMOUNTS.—In establishing payment 

4 amounts for items and services under the fee sched5 ule established under paragraph (1), the Secretary 

6 shall take into account— 

7 (A) the amounts payable for such items 

8 and services under title XVIII of the Social Se9 curity Act; and 

10 (B) the expertise of providers and value of 

11 items and services furnished by such providers. 

12 (c) ELECTRONIC BILLING.—The Secretary shall es13 tablish a uniform national system for electronic billing for 

14 purposes of making payments under this subsection. 

15 (d) PHYSICIAN PRACTICE REVIEW BOARD.—Each di16 rector of a regional office, in consultation with representa17 tives of physicians practicing in that region, shall establish 

18 and appoint a physician practice review board to assure 

19 quality, cost effectiveness, and fair reimbursements for 

20 physician-delivered items and services. The use of mecha21 nisms that discriminate against people with disabilities is 

22 prohibited for use in any value or cost-effectiveness assess23 ments. 


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1 SEC. 613. ENSURING ACCURATE VALUATION OF SERVICES 

2 UNDER THE MEDICARE PHYSICIAN FEE 

3 SCHEDULE. 

4 (a) STANDARDIZED AND DOCUMENTED REVIEW

5 PROCESS.—Section 1848(c)(2) of the Social Security Act 

6 (42 U.S.C. 1395w–4(c)(2)) is amended by adding at the 

7 end the following new subparagraph: 

8 ‘‘(P) STANDARDIZED AND DOCUMENTED

9 REVIEW PROCESS.— 

10 ‘‘(i) IN GENERAL.—Not later than one 

11 year after the date of enactment of this 

12 subparagraph, the Secretary shall estab13 lish, document, and make publicly avail14 able, in consultation with the Office of Pri15 mary Health Care, a standardized process 

16 for reviewing the relative values of physi17 cians’ services under this paragraph. 

18 ‘‘(ii) MINIMUM REQUIREMENTS.—The 

19 standardized process shall include, at a 

20 minimum, methods and criteria for identi21 fying services for review, prioritizing the 

22 review of services, reviewing stakeholder 

23 recommendations, and identifying addi24 tional resources to be considered during 

25 the review process.’’. 


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1 (b) PLANNED AND DOCUMENTED USE OF FUNDS.— 

2 Section 1848(c)(2)(M) of the Social Security Act (42 

3 U.S.C. 1395w–4(c)(2)(M)) is amended by adding at the 

4 end the following new clause: 

5 ‘‘(x) PLANNED AND DOCUMENTED

6 USE OF FUNDS.—For each fiscal year (be7 ginning with the first fiscal year beginning 

8 on or after the date of enactment of this 

9 clause), the Secretary shall provide to Con10 gress a written plan for using the funds 

11 provided under clause (ix) to collect and 

12 use information on physicians’ services in 

13 the determination of relative values under 

14 this subparagraph.’’. 

15 (c) INTERNAL TRACKING OF REVIEWS.— 

16 (1) IN GENERAL.—Not later than 1 year after 

17 the date of enactment of this Act, the Secretary 

18 shall submit to Congress a proposed plan for system19 atically and internally tracking the Secretary’s re20 view of the relative values of physicians’ services, 

21 such as by establishing an internal database, under 

22 section 1848(c)(2) of the Social Security Act (42 

23 U.S.C. 1395w–4(c)(2)), as amended by this section. 

24 (2) MINIMUM REQUIREMENTS.—The proposal 

25 shall include, at a minimum, plans and a timeline 


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1 for achieving the ability to systematically and inter2 nally track the following: 

3 (A) When, how, and by whom services are 

4 identified for review. 

5 (B) When services are reviewed or re6 viewed or when new services are added. 

7 (C) The resources, evidence, data, and rec8 ommendations used in reviews. 

9 (D) When relative values are adjusted. 

10 (E) The rationale for final relative value 

11 decisions. 

12 (d) FREQUENCY OF REVIEW.—Section 1848(c)(2) of 

13 the Social Security Act (42 U.S.C. 1395w–4(c)(2)) is 

14 amended— 

15 (1) in subparagraph (B)(i), by striking ‘‘5’’ and 

16 inserting ‘‘4’’; and 

17 (2) in subparagraph (K)(i)(I), by striking ‘‘peri18 odically’’ and inserting ‘‘annually’’. 

19 (e) CONSULTATION WITH MEDICARE PAYMENT AD20 VISORY COMMISSION.— 

21 (1) IN GENERAL.—Section 1848(c)(2) of the 

22 Social Security Act (42 U.S.C. 1395w–4(c)(2)) is 

23 amended— 

24 (A) in subparagraph (B)(i), by inserting 

25 ‘‘in consultation with the Medicare Payment 


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1 Advisory Commission,’’ after ‘‘The Secretary,’’; 

2 and 

3 (B) in subparagraph (K)(i)(I), as amended 

4 by subsection (d)(2), by inserting ‘‘, in coordi5 nation with the Medicare Payment Advisory 

6 Commission,’’ after ‘‘annually’’. 

7 (2) CONFORMING AMENDMENTS.—Section 1805 

8 of the Social Security Act (42 U.S.C. 1395b–6) is 

9 amended— 

10 (A) in subsection (b)(1)(A), by inserting 

11 the following before the semicolon at the end: 

12 ‘‘and including coordinating with the Secretary 

13 in accordance with section 1848(c)(2) to sys14 tematically review the relative values established 

15 for physicians’ services, identify potentially 

16 misvalued services, and propose adjustments to 

17 the relative values for physicians’ services’’; and 

18 (B) in subsection (e)(1), in the second sen19 tence, by inserting ‘‘or the Ranking Minority 

20 Member’’ after ‘‘the Chairman’’. 

21 (f) PERIODIC AUDIT BY THE COMPTROLLER GEN22 ERAL.—Section 1848(c)(2) of the Social Security Act (42 

23 U.S.C. 1395w–4(c)(2)), as amended by subsection (a), is 

24 amended by adding at the end the following new subpara25 graph: 


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1 ‘‘(Q) PERIODIC AUDIT BY THE COMP2 TROLLER GENERAL.— 

3 ‘‘(i) IN GENERAL.—The Comptroller 

4 General of the United States (in this sub5 section referred to as the ‘Comptroller 

6 General’) shall periodically audit the review 

7 by the Secretary of relative values estab8 lished under this paragraph for physicians’ 

9 services. 

10 ‘‘(ii) ACCESS TO INFORMATION.—The 

11 Comptroller General shall have unre12 stricted access to all deliberations, records, 

13 and data related to the activities carried 

14 out under this paragraph, in a timely man15 ner, upon request.’’. 

16 SEC. 614. PAYMENT PROHIBITIONS; CAPITAL EXPENDI17 TURES; SPECIAL PROJECTS. 

18 (a) SENSE OF CONGRESS.—It is the sense of Con19 gress that tens of millions of people in the United States 

20 do not receive healthcare services while billions of dollars 

21 that could be spent on providing health care are diverted 

22 to profit. There is a moral imperative to correct the mas23 sive deficiencies in our current health system and to elimi24 nate profit from the provision of health care. 


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1 (b) PROHIBITIONS.—Payments to providers under 

2 this Act may not take into account, include any process 

3 for the provision of funding for, or be used by a provider 

4 for— 

5 (1) marketing of the provider; 

6 (2) the profit or net revenue of the provider, or 

7 increasing the profit or net revenue of the provider; 

8 (3) incentive payments, bonuses, or other com9 pensation based on patient utilization of items and 

10 services or any financial measure applied with re11 spect to the provider (or any group practice, inte12 grated health care delivery system, or other provider 

13 with which the provider contracts or has a pecuniary 

14 interest), including any value-based payment or em15 ployment-based compensation; 

16 (4) any agreement or arrangement described in 

17 section 203(a)(4) of the Labor-Management Report18 ing and Disclosure Act of 1959 (29 U.S.C. 

19 433(a)(4)); or 

20 (5) political or contributions prohibited under 

21 section 317 of the Federal Elections Campaign Act 

22 of 1971 (52 U.S.C. 30119(a)(1)). 

23 (c) PAYMENTS FOR CAPITAL EXPENDITURES.— 

24 (1) IN GENERAL.—The Secretary shall pay, 

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1 tures pursuant to section 601(a)(2)(B), such sums 

2 determined appropriate by the Secretary to providers 

3 who have submitted an application to the regional 

4 director of the region or regions in which the pro5 vider operates or seeks to operate in a time and 

6 manner specified by the Secretary for purposes of 

7 funding capital expenditures of such providers. 

8 (2) PRIORITY.—The Secretary shall prioritize 

9 allocation of funding under paragraph (1) to 

10 projects that propose to use such funds to improve 

11 service in a medically underserved area (as defined 

12 in section 330(b)(3) of the Public Health Service 

13 Act (42 U.S.C. 254b(b)(3))) or to address health 

14 disparities, including racial, ethnic, national origin, 

15 primary language use, age, disability, sex (including 

16 gender identity and sexual orientation), geography, 

17 or socioeconomic health disparities. 

18 (3) LIMITATION.—The Secretary shall not 

19 grant funding for capital expenditures under this 

20 subsection for capital projects that are financed di21 rectly or indirectly through the diversion of private 

22 or other non-Medicare for All Program funding that 

23 results in reductions in care to patients, including 

24 reductions in registered nursing staffing patterns 


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1 and changes in emergency room or primary care 

2 services or availability. 

3 (4) CAPITAL ASSETS NOT FUNDED BY THE

4 MEDICARE FOR ALL PROGRAM.—Operating expenses 

5 and funds shall not be used by an institutional pro6 vider receiving payment for capital expenditures 

7 under this subsection for a capital asset that was 

8 not funded by the Medicare for All program without 

9 the approval of the regional director or directors of 

10 the region or regions where the capital asset is lo11 cated. 

12 (d) PROHIBITION AGAINST CO-MINGLING OPER13 ATING AND CAPITAL FUNDS.—Providers that receive pay14 ment under this title shall be prohibited from using, with 

15 respect to funds made available under this Act— 

16 (1) funds designated for operating expenditures 

17 for capital expenditures or for profit; or 

18 (2) funds designated for capital expenditures 

19 for operating expenditures. 

20 (e) PAYMENTS FOR SPECIAL PROJECTS.— 

21 (1) IN GENERAL.—The Secretary shall allocate 

22 to each regional director, from amounts made avail23 able for special projects pursuant to section 

24 601(a)(2)(C), such sums determined appropriate by 

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1 scribed in such section, including the construction, 

2 renovation, or staffing of health care facilities, in 

3 rural, underserved, or health professional or medical 

4 shortage areas within such region and to address 

5 health disparities, including racial, ethnic, national 

6 origin, primary language use, age, disability, sex, in7 cluding gender identity and sexual orientation, geog8 raphy, or socioeconomic health disparities. Each re9 gional director shall, prior to distributing such funds 

10 in accordance with paragraph (2), present a budget 

11 describing how such funds will be distributed to the 

12 Secretary. 

13 (2) DISTRIBUTION.—A regional director shall 

14 distribute funds to providers operating in the region 

15 of such director’s jurisdiction in a manner deter16 mined appropriate by the director. 

17 (f) PROHIBITION ON FINANCIAL INCENTIVE

18 METRICS IN PAYMENT DETERMINATIONS.—The Sec19 retary may not utilize any quality metrics or standards 

20 for the purposes of establishing provider payment meth21 odologies, programs, modifiers, or adjustments for pro22 vider payments under this title. 


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1 SEC. 615. OFFICE OF HEALTH EQUITY. 

2 Title XVII of the Public Health Service Act (42 

3 U.S.C. 300u et seq.) is amended by adding at the end 

4 the following: 

5 ‘‘SEC. 1712. OFFICE OF HEALTH EQUITY. 

6 ‘‘(a) IN GENERAL.—There is established, in the Of7 fice of the Secretary of Health and Human Services, an 

8 Office of Health Equity, to be headed by a Director, to 

9 ensure coordination and collaboration across the programs 

10 and activities of the Department of Health and Human 

11 Services with respect to ensuring health equity. 

12 ‘‘(b) MONITORING, TRACKING, AND AVAILABILITY OF

13 DATA.— 

14 ‘‘(1) IN GENERAL.—In carrying out subsection 

15 (a), the Director of the Office of Health Equity shall 

16 monitor, track, and make publicly available data 

17 on— 

18 ‘‘(A) the disproportionate burden of dis19 ease and death among people of color, 

20 disaggregated by race, major ethnic group, 

21 Tribal affiliation, national origin, primary lan22 guage use, English proficiency status, immigra23 tion status, length of stay in the United States 

24 age, disability, sex (including gender identity 

25 and sexual orientation), incarceration, home26 lessness, geography, and socioeconomic status; 


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1 ‘‘(B) barriers to health, including such 

2 barriers relating to income, education, housing, 

3 food insecurity (including availability, access, 

4 utilization, and stability), employment status, 

5 working conditions, and conditions related to 

6 the physical environment (including pollutants 

7 and population density); 

8 ‘‘(C) barriers to health care access, includ9 ing— 

10 ‘‘(i) lack of trust and awareness; 

11 ‘‘(ii) lack of transportation; 

12 ‘‘(iii) geography; 

13 ‘‘(iv) hospital and service closures; 

14 ‘‘(v) lack of health care infrastructure 

15 and facilities; and 

16 ‘‘(vi) lack of health care professional 

17 staffing and recruitment; 

18 ‘‘(D) disparities in quality of care received, 

19 including discrimination in health care settings 

20 and the use of racially-biased practice guide21 lines and algorithms; and 

22 ‘‘(E) disparities in utilization of care. 

23 ‘‘(2) ANALYSIS OF CROSS-SECTIONAL INFORMA24 TION.—The Director of the Office of Health Equity 

25 shall ensure that the data collection and reporting 


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1 process under paragraph (1) allows for the analysis 

2 of cross-sectional information on people’s identities. 

3 ‘‘(c) POLICIES.—In carrying out subsection (a), the 

4 Director of the Office of Health Equity shall develop, co5 ordinate, and promote policies that enhance health equity, 

6 including by— 

7 ‘‘(1) providing recommendations on— 

8 ‘‘(A) cultural competence, implicit bias, 

9 and ethics training with respect to health care 

10 workers; 

11 ‘‘(B) increasing diversity in the health care 

12 workforce; and 

13 ‘‘(C) ensuring sufficient health care profes14 sionals and facilities; and 

15 ‘‘(2) ensuring adequate public health funding at 

16 the local and State levels to address health dispari17 ties. 

18 ‘‘(d) CONSULTATION.—In carrying out subsection 

19 (a), the Director of the Office of Health Equity, in coordi20 nation with the Director of the Indian Health Service, 

21 shall consult with Indian Tribes and with Urban Indian 

22 organizations on data collection, reporting, and implemen23 tation of policies. 


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1 ‘‘(e) ANNUAL REPORT.—In carrying out subsection 

2 (a), the Director of the Office of Health Equity shall de3 velop and publish an annual report on— 

4 ‘‘(1) statistics collected by the Office; 

5 ‘‘(2) proposed evidence-based solutions to miti6 gate health inequities; and 

7 ‘‘(3) health care professional staffing levels and 

8 access to facilities. 

9 ‘‘(f) CENTRALIZED ELECTRONIC REPOSITORY.—In 

10 carrying out subsection (a), the Director of the Office of 

11 Health Equity shall— 

12 ‘‘(1) establish and maintain a centralized elec13 tronic repository to incorporate data collected across 

14 Federal departments and agencies on race, ethnicity, 

15 Tribal affiliation, national origin, primary language 

16 use, English proficiency status, immigration status, 

17 length of stay in the United States age, disability, 

18 sex (including gender identity and sexual orienta19 tion), incarceration, homelessness, geography, and 

20 socioeconomic status; and 

21 ‘‘(2) make such data available for public use 

22 and analysis. 

23 ‘‘(g) PRIVACY.—Notwithstanding any other Federal 

24 or State law, no Federal or State official or employee or 

25 other entity shall disclose, or use, for any law enforcement 


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1 or immigration purpose, any personally identifiable infor2 mation (including with respect to an individual’s religious 

3 beliefs, practices, or affiliation, national origin, ethnicity, 

4 or immigration status) that is collected or maintained pur5 suant to this section.’’. 

6 SEC. 616. OFFICE OF PRIMARY CARE. 

7 Title XVII of the Public Health Service Act (42 

8 U.S.C. 300u et seq.) is amended by adding at the end 

9 the following: 

10 ‘‘SEC. 1713. OFFICE OF PRIMARY CARE. 

11 ‘‘(a) IN GENERAL.—There is established, in the Of12 fice of Health Equity established under section 1712, an 

13 Office of Primary Health Care, to be headed by a Direc14 tor, to ensure coordination and collaboration across the 

15 programs and activities of the Department of Health and 

16 Human Services with respect to increasing access to high17 quality primary health care, particularly in underserved 

18 areas and for underserved populations. 

19 ‘‘(b) NATIONAL GOALS.—Not later than 1 year after 

20 the date of enactment of this section, the Director of the 

21 Office of Primary Health Care shall publish national 

22 goals— 

23 ‘‘(1) to increase access to high-quality primary 

24 health care, particularly in underserved areas and 

25 for underserved populations; and 


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1 ‘‘(2) to address health disparities, including 

2 with respect to race, ethnicity, national origin 

3 (disaggregated by major ethnic group and Tribal af4 filiation), primary language use, English proficiency 

5 status, immigration status, length of stay in the 

6 United States, age, disability, sex (including gender 

7 identity and sexual orientation), incarceration, home8 lessness, geography, and socioeconomic status. 

9 ‘‘(c) OTHER RESPONSIBILITIES.—In carrying out 

10 subsections (a) and (b), the Director of the Office of Pri11 mary Health Care shall— 

12 ‘‘(1) coordinate, in consultation with the Sec13 retary, health professional education policies and 

14 goals to achieve the national goals published pursu15 ant to subsection (b); 

16 ‘‘(2) develop and maintain a system to monitor 

17 the number and specialties of individuals pursuing 

18 careers in, or practicing, primary health care 

19 through their health professional education, any 

20 postgraduate training, and professional practice; 

21 ‘‘(3) develop, coordinate, and promote policies 

22 that expand the number of primary health care prac23 titioners, registered nurses, mid-level practitioners, 

24 and dentists; 


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1 ‘‘(4) recommend appropriate training, technical 

2 assistance, and patient protection enhancements for 

3 primary care health professionals, including reg4 istered nurses, to achieve uniform high quality and 

5 patient safety; 

6 ‘‘(5) provide recommendations on targeted pro7 grams and resources for Federally qualified health 

8 centers, rural health centers, community health cen9 ters, and other community-based organizations; 

10 ‘‘(6) provide recommendations for broader pa11 tient referral to additional resources, not limited to 

12 health care, and collaboration with other organiza13 tions and sectors that influence health outcomes; 

14 and 

15 ‘‘(7) consult with the Secretary on the alloca16 tion of the special projects budget under section 

17 601(a)(2)(C) of the Medicare for All Act of 2021. 

18 ‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec19 tion shall be construed— 

20 ‘‘(1) to preempt any provision of State law es21 tablishing practice standards or guidelines for health 

22 care professionals, including professional licensing or 

23 practice laws or regulations; or 


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1 ‘‘(2) to require that any State impose additional 

2 educational standards or guidelines for health care 

3 professionals.’’. 

4 SEC. 617. PAYMENTS FOR PRESCRIPTION DRUGS AND AP5 PROVED DEVICES AND EQUIPMENT. 

6 The prices to be paid for covered pharmaceuticals, 

7 medical supplies, medical technologies, and medically nec8 essary equipment covered under this Act shall be nego9 tiated annually by the Secretary. 

10 (1) IN GENERAL.—Notwithstanding any other 

11 provision of law, the Secretary shall, for fiscal years 

12 beginning on or after the date of the enactment of 

13 this subsection, negotiate with pharmaceutical man14 ufacturers the prices (including discounts, rebates, 

15 and other price concessions) that may be charged to 

16 the Medicare for All Program during a negotiated 

17 price period (as specified by the Secretary) for cov18 ered drugs for eligible individuals under the Medi19 care for All Program. In negotiating such prices 

20 under this section, the Secretary shall take into ac21 count the following factors: 

22 (A) The comparative clinical effectiveness 

23 and cost effectiveness, when available from an 

24 impartial source, of such drug. 


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1 (B) The budgetary impact of providing 

2 coverage of such drug. 

3 (C) The number of similarly effective 

4 drugs or alternative treatment regimens for 

5 each approved use of such drug. 

6 (D) The total revenues from global sales 

7 obtained by the manufacturer for such drug 

8 and the associated investment in research and 

9 development of such drug by the manufacturer. 

10 (2) FINALIZATION OF NEGOTIATED PRICE.— 

11 The negotiated price of each covered drug for a ne12 gotiated price period shall be finalized not later than 

13 30 days before the first fiscal year in such nego14 tiated price period. 

15 (3) COMPETITIVE LICENSING AUTHORITY.— 

16 (A) IN GENERAL.—Notwithstanding any 

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

18 505(j)(5)(F) of the Federal Food, Drug, and 

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

20 505(c)(3)(E) of such Act, section 351(k)(7)(A) 

21 of the Public Health Service Act, or section 

22 527(a) of the Federal Food, Drug, and Cos23 metic Act, or by an extension of such exclusivity 

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

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


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1 provides for market exclusivity (or extension of 

2 market exclusivity) with respect to a drug, in 

3 the case that the Secretary is unable to success 

4 fully negotiate an appropriate price for a cov5 ered drug for a negotiated price period, the Sec6 retary shall authorize the use of any patent, 

7 clinical trial data, or other exclusivity granted 

8 by the Federal Government with respect to such 

9 drug as the Secretary determines appropriate 

10 for purposes of manufacturing such drug for 

11 sale under Medicare for All Program. Any enti12 ty making use of a competitive license to use 

13 patent, clinical trial data, or other exclusivity 

14 under this section shall provide to the manufac15 turer holding such exclusivity reasonable com16 pensation, as determined by the Secretary 

17 based on the following factors: 

18 (i) The risk-adjusted value of any 

19 Federal Government subsidies and invest20 ments in research and development used to 

21 support the development of such drug. 

22 (ii) The risk-adjusted value of any in23 vestment made by such manufacturer in 

24 the research and development of such 

25 drug. 


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1 (iii) The impact of the price, including 

2 license compensation payments, on meeting 

3 the medical need of all patients at a rea4 sonable cost. 

5 (iv) The relationship between the 

6 price of such drug, including compensation 

7 payments, and the health benefits of such 

8 drug. 

9 (v) Other relevant factors determined 

10 appropriate by the Secretary to provide 

11 reasonable compensation. 

12 (B) REASONABLE COMPENSATION.—The 

13 manufacturer described in subparagraph (A) 

14 may seek recovery against the United States in 

15 the United States Court of Federal Claims. 

16 (C) INTERIM PERIOD.—Until 1 year after 

17 a drug described in subparagraph (A) is ap18 proved under section 505(j) of the Federal 

19 Food, Drug, and Cosmetic Act or section 

20 351(k) of the Public Health Service Act and is 

21 provided under license issued by the Secretary 

22 under such subparagraph, the Medicare for All 

23 Program shall not pay more for such drug than 

24 the average of the prices available, during the 

25 most recent 12-month period for which data is 


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1 available prior to the beginning of such nego2 tiated price period, from the manufacturer to 

3 any wholesaler, retailer, provider, health main4 tenance organization, nonprofit entity, or gov5 ernmental entity in the ten OECD (Organiza6 tion for Economic Cooperation and Develop7 ment) countries that have the largest gross do8 mestic product with a per capita income that is 

9 not less than half the per capita income of the 

10 United States. 

11 (D) AUTHORIZATION FOR SECRETARY TO

12 PROCURE DRUGS DIRECTLY.—The Secretary 

13 may procure a drug manufactured pursuant to 

14 a competitive license under subparagraph (A) 

15 for purposes of this Act. 

16 (4) FDA REVIEW OF LICENSED DRUG APPLICA17 TIONS.—The Secretary shall prioritize review of ap18 plications under section 505(j) of the Federal Food, 

19 Drug, and Cosmetic Act for drugs licensed under 

20 paragraph (3)(A). 

21 (5) PROHIBITION OF ANTICOMPETITIVE BEHAV22 IOR.—No drug manufacturer may engage in anti23 competitive behavior with another manufacturer that 

24 may interfere with the issuance and implementation 


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1 of a competitive license or run contrary to public 

2 policy. 

3 (6) REQUIRED REPORTING.—The Secretary 

4 may require pharmaceutical manufacturers to dis5 close to the Secretary such information that the Sec6 retary determines necessary for purposes of carrying 

7 out this subsection. 

8 TITLE VII—UNIVERSAL 

9 MEDICARE TRUST FUND 

10 SEC. 701. UNIVERSAL MEDICARE TRUST FUND. 

11 (a) IN GENERAL.—There is hereby created on the 

12 books of the Treasury of the United States a trust fund 

13 to be known as the Universal Medicare Trust Fund (in 

14 this section referred to as the ‘‘Trust Fund’’). The Trust 

15 Fund shall consist of such gifts and bequests as may be 

16 made and such amounts as may be deposited in, or appro17 priated to, such Trust Fund as provided in this Act. 

18 (b) APPROPRIATIONS INTO TRUST FUND.— 

19 (1) TAXES.—There are appropriated to the 

20 Trust Fund for each fiscal year beginning with the 

21 fiscal year which includes the date on which benefits 

22 first become available as described in section 106, 

23 out of any moneys in the Treasury not otherwise ap24 propriated, amounts equivalent to 100 percent of the 

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1 tributable to the amendments made by sections 801 

2 and 902. The amounts appropriated by the pre3 ceding sentence shall be transferred from time to 

4 time (but not less frequently than monthly) from the 

5 general fund in the Treasury to the Trust Fund, 

6 such amounts to be determined on the basis of esti7 mates by the Secretary of the Treasury of the taxes 

8 paid to or deposited into the Treasury, and proper 

9 adjustments shall be made in amounts subsequently 

10 transferred to the extent prior estimates were in ex11 cess of or were less than the amounts that should 

12 have been so transferred. 

13 (2) CURRENT PROGRAM RECEIPTS.— 

14 (A) INITIAL YEAR.—Notwithstanding any 

15 other provision of law, there is appropriated to 

16 the Trust Fund for the fiscal year containing 

17 January 1 of the first year following the date 

18 of the enactment of this Act, an amount equal 

19 to the aggregate amount appropriated for the 

20 preceding fiscal year for the following (in21 creased by the consumer price index for all 

22 urban consumers for the fiscal year involved): 

23 (i) The Medicare program under title 

24 XVIII of the Social Security Act (other 


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1 than amounts attributable to any pre2 miums under such title). 

3 (ii) The Medicaid program under 

4 State plans approved under title XIX of 

5 such Act. 

6 (iii) The Federal Employees Health 

7 Benefits program, under chapter 89 of title 

8 5, United States Code. 

9 (iv) The purchased care component of 

10 the TRICARE program, under chapter 55 

11 of title 10, United States Code (other than 

12 amounts appropriated for the purchased 

13 care component of the TRICARE Overseas 

14 Program). 

15 (v) The maternal and child health 

16 program (under title V of the Social Secu17 rity Act), vocational rehabilitation pro18 grams, programs for drug abuse and men19 tal health services under the Public Health 

20 Service Act, programs providing general 

21 hospital or medical assistance, and any 

22 other Federal program identified by the 

23 Secretary, in consultation with the Sec24 retary of the Treasury, to the extent the 

25 programs provide for payment for health 


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1 services the payment of which may be 

2 made under this Act. 

3 (B) SUBSEQUENT YEARS.—Notwithstand4 ing any other provision of law, there is appro5 priated to the trust fund for the fiscal year con6 taining January 1 of the second year following 

7 the date of the enactment of this Act, and for 

8 each fiscal year thereafter, an amount equal to 

9 the amount appropriated to the Trust Fund for 

10 the previous year, adjusted for reductions in 

11 costs resulting from the implementation of this 

12 Act, changes in the consumer price index for all 

13 urban consumers for the fiscal year involved, 

14 and other factors determined appropriate by the 

15 Secretary. 

16 (3) RESTRICTIONS SHALL NOT APPLY.—Any 

17 other provision of law in effect on the date of enact18 ment of this Act restricting the use of Federal funds 

19 for any reproductive health service shall not apply to 

20 monies in the Trust Fund. 

21 (c) INCORPORATION OF PROVISIONS.—The provisions 

22 of subsections (b) through (i) of section 1817 of the Social 

23 Security Act (42 U.S.C. 1395i) shall apply to the Trust 

24 Fund under this section in the same manner as such pro25 visions applied to the Federal Hospital Insurance Trust 


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1 Fund under such section 1817, except that, for purposes 

2 of applying such subsections to this section, the ‘‘Board 

3 of Trustees of the Trust Fund’’ shall mean the ‘‘Sec4 retary’’. 

5 (d) TRANSFER OF FUNDS.—Any amounts remaining 

6 in the Federal Hospital Insurance Trust Fund under sec7 tion 1817 of the Social Security Act (42 U.S.C. 1395i) 

8 or the Federal Supplementary Medical Insurance Trust 

9 Fund under section 1841 of such Act (42 U.S.C. 1395t) 

10 after the payment of claims for items and services fur11 nished under title XVIII of such Act have been completed, 

12 shall be transferred into the Universal Medicare Trust 

13 Fund under this section. 

14 TITLE VIII—CONFORMING 

15 AMENDMENTS TO THE EM16 PLOYEE RETIREMENT IN17 COME SECURITY ACT OF 1974 

18 SEC. 801. PROHIBITION OF EMPLOYEE BENEFITS DUPLICA19 TIVE OF BENEFITS UNDER THE MEDICARE 

20 FOR ALL PROGRAM; COORDINATION IN CASE 

21 OF WORKERS’ COMPENSATION. 

22 (a) IN GENERAL.—Part 5 of subtitle B of title I of 

23 the Employee Retirement Income Security Act of 1974 

24 (29 U.S.C. 1131 et seq.) is amended by adding at the end 

25 the following new section: 


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1 ‘‘SEC. 522. PROHIBITION OF EMPLOYEE BENEFITS DUPLI2 CATIVE OF UNIVERSAL MEDICARE PROGRAM 

3 BENEFITS; COORDINATION IN CASE OF 

4 WORKERS’ COMPENSATION. 

5 ‘‘(a) IN GENERAL.—Subject to subsection (b), no em6 ployee benefit plan may provide benefits that duplicate 

7 payment for any items or services for which payment may 

8 be made under the Medicare for All Act of 2021. 

9 ‘‘(b) REIMBURSEMENT.—Each workers compensation 

10 carrier that is liable for payment for workers compensa11 tion services furnished in a State shall reimburse the 

12 Medicare for All Program for the cost of such services. 

13 ‘‘(c) DEFINITIONS.—In this subsection— 

14 ‘‘(1) the term ‘workers compensation carrier’ 

15 means an insurance company that underwrite work16 ers compensation medical benefits with respect to 

17 one or more employers and includes an employer or 

18 fund that is financially at risk for the provision of 

19 workers compensation medical benefits; 

20 ‘‘(2) the term ‘workers compensation medical 

21 benefits’ means, with respect to an enrollee who is 

22 an employee subject to the workers compensation 

23 laws of a State, the comprehensive medical benefits 

24 for work-related injuries and illnesses provided for 

25 under such laws with respect to such an employee; 

26 and 


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1 ‘‘(3) the term ‘workers compensation services’ 

2 means items and services included in workers com3 pensation medical benefits and includes items and 

4 services (including rehabilitation services and long5 term care services) commonly used for treatment of 

6 work-related injuries and illnesses.’’. 

7 (b) CONFORMING AMENDMENT.—Section 4(b) of the 

8 Employee Retirement Income Security Act of 1974 (29 

9 U.S.C. 1003(b)) is amended by adding at the end the fol10 lowing: ‘‘Paragraph (3) shall apply subject to section 

11 522(b) (relating to reimbursement of the Medicare for All 

12 Program by workers compensation carriers).’’. 

13 (c) CLERICAL AMENDMENT.—The table of contents 

14 in section 1 of such Act is amended by inserting after the 

15 item relating to section 521 the following new item: 

‘‘Sec. 522. Prohibition of employee benefits duplicative of Universal Medicare 

Program benefits; coordination in case of workers’ compensation.’’. 

16 SEC. 802. APPLICATION OF CONTINUATION COVERAGE RE17 QUIREMENTS UNDER ERISA AND CERTAIN 

18 OTHER REQUIREMENTS RELATING TO 

19 GROUP HEALTH PLANS. 

20 (a) IN GENERAL.—Part 6 of subtitle B of title I of 

21 the Employee Retirement Income Security Act of 1974 

22 (29 U.S.C. 1161 et seq.) shall apply only with respect to 

23 any employee health benefit plan that does not duplicate 


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1 payments for any items or services for which payment may 

2 be made under the this Act. 

3 (b) CONFORMING AMENDMENT.—Section 601 of part 

4 6 of subtitle B of title I of the Employee Retirement In5 come Security Act of 1974 (19 U.S.C. 1161) is amended 

6 by adding the following subsection at the end: 

7 ‘‘(c) Subsection (a) shall apply to any group health 

8 plan that does not duplicate payments for any items or 

9 services for which payment may be made under the Medi10 care for All Act of 2021.’’. 

11 SEC. 803. EFFECTIVE DATE OF TITLE. 

12 The provisions of and amendments made by this title 

13 shall take effect on the date described in section 106(a). 

14 TITLE IX—ADDITIONAL 

15 CONFORMING AMENDMENTS 

16 SEC. 901. RELATIONSHIP TO EXISTING FEDERAL HEALTH 

17 PROGRAMS. 

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

19 HEALTH INSURANCE PROGRAM (SCHIP).— 

20 (1) IN GENERAL.—Notwithstanding any other 

21 provision of law and with respect to an individual el22 igible to enroll under this Act, subject to paragraphs 

23 (2) and (3)— 

24 (A) no benefits shall be available under 

25 title XVIII of the Social Security Act for any 


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1 item or service furnished beginning on the date 

2 that is 2 years after the date of the enactment 

3 of this Act; 

4 (B) no individual is entitled to medical as5 sistance under a State plan approved under 

6 title XIX of such Act for any item or service 

7 furnished on or after such date; 

8 (C) no individual is entitled to medical as9 sistance under a State child health plan under 

10 title XXI of such Act for any item or service 

11 furnished on or after such date; and 

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

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

14 with respect to medical assistance or child 

15 health assistance for any item or service fur16 nished on or after such date. 

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

19 continuous period of stay which began before the ef20 fective date of benefits under section 106, and which 

21 had not ended as of such date, for which benefits 

22 are provided under title XVIII of the Social Security 

23 Act, under a State plan under title XIX of such Act, 

24 or under a State child health plan under title XXI 

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1 ation of benefits under such title or plan until the 

2 end of the period of stay. 

3 (3) SCHOOL PROGRAMS.—All school related 

4 health programs, centers, initiatives, services, or 

5 other activities or work provided under title XIX or 

6 title XXI of the Social Security Act as of January 

7 1, 2019, shall be continued and covered by the Medi8 care for All Program. 

9 (b) FEDERAL EMPLOYEES HEALTH BENEFITS PRO10 GRAM.—No benefits shall be made available under chapter 

11 89 of title 5, United States Code, with respect to items 

12 and services furnished to any individual eligible to enroll 

13 under this Act. 

14 (c) TRICARE PROGRAM.— 

15 (1) DIRECT CARE COMPONENT.—Nothing in 

16 this Act shall affect the eligibility of beneficiaries 

17 under chapter 55 of title 10, United States Code, 

18 who are entitled to receive care furnished at facilities 

19 of the uniformed services under the TRICARE pro20 gram for such care. 

21 (2) PURCHASED CARE COMPONENT.— 

22 (A) IN GENERAL.—Except as provided in 

23 subparagraph (B), no benefits shall be made 

24 available under the purchased care component 

25 of the TRICARE program for items or services 


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1 furnished to any individual eligible to enroll 

2 under this Act. 

3 (B) TRICARE OVERSEAS.—During any 

4 period in which an individual is eligible for ben5 efits under the TRICARE Overseas Program 

6 and is located in a TRICARE overseas region, 

7 the individual may receive benefits for items or 

8 services furnished to the individual under the 

9 purchased care component of such program 

10 during such period. 

11 (d) TREATMENT OF BENEFITS FOR VETERANS AND

12 NATIVE AMERICANS.— 

13 (1) IN GENERAL.—Nothing in this Act shall af14 fect the eligibility of veterans for the medical bene15 fits and services provided under title 38, United 

16 States Code, or of Indians for the medical benefits 

17 and services provided by or through the Indian 

18 Health Service. 

19 (2) REEVALUATION.—No reevaluation of the 

20 Indian Health Service shall be undertaken without 

21 consultation with tribal leaders and stakeholders. 

22 SEC. 902. SUNSET OF PROVISIONS RELATED TO THE STATE 

23 EXCHANGES. 

24 Effective on the date that is 2 years after the date 

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1 changes established pursuant to title I of the Patient Pro2 tection and Affordable Care Act (Public Law 111–148) 

3 shall terminate, and any other provision of law that relies 

4 upon participation in or enrollment through such an Ex5 change, including such provisions of the Internal Revenue 

6 Code of 1986, shall cease to have force or effect. 

7 SEC. 903. SUNSET OF PROVISIONS RELATED TO PAY FOR 

8 PERFORMANCE PROGRAMS. 

9 (a) Effective on the date described in section 106(a), 

10 the Federal programs related to pay for performance pro11 grams and value-based purchasing shall terminate, and 

12 any other provision of law that relies upon participation 

13 in or enrollment in such program shall cease to have force 

14 or effect. Programs that shall terminate include— 

15 (1) the Merit-based Incentive Payment System 

16 established pursuant to subsection (q) of section 

17 1848 of the Social Security Act (42 U.S.C. 1395w– 

18 4(q)); 

19 (2) the incentives for meaningful use of cer20 tified EHR technology established pursuant to sub21 section (a)(7) of section 1848 of the Social Security 

22 Act (42 U.S.C. 1395w–4(a)(7)); 

23 (3) the incentives for adoption and meaningful 

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1 ant to subsection (o) of section 1848 of the Social 

2 Security Act (42 U.S.C. 1395w–4(o)); 

3 (4) alternative payment models established 

4 under section 1833(z) of the Social Security Act (42 

5 U.S.C. 1395(z)); and 

6 (5) the following programs as established pur7 suant to the following sections of the Patient Protec8 tion and Affordable Care Act: 

9 (A) Section 2701 (adult health quality 

10 measures). 

11 (B) Section 2702 (payment adjustments 

12 for health care acquired conditions). 

13 (C) Section 2706 (Pediatric Accountable 

14 Care Organization Demonstration Projects for 

15 the purposes of receiving incentive payments). 

16 (D) Section 3002(b) (42 U.S.C. 1395w– 

17 4(a)(8)) (incentive payments for quality report18 ing). 

19 (E) Section 3001(a) (42 U.S.C. 

20 1395ww(o)) (Hospital Value-Based Purchas21 ing). 

22 (F) Section 3006 (value-based purchasing 

23 program for skilled nursing facilities and home 

24 health agencies). 


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1 (G) Section 3007 (42 U.S.C. 1395w–4(p)) 

2 (value based payment modifier under physician 

3 fee schedule). 

4 (H) Section 3008 (42 U.S.C. 1395ww(p)) 

5 (payment adjustments for health care-acquired 

6 condition). 

7 (I) Section 3022 (42 U.S.C. 1395jjj) 

8 (Medicare shared savings programs). 

9 (J) Section 3023 (42 U.S.C. 1395cc–4) 

10 (National Pilot Program on Payment Bun11 dling). 

12 (K) Section 3024 (42 U.S.C. 1395cc–5) 

13 (Independence at home demonstration pro14 gram). 

15 (L) Section 3025 (42 U.S.C. 1395ww(q)) 

16 (hospital readmissions reduction program). 

17 (M) Section 10301 (plans for value-based 

18 purchasing program for ambulatory surgical 

19 centers). 


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1 TITLE X—TRANSITION 

2 Subtitle A—Medicare for All Tran3 sition Over 2 Years and Transi4 tional Buy-In Option 

5 SEC. 1001. MEDICARE FOR ALL TRANSITION OVER TWO 

6 YEARS. 

7 Title XVIII of the Social Security Act (42 U.S.C. 

8 1395c et seq.) is amended by adding at the end the fol9 lowing new section: 

10 ‘‘SEC. 1899C. MEDICARE FOR ALL TRANSITION OVER 2 

11 YEARS. 

12 ‘‘(a) TRANSITION.— 

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

14 the requirements described in paragraph (3) shall be 

15 eligible to enroll in the Medicare for All Program 

16 under this section during the transition period start17 ing one year after the date of enactment of the 

18 Medicare for All Act of 2021. 

19 ‘‘(2) BENEFITS.—An individual enrolled under 

20 this section is entitled to the benefits established 

21 under title II of the Medicare for All Act of 2021. 

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

23 requirements described in this paragraph are the fol24 lowing: 


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1 ‘‘(A) The individual meets the eligibility re2 quirements established by the Secretary under 

3 title I of the Medicare for All Act of 2021. 

4 ‘‘(B) The individual has attained the appli5 cable year of age, or is currently enrolled in 

6 Medicare at the time of the transition to Medi7 care for All. 

8 ‘‘(4) APPLICABLE YEAR OF AGE DEFINED.— 

9 For purposes of this section, the term ‘applicable 

10 year of age’ means one year after the date of enact11 ment of the Medicare for All Act of 2021, the age 

12 of 55 or older, the age 18 or younger. 

13 ‘‘(b) ENROLLMENT; COVERAGE.—The Secretary shall 

14 establish enrollment periods and coverage under this sec15 tion consistent with the principles for establishment of en16 rollment periods and coverage for individuals under other 

17 provisions of this title. The Secretary shall establish such 

18 periods so that coverage under this section shall first begin 

19 on January 1 of the year on which an individual first be20 comes eligible to enroll under this section. 

21 ‘‘(c) SATISFACTION OF INDIVIDUAL MANDATE.—For 

22 purposes of applying section 5000A of the Internal Rev23 enue Code of 1986, the coverage provided under this sec24 tion constitutes minimum essential coverage under sub25 section (f)(1)(A)(i) of such section 5000A. 


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1 ‘‘(d) CONSULTATION.—In promulgating regulations 

2 to implement this section, the Secretary shall consult with 

3 interested parties, including groups representing bene4 ficiaries, health care providers, employers, and insurance 

5 companies.’’. 

6 SEC. 1002. ESTABLISHMENT OF THE MEDICARE TRANSI7 TION BUY-IN. 

8 (a) IN GENERAL.—To carry out the purpose of this 

9 section, for the year beginning one year after the date of 

10 enactment of this Act and ending with the effective date 

11 described in section 106(a), the Secretary, acting through 

12 the Administrator of the Centers for Medicare & Medicaid 

13 (referred to in this section as the ‘‘Administrator’’), shall 

14 establish, and provide for the offering through the Ex15 changes, an option to buy in to the Medicare for All Pro16 gram (in this Act referred to as the ‘‘Medicare Transition 

17 buy-in’’). 

18 (b) ADMINISTERING THE MEDICARE TRANSITION

19 BUY-IN.— 

20 (1) ADMINISTRATOR.—The Administrator shall 

21 administer the Medicare Transition buy-in in accord22 ance with this section. 

23 (2) APPLICATION OF ACA REQUIREMENTS.— 

24 Consistent with this section, the Medicare Transition 

25 buy-in shall comply with requirements under title I 


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1 of the Patient Protection and Affordable Care Act 

2 (and the amendments made by that title) and title 

3 XXVII of the Public Health Service Act (42 U.S.C. 

4 300gg et seq.) that are applicable to qualified health 

5 plans offered through the Exchanges, subject to the 

6 limitation under subsection (e)(2). 

7 (3) OFFERING THROUGH EXCHANGES.—The 

8 Medicare Transition buy-in shall be made available 

9 only through the Exchanges, and shall be available 

10 to individuals wishing to enroll and to qualified em11 ployers (as defined in section 1312(f)(2) of the Pa12 tient Protection and Affordable Care Act (42 U.S.C. 

13 18032)) who wish to make such plan available to 

14 their employees. 

15 (4) ELIGIBILITY TO PURCHASE.—Any United 

16 States resident may enroll in the Medicare Transi17 tion buy-in. 

18 (c) BENEFITS; ACTUARIAL VALUE.—In carrying out 

19 this section, the Administrator shall ensure that the Medi20 care Transition buy-in provides— 

21 (1) coverage for the benefits required to be cov22 ered under title II of this Act; and 

23 (2) coverage of benefits that are actuarially 

24 equivalent to 90 percent of the full actuarial value 

25 of the benefits provided under the plan. 


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1 (d) PROVIDERS AND REIMBURSEMENT RATES.— 

2 (1) IN GENERAL.—With respect to the reim3 bursement provided to health care providers for cov4 ered benefits, as described in section 201, provided 

5 under the Medicare Transition buy-in, the Adminis6 trator shall reimburse such providers at rates deter7 mined for equivalent items and services under the 

8 Medicare for All fee-for-service schedule established 

9 in section 612(b) of this Act. 

10 (2) PRESCRIPTION DRUGS.—Any payment rate 

11 under this subsection for a prescription drug shall be 

12 at the prices negotiated under section 616 of this 

13 Act. 

14 (3) PARTICIPATING PROVIDERS.— 

15 (A) IN GENERAL.—A health care provider 

16 that is a participating provider of services or 

17 supplier under the Medicare program under 

18 title XVIII of the Social Security Act (42 

19 U.S.C. 1395 et seq.) or under a State Medicaid 

20 plan under title XIX of such Act (42 U.S.C. 

21 1396 et seq.) on the date of enactment of this 

22 Act shall be a participating provider in the 

23 Medicare Transition buy-in. 

24 (B) ADDITIONAL PROVIDERS.—The Ad25 ministrator shall establish a process to allow 


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1 health care providers not described in subpara2 graph (A) to become participating providers in 

3 the Medicare Transition buy-in. Such process 

4 shall be similar to the process applied to new 

5 providers under the Medicare program. 

6 (e) PREMIUMS.— 

7 (1) DETERMINATION.—The Administrator shall 

8 determine the premium amount for enrolling in the 

9 Medicare Transition buy-in, which— 

10 (A) may vary according to family or indi11 vidual coverage, age, and tobacco status (con12 sistent with clauses (i), (iii), and (iv) of section 

13 2701(a)(1)(A) of the Public Health Service Act 

14 (42 U.S.C. 300gg(a)(1)(A))); and 

15 (B) shall take into account the cost-shar16 ing reductions and premium tax credits which 

17 will be available with respect to the plan under 

18 section 1402 of the Patient Protection and Af19 fordable Care Act (42 U.S.C. 18071) and sec20 tion 36B of the Internal Revenue Code of 1986, 

21 as amended by subsection (g). 

22 (2) LIMITATION.—Variation in premium rates 

23 of the Medicare Transition buy-in by rating area, as 

24 described in clause (ii) of section 2701(a)(1)(A)(iii) 


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

2 300gg(a)(1)(A)) is not permitted. 

3 (f) TERMINATION.—This section shall cease to have 

4 force or effect on the effective date described in section 

5 106(a). 

6 (g) TAX CREDITS AND COST-SHARING SUBSIDIES.— 

7 (1) PREMIUM ASSISTANCE TAX CREDITS.— 

8 (A) CREDITS ALLOWED TO MEDICARE

9 TRANSITION BUY-IN ENROLLEES IN NON-EX10 PANSION STATES.—Paragraph (1) of section 

11 36B(c) of the Internal Revenue Code of 1986 

12 is amended by redesignating subparagraphs (C) 

13 and (D) as subparagraphs (D) and (E), respec14 tively, and by inserting after subparagraph (B) 

15 the following new subparagraph: 

16 ‘‘(C) SPECIAL RULES FOR MEDICARE

17 TRANSITION BUY-IN ENROLLEES.— 

18 ‘‘(i) IN GENERAL.—In the case of a 

19 taxpayer who is covered, or whose spouse 

20 or dependent (as defined in section 152) is 

21 covered, by the Medicare Transition buy-in 

22 established under section 1002(a) of the 

23 Medicare for All Act of 2021 for all 

24 months in the taxable year, subparagraph 


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1 (A) shall be applied without regard to ‘but 

2 does not exceed 400 percent’. 

3 ‘‘(ii) ENROLLEES IN MEDICAID NON4 EXPANSION STATES.—In the case of a tax5 payer residing in a State which (as of the 

6 date of the enactment of the Medicare for 

7 All Act of 2021) does not provide for eligi8 bility under clause (i)(VIII) or (ii)(XX) of 

9 section 1902(a)(10)(A) of the Social Secu10 rity Act for medical assistance under title 

11 XIX of such Act (or a waiver of the State 

12 plan approved under section 1115) who is 

13 covered, or whose spouse or dependent (as 

14 defined in section 152) is covered, by the 

15 Medicare Transition buy-in established 

16 under section 1002(a) of the Medicare for 

17 All Act of 2021 for all months in the tax18 able year, subparagraphs (A) and (B) shall 

19 be applied by substituting ‘0 percent’ for 

20 ‘100 percent’ each place it appears.’’. 

21 (B) PREMIUM ASSISTANCE AMOUNTS FOR

22 TAXPAYERS ENROLLED IN MEDICARE TRANSI23 TION BUY-IN.— 

24 (i) IN GENERAL.—Subparagraph (A) 

25 of section 36B(b)(3) of such Code is 


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1 amended—(I) by redesignating clause (ii) 

2 as clause (iii), (II) by striking ‘‘clause (ii)’’ 

3 in clause (i) and inserting ‘‘clauses (ii) and 

4 (iii)’’, and (III) by inserting after clause (i) 

5 the following new clause: 

6 ‘‘(ii) SPECIAL RULES FOR TAXPAYERS

7 ENROLLED IN MEDICARE TRANSITION BUY8 IN.—In the case of a taxpayer who is cov9 ered, or whose spouse or dependent (as de10 fined in section 152) is covered, by the 

11 Medicare Transition buy-in established 

12 under section 1002(a) of the Medicare for 

13 All Act of 2021 for all months in the tax14 able year, the applicable percentage for 

15 any taxable year shall be determined in the 

16 same manner as under clause (i), except 

17 that the following table shall apply in lieu 

18 of the table contained in such clause: 

‘‘In the case of household income 

(expressed as a percent of 

poverty line) within the 

following income tier: 

The initial 

premium 

percentage is— 

The final 

premium 

percentage is— 

Up to 100 percent .............................. 2.00 2.00

100 percent up to 138 percent ........... 2.04 2.04

138 percent up to 150 percent ........... 3.06 4.08

150 percent and above ........................ 4.08 5.00.’’. 

19 (ii) CONFORMING AMENDMENT.—Sub20 clause (I) of clause (iii) of section 

21 36B(b)(3) of such Code, as redesignated 


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1 by subparagraph (A)(i), is amended by in2 serting ‘‘, and determined after the appli3 cation of clause (ii)’’ after ‘‘after applica4 tion of this clause’’. 

5 (2) COST-SHARING SUBSIDIES.—Subsection (b) 

6 of section 1402 of the Patient Protection and Af7 fordable Care Act (42 U.S.C. 18071(b)) is amend8 ed— 

9 (A) by inserting ‘‘, or in the Medicare 

10 Transition buy-in established under section 

11 1002(a) of the Medicare for All Act of 2021,’’ 

12 after ‘‘coverage’’ in paragraph (1); 

13 (B) by redesignating paragraphs (1) (as so 

14 amended) and (2) as subparagraphs (A) and 

15 (B), respectively, and by moving such subpara16 graphs 2 ems to the right; 

17 (C) by striking ‘‘INSURED.—In this sec18 tion’’ and inserting ‘‘INSURED.— 

19 ‘‘(1) IN GENERAL.—In this section’’; 

20 (D) by striking the flush language; and 

21 (E) by adding at the end the following new 

22 paragraph: 

23 ‘‘(2) SPECIAL RULES.— 

24 ‘‘(A) INDIVIDUALS LAWFULLY PRESENT.— 

25 In the case of an individual described in section 


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1 36B(c)(1)(B) of the Internal Revenue Code of 

2 1986, the individual shall be treated as having 

3 household income equal to 100 percent of the 

4 poverty line for a family of the size involved for 

5 purposes of applying this section. 

6 ‘‘(B) MEDICARE TRANSITION BUY-IN EN7 ROLLEES IN MEDICAID NON-EXPANSION

8 STATES.—In the case of an individual residing 

9 in a State which (as of the date of the enact10 ment of the Medicare for All Act of 2021) does 

11 not provide for eligibility under clause (i)(VIII) 

12 or (ii)(XX) of section 1902(a)(10)(A) of the So13 cial Security Act for medical assistance under 

14 title XIX of such Act (or a waiver of the State 

15 plan approved under section 1115) who enrolls 

16 in such Medicare Transition buy-in, the pre17 ceding sentence, paragraph (1)(B), and para18 graphs (1)(A)(i) and (2)(A) of subsection (c) 

19 shall each be applied by substituting ‘0 percent’ 

20 for ‘100 percent’ each place it appears.’’. 

21 (h) CONFORMING AMENDMENTS.— 

22 (1) TREATMENT AS A QUALIFIED HEALTH

23 PLAN.—Section 1301(a)(2) of the Patient Protection 

24 and Affordable Care Act (42 U.S.C. 18021(a)(2)) is 

25 amended— 


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1 (A) in the paragraph heading, by inserting 

2 ‘‘THE MEDICARE TRANSITION BUY-IN,’’ before 

3 ‘‘AND’’; and 

4 (B) by inserting ‘‘The Medicare Transition 

5 buy-in,’’ before ‘‘and a multi-State plan’’. 

6 (2) LEVEL PLAYING FIELD.—Section 1324(a) 

7 of the Patient Protection and Affordable Care Act 

8 (42 U.S.C. 18044(a)) is amended by inserting ‘‘the 

9 Medicare Transition buy-in,’’ before ‘‘or a multi10 State qualified health plan’’. 

11 Subtitle B—Transitional Medicare 

12 Reforms 

13 SEC. 1011. ELIMINATING THE 24-MONTH WAITING PERIOD 

14 FOR MEDICARE COVERAGE FOR INDIVID15 UALS WITH DISABILITIES. 

16 (a) IN GENERAL.—Section 226(b) of the Social Secu17 rity Act (42 U.S.C. 426(b)) is amended— 

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

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

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

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

22 (3) in paragraph (2)(C)(ii), by striking ‘‘, in23 cluding the requirement that he has been entitled to 

24 the specified benefits for 24 months,’’; 


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

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

3 (II) the twenty-fifth month of his entitlement or sta4 tus as a qualified railroad retirement beneficiary de5 scribed in paragraph (2), and’’ and inserting ‘‘for 

6 each month for which the individual meets the re7 quirements of paragraph (2), beginning with the 

8 month following the month in which the individual 

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

10 and 

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

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

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

14 (b) CONFORMING AMENDMENTS.— 

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

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

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

18 (h); and 

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

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

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

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

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

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


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

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

3 is amended by striking ‘‘25th month of’’ and insert4 ing ‘‘month following the first month of’’. 

5 (4) RAILROAD RETIREMENT SYSTEM.—Section 

6 7(d)(2)(ii) of the Railroad Retirement Act of 1974 

7 (45 U.S.C. 231f(d)(2)(ii)) is amended— 

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

9 annuity’’ and inserting ‘‘is entitled to an annu10 ity’’; 

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

12 months’’; and 

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

14 for 24 calendar months, and’’. 

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

16 this section shall apply to insurance benefits under title 

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

18 services furnished in months beginning after December 1 

19 following the date of enactment of this Act, and before 

20 the date that is 2 years after the date of the enactment 

21 of such Act. 

22 SEC. 1012. ENSURING CONTINUITY OF CARE. 

23 (a) IN GENERAL.—The Secretary shall ensure that 

24 all persons enrolled or who seeks to enroll in a health plan 

25 during the transition period of the Medicare for All ProVerDate Sep 11 2014 23:21 May 17, 2021 Jkt 019200 PO 00000 Frm 00124 Fmt 6652 Sfmt 6201 E:\BILLS\H1976.IH H1976

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1 gram are protected from disruptions in their care during 

2 the transition period, including continuity of care with 

3 such persons current health care provider teams. 

4 (b) CONTINUITY OF COVERAGE AND CARE IN GEN5 ERAL.—During the transition period of the Medicare for 

6 All Act, group health plans and health insurance issuers 

7 offering group or individual health insurance coverage 

8 shall not end coverage for an enrollee during the transition 

9 period described in the Act until all ages are eligible to 

10 enroll in the Medicare for All Program except as expressly 

11 agreed upon under the terms of the plan. 

12 (c) CONTINUITY OF COVERAGE AND CARE FOR PER13 SONS WITH COMPLEX MEDICAL NEEDS.— 

14 (1) The Secretary shall ensure that persons 

15 with disabilities, complex medical needs, or chronic 

16 conditions are protected from disruptions in their 

17 care during the transition period, including con18 tinuity of care with such persons current health care 

19 provider teams. 

20 (2) During the transition period of the Medi21 care for All Act group health plans and health insur22 ance issuers offering group or individual health in23 surance coverage shall not— 

24 (A) end coverage for an enrollee who has 

25 a disability, complex medical need, or chronic 


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1 condition during the transition period described 

2 in the Act until all ages are eligible to enroll in 

3 the Medicare for All Program; or 

4 (B) impose any exclusion with respect to 

5 such plan or coverage on the basis of a person’s 

6 disability, complex medical need, or chronic con7 dition during the transition period described 

8 under this Act until all ages are eligible to en9 roll in the Medicare for All Program. 

10 (d) PUBLIC CONSULTATION DURING TRANSITION.— 

11 The Secretary shall consult with communities and advo12 cacy organizations of persons living with disabilities as 

13 well as other patient advocacy organizations to ensure that 

14 the transition buy-in takes into account the continuity of 

15 care for persons with disabilities, complex medical needs, 

16 or chronic conditions. 

17 TITLE XI—MISCELLANEOUS 

18 SEC. 1101. DEFINITIONS. 

19 In this Act— 

20 (1) the term ‘‘global budget’’ means the pay21 ment negotiated between an institutional provider 

22 and as described in section 611(b); 

23 (2) the term ‘‘group practice’’ has the meaning 

24 given such term in section 1877(h)(4) of the Social 

25 Security Act (42 U.S.C. 1395nn(h)(4)); 


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1 (3) the term ‘‘individual provider’’ means a sup2 plier (as defined in section 1861(d) of such Act (42 

3 U.S.C. 1395x(d))); 

4 (4) the term ‘‘institutional provider’’ means— 

5 (A) providers of services described in sec6 tion 1861(u) of such Act (42 U.S.C. 1395x(u)); 

7 (B) hospitals as defined in section 1861(e) 

8 of the Social Security Act (42 U.S.C. 

9 1395x(e)), and any outpatient settings or clinics 

10 operating within a hospital license or any set11 ting or clinic that provides outpatient hospital 

12 services; 

13 (C) psychiatric hospitals (as defined in sec14 tion 1861(e) of the Social Security Act (42 

15 U.S.C. 1395x(f))); 

16 (D) rehabilitation hospitals (as defined by 

17 the Secretary of Health and Human Services 

18 under section 1886(d)(1)(B)(ii) of the Social 

19 Security Act (42 U.S.C. 1395ww(d)(1)(B)(ii))); 

20 (E) long-term care hospitals as defined in 

21 section 1861 of the Social Security Act (42 

22 U.S.C. 1395x(ccc)); and 

23 (F) independent dialysis facilities and inde24 pendent end-stage renal disease facilities as de25 scribed in 42 CFR 413.174(b); 


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1 (5) the term ‘‘medically necessary or appro2 priate’’ means the health care items and services or 

3 supplies that are needed or appropriate to prevent, 

4 diagnose, or treat an illness, injury, condition, dis5 ease, or its symptoms for an individual and are de6 termined to be necessary or appropriate for such in7 dividual by the physician or other health care profes8 sional treating such individual, after such profes9 sional performs an assessment of such individual’s 

10 condition, in a manner that meets— 

11 (A) the scope of practice, licensing, and 

12 other law of the State in which the individual 

13 receiving such items and services is located; and 

14 (B) appropriate standards established by 

15 the Secretary for purposes of carrying out this 

16 Act; 

17 (6) the term ‘‘provider’’ means an institutional 

18 provider or a supplier (as defined in section 1861(d) 

19 of such Act (42 U.S.C. 1395x(d)) if the reference to 

20 ‘‘this title’’ were a reference to the Medicare for All 

21 Program); 

22 (7) the term ‘‘Secretary’’ means the Secretary 

23 of Health and Human Services; 


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1 (8) the term ‘‘State’’ means a State, the Dis2 trict of Columbia, or a territory of the United 

3 States; 

4 (9) the term ‘‘TRICARE Overseas Program’’ 

5 means the element of the TRICARE program ad6 ministered by International SOS (or such successor 

7 administrator) under which care and health benefits 

8 are furnished to TRICARE beneficiaries located in 

9 a TRICARE overseas region; 

10 (10) the term ‘‘TRICARE program’’ has the 

11 meaning given such term in section 1072 of title 10, 

12 United States Code; 

13 (11) the term ‘‘uniformed services’’ has the 

14 meaning given such term in section 101 of title 10, 

15 United States Code; and 

16 (12) the term ‘‘United States’’ shall include the 

17 States, the District of Columbia, and the territories 

18 of the United States. 

19 SEC. 1102. RULES OF CONSTRUCTION. 

20 (a) IN GENERAL.—A State or local government may 

21 set additional standards or apply other State or local laws 

22 with respect to eligibility, benefits, and minimum provider 

23 standards, only if such State or local standards— 

24 (1) provide equal or greater eligibility than is 

25 available under this Act; 


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1 (2) provide equal or greater in-person access to 

2 benefits under this Act; 

3 (3) do not reduce access to benefits under this 

4 Act; 

5 (4) allow for the effective exercise of the profes6 sional judgment of physicians or other health care 

7 professionals; and 

8 (5) are otherwise consistent with this Act. 

9 (b) RELATION TO STATE LICENSING LAW.—Nothing 

10 in this Act shall be construed to preempt State licensing, 

11 practice, or educational laws or regulations with respect 

12 to health care professionals and health care providers, for 

13 such professionals and providers who practice in that 

14 State. 

15 (c) APPLICATION TO STATE AND FEDERAL LAW ON

16 WORKPLACE RIGHTS.—Nothing in this Act shall be con17 strued to diminish or alter the rights, privileges, remedies, 

18 or obligations of any employee or employer under any Fed19 eral or State law or regulation or under any collective bar20 gaining agreement. 

21 (d) RESTRICTIONS ON PROVIDERS.—With respect to 

22 any individuals or entities certified to provide items and 

23 services covered under section 201(a)(7), a State may not 

24 prohibit an individual or entity from participating in the 


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1 program under this Act for reasons other than the ability 

2 of the individual or entity to provide such services. 

3 SEC. 1103. NO USE OF RESOURCES FOR LAW ENFORCE4 MENT OF CERTAIN REGISTRATION REQUIRE5 MENTS. 

6 Notwithstanding any provision of Federal or State 

7 law, no Federal or State law enforcement official or em8 ployee shall use any funds, facilities, property, equipment, 

9 or personnel made available pursuant to this Act (or any 

10 amendment made thereby) to investigate, enforce, or as11 sist in the investigation or enforcement of any criminal, 

12 civil, or administrative violation or warrant for a violation 

13 of any requirement that individuals register with the Fed14 eral Government based on religion, national origin, eth15 nicity, immigration status, or other protected category. 

Æ 


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