I 

116TH CONGRESS 

1ST SESSION H. R. 1384 

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

IN THE HOUSE OF REPRESENTATIVES 

FEBRUARY 27, 2019 

Ms. JAYAPAL (for herself, Mrs. DINGELL, Ms. ADAMS, Ms. BARRAGA ́N, Ms. 

BASS, Mrs. BEATTY, Mr. BEYER, Mr. BLUMENAUER, Ms. BONAMICI, Mr. 

BRENDAN F. BOYLE of Pennsylvania, Mr. BROWN of Maryland, Mr. CARSON of Indiana, Mr. CARTWRIGHT, Ms. JUDY CHU of California, Mr. 

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

CLAY, Mr. CLEAVER, Mr. COHEN, Mr. DANNY K. DAVIS of Illinois, Mr. 

DEFAZIO, Ms. DEGETTE, Mr. DESAULNIER, Mr. MICHAEL F. DOYLE of 

Pennsylvania, Mr. ENGEL, Ms. ESCOBAR, Mr. ESPAILLAT, Ms. FRANKEL, 

Ms. FUDGE, Ms. GABBARD, Mr. GALLEGO, Mr. GARCI ́A of Illinois, Mr. 

GOLDEN, Mr. GOMEZ, Mr. GONZALEZ of Texas, Mr. GREEN of Texas, 

Mr. GRIJALVA, Ms. HAALAND, Mr. HARDER of California, Mr. HASTINGS, Mrs. HAYES, Mr. HIGGINS of New York, Ms. HILL of California, 

Ms. NORTON, Mr. HUFFMAN, Ms. JACKSON LEE, Mr. JOHNSON of Georgia, Mr. KEATING, Ms. KELLY of Illinois, Mr. KENNEDY, Mr. KHANNA, 

Mrs. KIRKPATRICK, Mr. LANGEVIN, Mrs. LAWRENCE, Ms. LEE of California, Mr. LEVIN of California, Mr. LEVIN of Michigan, Mr. LEWIS, Mr. 

TED LIEU of California, Mr. LOWENTHAL, Mrs. LOWEY, Mrs. CAROLYN

B. MALONEY of New York, Mr. MCGOVERN, Mr. MCNERNEY, Mr. 

MEEKS, Ms. MENG, Mr. NADLER, Mrs. NAPOLITANO, Mr. NEGUSE, 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. RYAN, Mr. SABLAN, Ms. 

SA ́NCHEZ, Mr. SARBANES, Ms. SCHAKOWSKY, Mr. SCHIFF, Mr. SCOTT of 

Virginia, Mr. SERRANO, Mr. SMITH of Washington, Ms. SPEIER, Mr. 

SWALWELL of California, Mr. TAKANO, Mr. THOMPSON of California, Mr. 

THOMPSON of Mississippi, Ms. TITUS, Ms. TLAIB, Mr. TONKO, Mr. 

VEASEY, Ms. VELA ́ZQUEZ, Mr. VISCLOSKY, Ms. WATERS, Mrs. WATSON

COLEMAN, Mr. WELCH, Ms. WILD, and Ms. WILSON of Florida) 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, and Armed Services, 

for a period to be subsequently determined by the Speaker, in each case 

for consideration of such provisions as fall within the jurisdiction of the 

committee concerned 


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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 2019’’. 

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. 

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 

Subtitle A—General Administration Provisions 

Sec. 401. Administration. 

Sec. 402. Consultation. 

Sec. 403. Regional administration. 

Sec. 404. Beneficiary ombudsman. 


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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 primary health care. 

Sec. 616. 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 

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 


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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. 

1 TITLE I—ESTABLISHMENT OF 

2 THE MEDICARE FOR ALL PRO3 GRAM; UNIVERSAL COVER4 AGE; 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. 

18 (b) TREATMENT OF OTHER INDIVIDUALS.—The Sec19 retary may make eligible for benefits for health care serv20 ices under this Act other individuals not described in sub21 section (a), and regulate the eligibility of such individuals, 

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1 cess to health care. In regulating such eligibility, the Sec2 retary shall ensure that individuals are not allowed to 

3 travel to the United States for the sole purpose of obtain4 ing health care items and services provided under the pro5 gram established under this Act. 

6 SEC. 103. FREEDOM OF CHOICE. 

7 Any individual entitled to benefits under this Act may 

8 obtain health services from any institution, agency, or in9 dividual qualified to participate under this Act. 

10 SEC. 104. NON-DISCRIMINATION. 

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

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

13 citizenship status, primary language use, genetic condi14 tions, previous or existing medical conditions, religion, or 

15 sex, including sex stereotyping, gender identity, sexual ori16 entation, and pregnancy and related medical conditions 

17 (including termination of pregnancy), be excluded from 

18 participation in or be denied the benefits of the program 

19 established under this Act (except as expressly authorized 

20 by this Act for purposes of enforcing eligibility standards 

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

22 of benefits or other discrimination by any participating 

23 provider (as defined in section 301), or any entity con24 ducting, administering, or funding a health program or 


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1 activity, including contracts of insurance, pursuant to this 

2 Act. 

3 (b) CLAIMS OF DISCRIMINATION.— 

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

5 a procedure for adjudication of administrative com6 plaints alleging a violation of subsection (a). 

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

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

9 file suit in any district court of the United States 

10 having jurisdiction of the parties. A person may 

11 bring an action under this paragraph concurrently 

12 as such administrative remedies as established in 

13 paragraph (1). 

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

15 subsection (a), the court may grant compensatory 

16 and punitive damages, declaratory relief, injunctive 

17 relief, attorneys’ fees and costs, or other relief as ap18 propriate. 

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

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

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

22 remedies, procedures, or legal standards available to indi23 viduals aggrieved under section 1557 of the Patient Pro24 tection and Affordable Care Act (42 U.S.C. 18116), title 

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


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

2 2000e et seq.), title IX of the Education Amendments of 

3 1972 (20 U.S.C. 1681 et seq.), section 504 of the Reha4 bilitation Act of 1973 (29 U.S.C. 794), or the Age Dis5 crimination Act of 1975 (42 U.S.C. 611 et seq.). Nothing 

6 in this title (or an amendment to this title) shall be con7 strued to supersede State laws that provide additional pro8 tections against discrimination on any basis described in 

9 subsection (a). 

10 SEC. 105. ENROLLMENT. 

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

12 mechanism for the enrollment of individuals eligible for 

13 benefits under this Act. The mechanism shall— 

14 (1) include a process for the automatic enroll15 ment of individuals at the time of birth in the 

16 United States (or upon establishment of residency in 

17 the United States); 

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

19 described in section 106, of all individuals who are 

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

21 and 

22 (3) include a process for the enrollment of indi23 viduals made eligible for health care services under 

24 section 102(b). 


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1 (b) ISSUANCE OF UNIVERSAL MEDICARE CARDS.— 

2 In conjunction with an individual’s enrollment for benefits 

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

4 of a Universal Medicare card that shall be used for pur5 poses of identification and processing of claims for bene6 fits under this program. The card shall not include an in7 dividual’s Social Security number. 

8 SEC. 106. EFFECTIVE DATE OF BENEFITS. 

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

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

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

12 enactment of this Act. 

13 (b) COVERAGE FOR CERTAIN INDIVIDUALS.— 

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

15 who— 

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

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

18 enactment of this Act; or 

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

20 date that is 1 year after the date of the enact21 ment of this Act, 

22 benefits shall first be available under this Act for 

23 items and services furnished as of such date. 

24 (2) OPTION TO CONTINUE IN OTHER COVERAGE

25 DURING TRANSITION PERIOD.—Any person who is 


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1 eligible to receive benefits as described in paragraph 

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

3 section 901, private health insurance coverage, or 

4 coverage offered pursuant to subtitle A of title X 

5 (including the amendments made by such subtitle) 

6 until the date described in subsection (a). 

7 SEC. 107. PROHIBITION AGAINST DUPLICATING COVERAGE. 

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

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

10 (1) a private health insurer to sell health insur11 ance coverage that duplicates the benefits provided 

12 under this Act; or 

13 (2) an employer to provide benefits for an em14 ployee, former employee, or the dependents of an 

15 employee or former employee that duplicate the ben16 efits provided under this Act. 

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

18 construed as prohibiting the sale of health insurance cov19 erage for any additional benefits not covered by this Act, 

20 including additional benefits that an employer may provide 

21 to employees or their dependents, or to former employees 

22 or their dependents. 


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1 TITLE II—COMPREHENSIVE BEN2 EFITS, INCLUDING PREVEN3 TIVE BENEFITS AND BENE4 FITS FOR LONG-TERM CARE 

5 SEC. 201. COMPREHENSIVE BENEFITS. 

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

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

8 benefits under this Act are entitled to have payment made 

9 by the Secretary to an eligible provider for the following 

10 items and services if medically necessary or appropriate 

11 for the maintenance of health or for the diagnosis, treat12 ment, or rehabilitation of a health condition: 

13 (1) Hospital services, including inpatient and 

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

15 emergency services and inpatient prescription drugs. 

16 (2) Ambulatory patient services. 

17 (3) Primary and preventive services, including 

18 chronic disease management. 

19 (4) Prescription drugs and medical devices, in20 cluding outpatient prescription drugs, medical de21 vices, and biological products. 

22 (5) Mental health and substance abuse treat23 ment services, including inpatient care. 

24 (6) Laboratory and diagnostic services. 


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1 (7) Comprehensive reproductive, maternity, and 

2 newborn care. 

3 (8) Pediatrics. 

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

5 (10) Rehabilitative and habilitative services and 

6 devices. 

7 (11) Emergency services and transportation. 

8 (12) 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 (13) Necessary transportation to receive health 

15 care services for persons with disabilities or low-in16 come individuals (as determined by the Secretary). 

17 (14) Long-term care services and support (as 

18 described in section 204). 

19 (b) REVISION AND ADJUSTMENT.—The Secretary 

20 shall, at least annually, and on a regular basis, evaluate 

21 whether the benefits package should be improved or ad22 justed to promote the health of beneficiaries, account for 

23 changes in medical practice or new information from med24 ical research, or respond to other relevant developments 

25 in health science, and shall make recommendations to 


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1 Congress regarding any such improvements or adjust2 ments. 

3 (c) HEARINGS.— 

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

5 and Commerce and the Committee on Ways and 

6 Means of the House of Representatives shall, not 

7 less frequently than annually, hold a hearing on the 

8 recommendations submitted by the Secretary under 

9 subsection (b). 

10 (2) EXERCISE OF RULEMAKING AUTHORITY.— 

11 Paragraph (1) is enacted— 

12 (A) as an exercise of rulemaking power of 

13 the House of Representatives, and, as such, 

14 shall be considered as part of the rules of the 

15 House, and such rules shall supersede any other 

16 rule of the House only to the extent that rule 

17 is inconsistent therewith; and 

18 (B) with full recognition of the constitu19 tional right of either House to change such 

20 rules (so far as relating to the procedure in 

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

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

23 other rule of the House. 

24 (d) COMPLEMENTARY AND INTEGRATIVE MEDI25 CINE.— 


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

2 (b), the Secretary shall consult with the persons de3 scribed in paragraph (2) with respect to— 

4 (A) identifying specific complementary and 

5 integrative medicine practices that are appro6 priate to include in the benefits package; and 

7 (B) identifying barriers to the effective 

8 provision and integration of such practices into 

9 the delivery of health care, and identifying 

10 mechanisms for overcoming such barriers. 

11 (2) CONSULTATION.—In accordance with para12 graph (1), the Secretary shall consult with— 

13 (A) the Director of the National Center for 

14 Complementary and Integrative Health; 

15 (B) the Commissioner of Food and Drugs; 

16 (C) institutions of higher education, pri17 vate research institutes, and individual re18 searchers with extensive experience in com19 plementary and alternative medicine and the in20 tegration of such practices into the delivery of 

21 health care; 

22 (D) nationally recognized providers of com23 plementary and integrative medicine; and 

24 (E) such other officials, entities, and indi25 viduals with expertise on complementary and 


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1 integrative medicine as the Secretary deter2 mines appropriate. 

3 (e) STATES MAY PROVIDE ADDITIONAL BENE4 FITS.—Individual States may provide additional benefits 

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

6 State, and may provide benefits to individuals not eligible 

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

8 subject to the requirements specified in section 1102. 

9 SEC. 202. NO COST-SHARING. 

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

11 no cost-sharing, including deductibles, coinsurance, copay12 ments, or similar charges, is imposed on an individual for 

13 any benefits provided under this Act. 

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

15 a charge to an enrolled individual for covered services for 

16 which benefits are provided under this Act. 

17 SEC. 203. EXCLUSIONS AND LIMITATIONS. 

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

19 are not available under this Act unless the items and serv20 ices meet the standards developed by the Secretary pursu21 ant to section 201(a). 

22 (b) TREATMENT OF EXPERIMENTAL ITEMS AND

23 SERVICES AND DRUGS.— 

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

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1 minations with respect to items and services that are 

2 experimental in nature. Such determinations shall be 

3 consistent with the national coverage determination 

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

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

6 (2) APPEALS PROCESS.—The Secretary shall 

7 establish a process by which individuals can appeal 

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

9 feasible, follow the process for appeals under the 

10 Medicare program described in section 1869 of the 

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

12 (c) APPLICATION OF PRACTICE GUIDELINES.— 

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

14 services for which the Department of Health and 

15 Human Services has recognized a national practice 

16 guideline, such items and services shall be deemed to 

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

18 they have been provided in accordance with such 

19 guideline. For purposes of this subsection, an item 

20 or service not provided in accordance with a practice 

21 guideline shall be deemed to have been provided in 

22 accordance with the guideline if the health care pro23 vider providing the item or service— 

24 (A) exercised appropriate professional 

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1 quirements of the State in which such item or 

2 service is furnished in deviating from the guide3 line; 

4 (B) acted in the best interest of the indi5 vidual receiving the item or service; and 

6 (C) acted in a manner consistent with the 

7 individual’s wishes. 

8 (2) OVERRIDE OF STANDARDS.— 

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

10 physician or other health care professional au11 thorized to exercise independent professional 

12 judgment in implementing a patient’s medical 

13 or nursing care plan in accordance with the 

14 scope of practice, licensure, and other law of 

15 the State where items and services are to be 

16 furnished may override practice standards es17 tablished pursuant to section 201(a) or practice 

18 guidelines described in paragraph (1), including 

19 such standards and guidelines that are imple20 mented by a provider through the use of health 

21 information technology, such as electronic 

22 health record technology, clinical decision sup23 port technology, and computerized order entry 

24 programs. 


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1 (B) LIMITATION.—An override described 

2 in subparagraph (A) shall, in the professional 

3 judgment of such physician, nurse, or health 

4 care professional, be— 

5 (i) consistent with such physician’s, 

6 nurse’s, or health care professional’s deter7 mination of medical necessity and appro8 priateness or nursing assessment; 

9 (ii) in the best interests of the indi10 vidual; and 

11 (iii) consistent with the individual’s 

12 wishes. 

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

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

15 this Act, individuals enrolled for benefits under this Act 

16 are entitled to the following long-term services and sup17 ports and to have payment made by the Secretary to an 

18 eligible provider for such services and supports if medically 

19 necessary and appropriate and in accordance with the 

20 standards established in this Act, for maintenance of 

21 health or for care, services, diagnosis, treatment, or reha22 bilitation that is related to a medically determinable condi23 tion, whether physical or mental, of health, injury, or age 

24 that— 


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1 (1) causes a functional limitation in performing 

2 one or more activities of daily living; or 

3 (2) requires a similar need of assistance in per4 forming instrumental activities of daily living due to 

5 cognitive or other impairments. 

6 (b) ELIGIBILITY.—The Secretary shall promulgate 

7 rules that provide for the following: 

8 (1) The determination of individual eligibility 

9 for long-term services and supports under this sec10 tion. 

11 (2) The assessment of the long-term services 

12 and supports needed for eligible individuals. 

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

14 and supports under this section shall be tailored to an in15 dividual’s needs, as determined through assessment, and 

16 shall be defined by the Secretary to— 

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

18 the enrollee, whether provided in an institution or in 

19 a home and community-based setting; 

20 (2) provide coverage for a broad spectrum of 

21 long-term services and supports, including for home 

22 and community-based services and other care pro23 vided through non-institutional settings; 

24 (3) provide coverage that meets the physical, 

25 mental, and social needs of recipients while allowing 


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1 recipients their maximum possible autonomy and 

2 their maximum possible civic, social, and economic 

3 participation; 

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

5 supports through home and community-based serv6 ices over institutionalization; 

7 (5) unless an individual elects otherwise, ensure 

8 that recipients will receive home and community 

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

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

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

12 (6) be provided with the goal of enabling per13 sons with disabilities to receive services in the least 

14 restrictive and most integrated setting appropriate 

15 to the individual’s needs; 

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

17 persons with disabilities to maintain their independ18 ence, self-determination, and dignity; 

19 (8) provide long-term services and supports 

20 that are of equal quality and equally accessible 

21 across geographic regions; and 

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

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

24 services from either the recipient or care coordina25 tors of the recipient’s choosing. 


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1 (d) PUBLIC CONSULTATION.—In developing regula2 tions to implement this section, the Secretary shall consult 

3 with an advisory commission on long-term services and 

4 supports that includes— 

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

6 services and supports and older adults who use long7 term services and supports; 

8 (2) representatives of people with disabilities 

9 and representatives of older adults; 

10 (3) groups that represent the diversity of the 

11 population of people living with disabilities, including 

12 gender, racial, and economic diversity; 

13 (4) providers of long-term services and sup14 ports, including family attendants and family care15 givers, and members of organized labor; 

16 (5) disability rights organizations; and 

17 (6) relevant academic institutions and research18 ers. 

19 (e) BUDGETING AND PAYMENTS.—Budgeting and 

20 payments for long-term services and supports provided 

21 under this section shall be made in accordance with the 

22 provisions under title VI. 

23 (f) DEFINITIONS.—In this section: 

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

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


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1 services needed to support the activities of daily liv2 ing and instrumental activities of daily living, includ3 ing all long-term services and supports available 

4 under section 1915 of the Social Security Act (42 

5 U.S.C. 1396n), home and community-based services, 

6 and any additional services and supports identified 

7 by the Secretary to support people with disabilities 

8 to live, work, and participate in their communities. 

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

10 basic personal everyday activities, including tasks 

11 such as eating, toileting, grooming, dressing, bath12 ing, and transferring. 

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

14 living’’ means activities related to living independ15 ently in the community, including but not limited to, 

16 meal planning and preparation, managing finances, 

17 shopping for food, clothing, and other essential 

18 items, performing essential household chores, com19 municating by phone or other media, and traveling 

20 around and participating in the community. 

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

22 services’’ means the home and community-based 

23 services that are coverable under subsections (c), 

24 (d), (i), and (k) of section 1915 of the Social Secu25 rity Act (42 U.S.C. 1396n), and as defined by the 


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1 Secretary, including as defined in the home and 

2 community-based services settings rule in sections 

3 441.530 and 441.710 of title 42, Code of Federal 

4 Regulations (or a successor regulation). 

5 TITLE III—PROVIDER 

6 PARTICIPATION 

7 SEC. 301. PROVIDER PARTICIPATION AND STANDARDS; 

8 WHISTLEBLOWER PROTECTIONS. 

9 (a) IN GENERAL.—An individual or other entity fur10 nishing any covered item or service under this Act is not 

11 a qualified provider unless the individual or entity— 

12 (1) is a qualified provider of the items or serv13 ices under section 302; 

14 (2) has filed with the Secretary a participation 

15 agreement described in subsection (b); and 

16 (3) meets, as applicable, such other qualifica17 tions and conditions with respect to a provider of 

18 services under title XVIII of the Social Security Act 

19 as described in section 1866 of the Social Security 

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

21 (b) REQUIREMENTS IN PARTICIPATION AGREE22 MENT.— 

23 (1) IN GENERAL.—A participation agreement 

24 described in this subsection between the Secretary 


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1 and a provider shall provide at least for the fol2 lowing: 

3 (A) Items and services to eligible persons 

4 shall be furnished by the provider without dis5 crimination, in accordance with section 104(a). 

6 Nothing in this subparagraph shall be con7 strued as requiring the provision of a type or 

8 class of items or services that are outside the 

9 scope of the provider’s normal practice. 

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

11 individual for any covered items or services 

12 other than for payment authorized by this Act. 

13 (C) The provider agrees to furnish such in14 formation as may be reasonably required by the 

15 Secretary, in accordance with uniform reporting 

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

17 for— 

18 (i) quality review by designated enti19 ties; 

20 (ii) making payments under this Act, 

21 including the examination of records as 

22 may be necessary for the verification of in23 formation on which such payments are 

24 based; 


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1 (iii) statistical or other studies re2 quired for the implementation of this Act; 

3 and 

4 (iv) such other purposes as the Sec5 retary may specify. 

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

7 an individual, the provider agrees not to employ 

8 or use for the provision of health services any 

9 individual or other provider that has had a par10 ticipation agreement under this subsection ter11 minated for cause. The Secretary may authorize 

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

13 basis. 

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

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

16 furnished under this Act, the provider agrees to 

17 submit bills and any required supporting docu18 mentation relating to the provision of covered 

19 items and services within 30 days after the date 

20 of providing such items and services. 

21 (F) In the case of an institutional provider 

22 paid pursuant to section 611, the provider 

23 agrees to submit information and any other re24 quired supporting documentation as may be 

25 reasonably required by the Secretary within 30 


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1 days after the date of providing such items and 

2 services and in accordance with the uniform re3 porting standards established under section 

4 401(b)(1), including information on a quarterly 

5 basis that— 

6 (i) relates to the provision of covered 

7 items and services; and 

8 (ii) describes items and services fur9 nished with respect to specific individuals. 

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

11 payment for items and services furnished under 

12 this Act based on diagnosis-related coding, pro13 cedure coding, or other coding system or data, 

14 the provider agrees— 

15 (i) to disclose to the Secretary any 

16 system or index of coding or classifying pa17 tient symptoms, diagnoses, clinical inter18 ventions, episodes, or procedures that such 

19 provider utilizes for global budget negotia20 tions under title VI or for meeting any 

21 other payment, documentation, or data col22 lection requirements under this Act; and 

23 (ii) not to use any such system or 

24 index to establish financial incentives or 

25 disincentives for health care professionals, 


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1 or that is proprietary, interferes with the 

2 medical or nursing process, or is designed 

3 to increase the amount or number of pay4 ments. 

5 (H) The provider complies with the duty of 

6 provider ethics and reporting requirements de7 scribed in paragraph (2). 

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

9 individual, the provider agrees that no board 

10 member, executive, or administrator of such 

11 provider receives compensation from, owns 

12 stock or has other financial investments in, or 

13 serves as a board member of any entity that 

14 contracts with or provides items or services, in15 cluding pharmaceutical products and medical 

16 devices or equipment, to such provider. 

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

18 care provider, including institutional providers, has a 

19 duty to advocate for and to act in the exclusive in20 terest of each individual under the care of such pro21 vider according to the applicable legal standard of 

22 care, such that no financial interest or relationship 

23 impairs any health care provider’s ability to furnish 

24 necessary and appropriate care to such individual. 


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1 To implement the duty established in this para2 graph, the Secretary shall— 

3 (A) promulgate reasonable reporting rules 

4 to evaluate participating provider compliance 

5 with this paragraph; 

6 (B) prohibit participating providers, 

7 spouses, and immediate family members of par8 ticipating providers, from accepting or entering 

9 into any arrangement for any bonus, incentive 

10 payment, profit-sharing, or compensation based 

11 on patient utilization or based on financial out12 comes of any other provider or entity; and 

13 (C) prohibit participating providers or any 

14 board member or representative of such pro15 vider from serving as board members for or re16 ceiving any compensation, stock, or other finan17 cial investment in an entity that contracts with 

18 or provides items or services (including pharma19 ceutical products and medical devices or equip20 ment) to such provider. 

21 (3) TERMINATION OF PARTICIPATION AGREE22 MENT.— 

23 (A) IN GENERAL.—Participation agree24 ments may be terminated, with appropriate no25 tice— 


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1 (i) by the Secretary for failure to meet 

2 the requirements of this Act; 

3 (ii) in accordance with the provisions 

4 described in section 411; or 

5 (iii) by a provider. 

6 (B) TERMINATION PROCESS.—Providers 

7 shall be provided notice and a reasonable oppor8 tunity to correct deficiencies before the Sec9 retary terminates an agreement unless a more 

10 immediate termination is required for public 

11 safety or similar reasons. 

12 (C) PROVIDER PROTECTIONS.— 

13 (i) PROHIBITION.—The Secretary may 

14 not terminate a participation agreement or 

15 in any other way discriminate against, or 

16 cause to be discriminated against, any cov17 ered provider or authorized representative 

18 of the provider, on account of such pro19 vider or representative— 

20 (I) providing, causing to be pro21 vided, or being about to provide or 

22 cause to be provided to the provider, 

23 the Federal Government, or the attor24 ney general of a State information re25 lating to any violation of, or any act 


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1 or omission the provider or represent2 ative reasonably believes to be a viola3 tion of, any provision of this title (or 

4 an amendment made by this title); 

5 (II) testifying or being about to 

6 testify in a proceeding concerning 

7 such violation; 

8 (III) assisting or participating, or 

9 being about to assist or participate, in 

10 such a proceeding; or 

11 (IV) objecting to, or refusing to 

12 participate in, any activity, policy, 

13 practice, or assigned task that the 

14 provider or representative reasonably 

15 believes to be in violation of any provi16 sion of this Act (including any amend17 ment made by this Act), or any order, 

18 rule, regulation, standard, or ban 

19 under this Act (including any amend20 ment made by this Act). 

21 (ii) COMPLAINT PROCEDURE.—A pro22 vider or representative who believes that he 

23 or she has been discriminated against in 

24 violation of this section may seek relief in 

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1 tions, burdens of proof, remedies, and stat2 utes of limitation set forth in section 

3 2087(b) of title 15, United States Code. 

4 (c) WHISTLEBLOWER PROTECTIONS.— 

5 (1) RETALIATION PROHIBITED.—No person 

6 may discharge or otherwise discriminate against any 

7 employee because the employee or any person acting 

8 pursuant to a request of the employee— 

9 (A) notified the Secretary or the employ10 ee’s employer of any alleged violation of this 

11 title, including communications related to car12 rying out the employee’s job duties; 

13 (B) refused to engage in any practice made 

14 unlawful by this title, if the employee has iden15 tified the alleged illegality to the employer; 

16 (C) testified before or otherwise provided 

17 information relevant for Congress or for any 

18 Federal or State proceeding regarding any pro19 vision (or proposed provision) of this title; 

20 (D) commenced, caused to be commenced, 

21 or is about to commence or cause to be com22 menced a proceeding under this title; 

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

24 such proceeding; or 


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1 (F) assisted or participated or is about to 

2 assist or participate in any manner in such a 

3 proceeding or in any other manner in such a 

4 proceeding or in any other action to carry out 

5 the purposes of this title. 

6 (2) ENFORCEMENT ACTION.—Any employee 

7 covered by this section who alleges discrimination by 

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

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

10 anti-retaliation provisions of the False Claims Act 

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

12 and remedies applicable under the employee protec13 tions provisions of the Surface Transportation As14 sistance Act. 

15 (3) APPLICATION.— 

16 (A) Nothing in this subsection shall be 

17 construed to diminish the rights, privileges, or 

18 remedies of any employee under any Federal or 

19 State law or regulation, including the rights 

20 and remedies against retaliatory action under 

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

22 under any collective bargaining agreement. The 

23 rights and remedies in this section may not be 

24 waived by any agreement, policy, form, or con25 dition of employment. 


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1 (B) Nothing in this subsection shall be 

2 construed to preempt or diminish any other 

3 Federal or State law or regulation against dis4 crimination, demotion, discharge, suspension, 

5 threats, harassment, reprimand, retaliation, or 

6 any other manner of discrimination, including 

7 the rights and remedies against retaliatory ac8 tion under the False Claims Act (31 U.S.C. 

9 3730(h)). 

10 (4) DEFINITIONS.—In this subsection: 

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

12 means any person engaged in profit or non13 profit business or industry, including one or 

14 more individuals, partnerships, associations, 

15 corporations, trusts, professional membership 

16 organization including a certification, discipli17 nary, or other professional body, unincorporated 

18 organizations, nongovernmental organizations, 

19 or trustees, and subject to liability for violating 

20 the provisions of this Act. 

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

22 means any individual performing activities 

23 under this Act on behalf of an employer. 


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1 SEC. 302. QUALIFICATIONS FOR PROVIDERS. 

2 (a) IN GENERAL.—A health care provider is consid3 ered to be qualified to furnish covered items and services 

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

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

6 items or services are furnished and meets— 

7 (1) the requirements of such State’s law to fur8 nish such items and services; and 

9 (2) applicable requirements of Federal law to 

10 furnish such items and services. 

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

12 qualified to furnish covered items and services under this 

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

14 directly to individuals, including— 

15 (1) entities or providers that contract with 

16 other entities or providers to provide such items and 

17 services; and 

18 (2) entities that are currently approved to co19 ordinate care plans under the Medicare Advantage 

20 program established in part C of title XVIII of the 

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

22 not directly provide items and services of such care 

23 plans. 

24 (c) MINIMUM PROVIDER STANDARDS.— 

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1 ards to ensure the quality of items and services pro2 vided under this Act and to monitor efforts by 

3 States to ensure the quality of such items and serv4 ices. A State may establish additional minimum 

5 standards which providers shall meet with respect to 

6 items and services provided in such State. 

7 (2) NATIONAL MINIMUM STANDARDS.—The 

8 Secretary shall establish national minimum stand9 ards under paragraph (1) for institutional providers 

10 of services and individual health care practitioners. 

11 Except as the Secretary may specify in order to 

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

13 or other institutional provider of services shall meet 

14 standards applicable to such a provider under the 

15 Medicare program under title XVIII of the Social 

16 Security Act (42 U.S.C. 1395 et seq.). Such stand17 ards also may include, where appropriate, elements 

18 relating to— 

19 (A) adequacy and quality of facilities; 

20 (B) mandatory minimum safe registered 

21 nurse-to-patient staffing ratios and optimal 

22 staffing levels for physicians and other health 

23 care practitioners; 

24 (C) training and competence of personnel 

25 (including requirements related to the number 


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1 of or type of required continuing education 

2 hours); 

3 (D) comprehensiveness of service; 

4 (E) continuity of service; 

5 (F) patient waiting time, access to serv6 ices, and preferences; and 

7 (G) performance standards, including orga8 nization, facilities, structure of services, effi9 ciency of operation, and outcome in palliation, 

10 improvement of health, stabilization, cure, or 

11 rehabilitation. 

12 (3) TRANSITION IN APPLICATION.—If the Sec13 retary provides for additional requirements for pro14 viders under this subsection, any such additional re15 quirement shall be implemented in a manner that 

16 provides for a reasonable period during which a pre17 viously qualified provider is permitted to meet such 

18 an additional requirement. 

19 (4) ABILITY TO PROVIDE SERVICES.—With re20 spect to any entity or provider certified to provide 

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

22 the Secretary may not prohibit such entity or pro23 vider from participating for reasons other than such 

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

25 and services. 


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

2 provide health care items and services through the Depart3 ment of Veterans Affairs or Indian Health Service is a 

4 qualifying provider under this section with respect to any 

5 individual who qualifies for such items and services under 

6 applicable Federal law. 

7 SEC. 303. USE OF PRIVATE CONTRACTS. 

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

9 2 years after the date of the enactment of this Act. 

10 (b) PARTICIPATING PROVIDERS.— 

11 (1) PRIVATE CONTRACTS FOR COVERED ITEMS

12 AND SERVICES FOR ELIGIBLE INDIVIDUALS.—An in13 stitutional or individual provider with an agreement 

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

15 any private contract with any individual eligible for 

16 benefits under the Act for any item or service that 

17 is a benefit under this Act. 

18 (2) PRIVATE CONTRACTS FOR NONCOVERED

19 ITEMS AND SERVICES FOR ELIGIBLE INDIVIDUALS.— 

20 An institutional or individual provider with an agree21 ment in effect under section 301 may bill or enter 

22 into a private contract with an individual eligible for 

23 benefits under the Act for any item or service that 

24 is not a benefit under this Act only if— 


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1 (A) the contract and provider meet the re2 quirements specified in paragraphs (3) and (4), 

3 respectively; 

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

5 available under this Act; and 

6 (C) the provider receives— 

7 (i) no reimbursement under this Act 

8 directly or indirectly for such item or serv9 ice, and 

10 (ii) receives no amount for such item 

11 or service from an organization which re12 ceives reimbursement for such items or 

13 service under this Act directly or indirectly. 

14 (3) CONTRACT REQUIREMENTS.—Any contract 

15 to provide items and services described in paragraph 

16 (2) shall— 

17 (A) be in writing and signed by the indi18 vidual (or authorized representative of the indi19 vidual) receiving the item or service before the 

20 item or service is furnished pursuant to the 

21 contract; 

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

23 individual is facing an emergency health care 

24 situation; and 


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1 (C) clearly indicate to the individual receiv2 ing such items and services that by signing 

3 such a contract the individual— 

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

5 request that the provider submit a claim) 

6 under this Act for such items or services; 

7 (ii) agrees to be responsible for pay8 ment of such items or services and under9 stands that no reimbursement will be pro10 vided under this Act for such items or 

11 services; 

12 (iii) acknowledges that no limits under 

13 this Act apply to amounts that may be 

14 charged for such items or services; and 

15 (iv) acknowledges that the provider is 

16 providing services outside the scope of the 

17 program under this Act. 

18 (4) AFFIDAVIT.—A participating provider who 

19 enters into a contract described in paragraph (2) 

20 shall have in effect during the period any item or 

21 service is to be provided pursuant to the contract an 

22 affidavit that shall— 

23 (A) identify the provider who is to furnish 

24 such noncovered item or service, and be signed 

25 by such provider; 


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1 (B) state that the provider will not submit 

2 any claim under this Act for any noncovered 

3 item or service provided to any individual en4 rolled under this Act; and 

5 (C) be filed with the Secretary no later 

6 than 10 days after the first contract to which 

7 such affidavit applies is entered into. 

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

9 affidavit described in paragraph (4) knowingly and 

10 willfully submits a claim under this title for any item 

11 or service provided or receives any reimbursement or 

12 amount for any such item or service provided pursu13 ant to a private contract described in paragraph (2) 

14 with respect to such affidavit— 

15 (A) any contract described in paragraph 

16 (2) shall be null and void; 

17 (B) no payment shall be made under this 

18 title for any item or service furnished by the 

19 provider during the 1-year period beginning on 

20 the date the affidavit was signed; and 

21 (C) any payment received under this title 

22 for any item or service furnished during such 

23 period shall be remitted. 

24 (6) PRIVATE CONTRACTS FOR INELIGIBLE INDI25 VIDUALS.—An institutional or individual provider 


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1 with an agreement in effect under section 301 may 

2 bill or enter into a private contract with any indi3 vidual ineligible for benefits under the Act for any 

4 item or service. 

5 (c) NONPARTICIPATING PROVIDERS.— 

6 (1) PRIVATE CONTRACTS FOR COVERED ITEMS

7 AND SERVICES FOR ELIGIBLE INDIVIDUALS.—An in8 stitutional or individual provider with no agreement 

9 in effect under section 301 may bill or enter into 

10 any private contract with any individual eligible for 

11 benefits under the Act for any item or service that 

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

13 if the contract and provider meet the requirements 

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

15 (2) ITEMS REQUIRED TO BE INCLUDED IN CON16 TRACT.—Any contract to provide items and services 

17 described in paragraph (1) shall— 

18 (A) be in writing and signed by the indi19 vidual (or authorized representative of the indi20 vidual) receiving the item or service before the 

21 item or service is furnished pursuant to the 

22 contract; 

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

24 individual is facing an emergency health care 

25 situation; and 


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1 (C) clearly indicate to the individual receiv2 ing such items and services that by signing 

3 such a contract the individual— 

4 (i) acknowledges that the individual 

5 has the right to have such items or services 

6 provided by other providers for whom pay7 ment would be made under this Act; 

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

9 to request that the provider submit a 

10 claim) under this Act for such items or 

11 services even if such items or services are 

12 otherwise covered by this Act; 

13 (iii) agrees to be responsible for pay14 ment of such items or services and under15 stands that no reimbursement will be pro16 vided under this Act for such items or 

17 services; 

18 (iv) acknowledges that no limits under 

19 this Act apply to amounts that may be 

20 charged for such items or services; and 

21 (v) acknowledges that the provider is 

22 providing services outside the scope of the 

23 program under this Act. 

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

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1 fect during the period any item or service is to be 

2 provided pursuant to the contract an affidavit that 

3 shall— 

4 (A) identify the provider who is to furnish 

5 such covered item or service, and be signed by 

6 such provider; 

7 (B) state that the provider will not submit 

8 any claim under this Act for any covered item 

9 or service provided to any individual enrolled 

10 under this Act during the 2-year period begin11 ning on the date the affidavit is signed; and 

12 (C) be filed with the Secretary no later 

13 than 10 days after the first contract to which 

14 such affidavit applies is entered into. 

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

16 affidavit described in paragraph (3) knowingly and 

17 willfully submits a claim under this title for any item 

18 or service provided or receives any reimbursement or 

19 amount for any such item or service provided pursu20 ant to a private contract described in paragraph (1) 

21 with respect to such affidavit— 

22 (A) any contract described in paragraph 

23 (1) shall be null and void; and 

24 (B) no payment shall be made under this 

25 title for any item or service furnished by the 


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1 provider during the 2-year period beginning on 

2 the date the affidavit was signed. 

3 (5) PRIVATE CONTRACTS FOR NONCOVERED

4 ITEMS AND SERVICES FOR ANY INDIVIDUAL.—An in5 stitutional or individual provider with no agreement 

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

7 private contract with any individual for a item or 

8 service that is not a benefit under this Act. 

9 TITLE IV—ADMINISTRATION 

10 Subtitle A—General 

11 Administration Provisions 

12 SEC. 401. ADMINISTRATION. 

13 (a) GENERAL DUTIES OF THE SECRETARY.— 

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

15 policies, procedures, guidelines, and requirements to 

16 carry out this Act, including related to— 

17 (A) eligibility for benefits; 

18 (B) enrollment; 

19 (C) benefits provided; 

20 (D) provider participation standards and 

21 qualifications, as described in title III; 

22 (E) levels of funding; 

23 (F) methods for determining amounts of 

24 payments to providers of covered items and 

25 services, consistent with subtitle B; 


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1 (G) a process for appealing or petitioning 

2 for a determination of coverage or noncoverage 

3 of items and services under this Act; 

4 (H) planning for capital expenditures and 

5 service delivery; 

6 (I) planning for health professional edu7 cation funding; 

8 (J) encouraging States to develop regional 

9 planning mechanisms; and 

10 (K) any other regulations necessary to 

11 carry out the purposes of this Act. 

12 (2) REGULATIONS.—Regulations authorized by 

13 this Act shall be issued by the Secretary in accord14 ance with section 553 of title 5, United States Code. 

15 (3) ACCESSIBILITY.—The Secretary shall have 

16 the obligation to ensure the timely and accessible 

17 provision of items and services that all eligible indi18 viduals are entitled to under this Act. 

19 (b) UNIFORM REPORTING STANDARDS; ANNUAL RE20 PORT; STUDIES.— 

21 (1) UNIFORM REPORTING STANDARDS.— 

22 (A) IN GENERAL.—The Secretary shall es23 tablish uniform State reporting requirements 

24 and national standards to ensure an adequate 

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1 taining to health services practitioners, ap2 proved providers, the costs of facilities and 

3 practitioners providing items and services, the 

4 quality of such items and services, the outcomes 

5 of such items and services, and the equity of 

6 health among population groups. Such database 

7 shall include, to the maximum extent feasible 

8 without compromising patient privacy, health 

9 outcome measures used under this Act, and to 

10 the maximum extent feasible without excessively 

11 burdening providers, a description of the stand12 ards and qualifications, levels of finding, and 

13 methods described in subparagraphs (D) 

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

15 (B) REQUIRED DATA DISCLOSURES.—In 

16 establishing reporting requirements and stand17 ards under subparagraph (A), the Secretary 

18 shall require a provider with an agreement in 

19 effect under section 301 to disclose to the Sec20 retary, in a time and manner specified by the 

21 Secretary, the following (as applicable to the 

22 type of provider): 

23 (i) Any data the provider is required 

24 to report or does report to any State or 

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


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1 the Secretary or any entity that is part of 

2 the Department of Health and Human 

3 Services, except data that are required 

4 under the programs terminated in section 

5 903. 

6 (ii) Annual financial data that in7 cludes information on employees (including 

8 the number of employees, hours worked, 

9 and wage information) by job title and by 

10 each patient care unit or department with11 in each facility (including outpatient units 

12 or departments); the number of registered 

13 nurses per staffed bed by each such unit or 

14 department; information on the dollar 

15 value and annual spending (including pur16 chases, upgrades, and maintenance) for 

17 health information technology; and risk-ad18 justed and raw patient outcome data (in19 cluding data on medical, surgical, obstet20 ric, and other procedures). 

21 (C) REPORTS.—The Secretary shall regu22 larly analyze information reported to the Sec23 retary and shall define rules and procedures to 

24 allow researchers, scholars, health care pro25 viders, and others to access and analyze data 


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1 for purposes consistent with quality and out2 comes research, without compromising patient 

3 privacy. 

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

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

6 shall annually report to Congress on the following: 

7 (A) The status of implementation of the 

8 Act. 

9 (B) Enrollment under this Act. 

10 (C) Benefits under this Act. 

11 (D) Expenditures and financing under this 

12 Act. 

13 (E) Cost-containment measures and 

14 achievements under this Act. 

15 (F) Quality assurance. 

16 (G) Health care utilization patterns, in17 cluding any changes attributable to the pro18 gram. 

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

20 health care. 

21 (I) Differences in the health status of the 

22 populations of the different States, including in23 come and racial characteristics, and other popu24 lation health inequities. 


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1 (J) Progress on quality and outcome meas2 ures, and long-range plans and goals for 

3 achievements in such areas. 

4 (K) Plans for improving service to medi5 cally underserved populations. 

6 (L) Transition problems as a result of im7 plementation of this Act. 

8 (M) Opportunities for improvements under 

9 this Act. 

10 (3) STATISTICAL ANALYSES AND OTHER STUD11 IES.—The Secretary may, either directly or by con12 tract— 

13 (A) make statistical and other studies, on 

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

15 any aspect of the operation of this Act; 

16 (B) develop and test methods of delivery of 

17 items and services as the Secretary may con18 sider necessary or promising for the evaluation, 

19 or for the improvement, of the operation of this 

20 Act; and 

21 (C) develop methodological standards for 

22 policymaking. 

23 (c) AUDITS.— 

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

25 the United States shall conduct an audit of the DeVerDate Sep 11 2014 00:18 Mar 16, 2019 Jkt 089200 PO 00000 Frm 00048 Fmt 6652 Sfmt 6201 E:\BILLS\H1384.IH H1384

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1 partment of Health and Human Services every fifth 

2 fiscal year following the effective date of this Act to 

3 determine the effectiveness of the program in car4 rying out the duties under subsection (a). 

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

6 United States shall submit a report to Congress con7 cerning the results of each audit conducted under 

8 this subsection. 

9 SEC. 402. CONSULTATION. 

10 The Secretary shall consult with Federal agencies, 

11 Indian tribes and urban Indian health organizations, and 

12 private entities, such as labor organizations representing 

13 health care workers, professional societies, national asso14 ciations, nationally recognized associations of health care 

15 experts, medical schools and academic health centers, con16 sumer groups, and business organizations in the formula17 tion of guidelines, regulations, policy initiatives, and infor18 mation gathering to ensure the broadest and most in19 formed input in the administration of this Act. Nothing 

20 in this Act shall prevent the Secretary from adopting 

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

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

23 judgment, such guidelines are generally accepted as rea24 sonable and prudent and consistent with this Act. 


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1 SEC. 403. REGIONAL ADMINISTRATION. 

2 (a) COORDINATION WITH REGIONAL OFFICES.—The 

3 Secretary shall establish and maintain regional offices for 

4 purposes of carrying out the duties specified in subsection 

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

6 of, tertiary care facilities, equipment, and services by indi7 viduals enrolled under this Act. Wherever possible, the 

8 Secretary shall incorporate regional offices of the Centers 

9 for Medicare & Medicaid Services for this purpose. 

10 (b) APPOINTMENT OF REGIONAL DIRECTORS.—In 

11 each such regional office there shall be— 

12 (1) one regional director appointed by the Sec13 retary; and 

14 (2) one deputy director appointed by the re15 gional director to represent the Indian and Alaska 

16 Native tribes in the region, if any. 

17 (c) REGIONAL OFFICE DUTIES.—Each regional di18 rector shall— 

19 (1) provide an annual health care needs assess20 ment with respect to the region under the director’s 

21 jurisdiction to the Secretary after a thorough exam22 ination of health needs and in consultation with pub23 lic health officials, clinicians, patients, and patient 

24 advocates; 

25 (2) recommend any changes in provider reim26 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 Quality-Adjusted Life Years, Disability-Adjusted 

18 Life Years, or other similar mechanisms that dis19 criminate against people with disabilities is prohib20 ited for use in any value or cost-effectiveness assess21 ments. The Center shall consider the evidentiary 

22 basis for the standard, and the validity, reliability, 

23 and feasibility of measuring the standard. 


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1 (3) Adoption of methodologies for profiling the 

2 patterns of practice of health care professionals and 

3 for identifying and notifying outliers. 

4 (4) Development of minimum criteria for com5 petence for entities that can qualify to conduct ongo6 ing and continuous external quality reviews in the 

7 administrative regions. Such criteria shall require 

8 such an entity to be administratively independent of 

9 the individual or board that administers the region 

10 and shall ensure that such entities do not provide fi11 nancial incentives to reviewers to favor one pattern 

12 of practice over another. The Center shall ensure co13 ordination and reporting by such entities to ensure 

14 national consistency in quality standards. 

15 (5) Submission of a report to the Secretary an16 nually specifically on findings from outcomes re17 search and development of practice guidelines that 

18 may affect the Secretary’s determination of coverage 

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

20 SEC. 502. ADDRESSING HEALTH CARE DISPARITIES. 

21 (a) EVALUATING DATA COLLECTION AP22 PROACHES.—The Center shall evaluate approaches for the 

23 collection of data under this Act, to be performed in con24 junction with existing quality reporting requirements and 

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1 rate, and timely collection of data on disparities in health 

2 care services and performance on the basis of race, eth3 nicity, gender, geography, disability, or socioeconomic sta4 tus. In conducting such evaluation, the Center shall con5 sider the following objectives: 

6 (1) Protecting patient privacy. 

7 (2) Minimizing the administrative burdens of 

8 data collection and reporting on providers under this 

9 Act. 

10 (3) Improving data on race, ethnicity, gender, 

11 geography, and socioeconomic status. 

12 (b) REPORTS TO CONGRESS.— 

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

14 18 months after the date on which benefits first be15 come available as described in section 106(a), the 

16 Center shall submit to Congress and the Secretary 

17 a report on the evaluation conducted under sub18 section (a). Such report shall, taking into consider19 ation the results of such evaluation— 

20 (A) identify approaches (including defining 

21 methodologies) for identifying and collecting 

22 and evaluating data on health care disparities 

23 on the basis of race, ethnicity, gender, geog24 raphy, or socioeconomic status under the Medi25 care for All Program; and 


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1 (B) include recommendations on the most 

2 effective strategies and approaches to reporting 

3 quality measures, as appropriate, on the basis 

4 of race, ethnicity, gender, geography, or socio5 economic status. 

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

7 than 4 years after the submission of the report 

8 under subsection (b)(1), and every 4 years there9 after, the Center shall submit to Congress and the 

10 Secretary a report that includes recommendations 

11 for improving the identification of health care dis12 parities based on the analyses of data collected 

13 under subsection (c). 

14 (c) IMPLEMENTING EFFECTIVE APPROACHES.—Not 

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

16 become available as described in section 106(a), the Sec17 retary shall implement the approaches identified in the re18 port submitted under subsection (b)(1) for the ongoing, 

19 accurate, and timely collection and evaluation of data on 

20 health care disparities on the basis of race, ethnicity, gen21 der, geography, or socioeconomic status. 


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1 TITLE VI—HEALTH BUDGET; 

2 PAYMENTS; COST CONTAIN3 MENT MEASURES 

4 Subtitle A—Budgeting 

5 SEC. 601. NATIONAL HEALTH BUDGET. 

6 (a) NATIONAL HEALTH BUDGET.— 

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

8 1 of each year, beginning with the year prior to the 

9 date on which benefits first become available as de10 scribed in section 106(a), the Secretary shall estab11 lish a national health budget, which specifies a budg12 et for the total expenditures to be made for covered 

13 health care items and services under this Act. 

14 (2) DIVISION OF BUDGET INTO COMPONENTS.— 

15 The national health budget shall consist of the fol16 lowing components: 

17 (A) An operating budget. 

18 (B) A capital expenditures budget. 

19 (C) A special projects budget for purposes 

20 of allocating funds for capital expenditures and 

21 staffing needs of providers located in rural or 

22 medically underserved areas (as defined in sec23 tion 330(b)(3) of the Public Health Service Act 

24 (42 U.S.C. 254b(b)(3))), including areas des25 ignated as health professional shortage areas 


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1 (as defined in section 332(a) of the Public 

2 Health Service Act (42 U.S.C. 254e(a))). 

3 (D) Quality assessment activities under 

4 title V. 

5 (E) Health professional education expendi6 tures. 

7 (F) Administrative costs, including costs 

8 related to the operation of regional offices. 

9 (G) A reserve fund to respond to the costs 

10 of treating an epidemic, pandemic, natural dis11 aster, or other such health emergency, or mar12 ket-shift adjustments related to patient volume. 

13 (H) Prevention and public health activities. 

14 (3) ALLOCATION AMONG COMPONENTS.—The 

15 Secretary shall allocate the funds received for pur16 poses of carrying out this Act among the compo17 nents described in paragraph (2) in a manner that 

18 ensures— 

19 (A) that the operating budget allows for 

20 every participating provider in the Medicare for 

21 All Program to meet the needs of their respec22 tive patient populations; 

23 (B) that the special projects budget is suf24 ficient to meet the health care needs within 

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


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1 the construction, renovation, and staffing of 

2 health care facilities in a reasonable timeframe; 

3 (C) a fair allocation for quality assessment 

4 activities; and 

5 (D) that the health professional education 

6 expenditure component is sufficient to provide 

7 for the amount of health professional education 

8 expenditures sufficient to meet the need for cov9 ered health care services. 

10 (4) REGIONAL ALLOCATION.—The Secretary 

11 shall annually provide each regional office with an 

12 allotment the Secretary determines appropriate for 

13 purposes of carrying out this Act in such region, in14 cluding payments to providers in such region, capital 

15 expenditures in such region, special projects in such 

16 region, health professional education in such region, 

17 administrative expenses in such region, and preven18 tion and public health activities in such region. 

19 (5) OPERATING BUDGET.—The operating budg20 et described in paragraph (2)(A) shall be used for— 

21 (A) payments to institutional providers 

22 pursuant to section 611; and 

23 (B) payments to individual providers pur24 suant to section 612. 


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1 (6) CAPITAL EXPENDITURES BUDGET.—The 

2 capital expenditures budget described in paragraph 

3 (2)(B) shall be used for— 

4 (A) the construction or renovation of 

5 health care facilities, excluding congregate or 

6 segregated facilities for individuals with disabil7 ities who receive long-term care services and 

8 support; and 

9 (B) major equipment purchases. 

10 (7) SPECIAL PROJECTS BUDGET.—The special 

11 projects budget shall be used for the construction of 

12 new facilities, major equipment purchases, and staff13 ing in rural or medically underserved areas (as de14 fined in section 330(b)(3) of the Public Health Serv15 ice Act (42 U.S.C. 254b(b)(3))), including areas des16 ignated as health professional shortage areas (as de17 fined in section 332(a) of the Public Health Service 

18 Act (42 U.S.C. 254e(a))). 

19 (8) TEMPORARY WORKER ASSISTANCE.— 

20 (A) IN GENERAL.—For up to 5 years fol21 lowing the date on which benefits first become 

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

23 1 percent of the budget shall be allocated to 

24 programs providing assistance to workers who 

25 perform functions in the administration of the 


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1 health insurance system, or related functions 

2 within health care institutions or organizations 

3 who may be affected by the implementation of 

4 this Act and who may experience economic dis5 location as a result of the implementation of 

6 this Act. 

7 (B) CLARIFICATION.—Assistance described 

8 in subparagraph (A) shall include wage replace9 ment, retirement benefits, job training, and 

10 education benefits. 

11 (b) DEFINITIONS.—In this section: 

12 (1) CAPITAL EXPENDITURES.—The term ‘‘cap13 ital expenditures’’ means expenses for the purchase, 

14 lease, construction, or renovation of capital facilities 

15 and for major equipment. 

16 (2) HEALTH PROFESSIONAL EDUCATION EX17 PENDITURES.—The term ‘‘health professional edu18 cation expenditures’’ means expenditures in hospitals 

19 and other health care facilities to cover costs associ20 ated with teaching and related research activities, in21 cluding the impact of workforce diversity on patient 

22 outcomes. 


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1 Subtitle B—Payments to Providers 

2 SEC. 611. PAYMENTS TO INSTITUTIONAL PROVIDERS 

3 BASED ON GLOBAL BUDGETS. 

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

5 each fiscal quarter during which an institutional provider 

6 of care (including hospitals, skilled nursing facilities, Fed7 erally qualified health centers, home health agencies, and 

8 independent dialysis facilities) is to furnish items and 

9 services under this Act, the Secretary shall pay to such 

10 institutional provider a lump sum in accordance with the 

11 succeeding provisions of this subsection and consistent 

12 with the following: 

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

14 considered as payment in full for all operating ex15 penses for items and services furnished under this 

16 Act, whether inpatient or outpatient, by such pro17 vider for such quarter, including outpatient or any 

18 other care provided by the institutional provider or 

19 provided by any health care provider who provided 

20 items and services pursuant to an agreement paid 

21 through the global budget as described in paragraph 

22 (3). 

23 (2) QUARTERLY REVIEW.—The regional direc24 tor, on a quarterly basis, shall review whether re25 quirements of the institutional provider’s participaVerDate Sep 11 2014 00:18 Mar 16, 2019 Jkt 089200 PO 00000 Frm 00063 Fmt 6652 Sfmt 6201 E:\BILLS\H1384.IH H1384

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1 tion agreement and negotiated global budget have 

2 been performed and shall determine whether adjust3 ments to such institutional provider’s payment are 

4 warranted. This review shall include consideration 

5 for additional funding necessary for unanticipated 

6 items and services for individuals with complex med7 ical needs or market-shift adjustments related to pa8 tient value. The review shall also include an assess9 ment of any adjustments made to ensure that accu10 racy and need for adjustment was appropriate. 

11 (3) AGREEMENTS FOR SALARIED PAYMENTS

12 FOR CERTAIN PROVIDERS.—Certain group practices 

13 and other health care providers, as determined by 

14 the Secretary, with agreements to provide items and 

15 services at a specified institutional provider paid a 

16 global budget under this subsection may elect to be 

17 paid through such institutional provider’s global 

18 budget in lieu of payment under section 612 of this 

19 title. Any— 

20 (A) individual health care professional of 

21 such group practice or other provider receiving 

22 payment through an institutional provider’s 

23 global budget shall be paid on a salaried basis 

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1 tion rates negotiated for individual health care 

2 professionals of such institutional provider; and 

3 (B) any group practice or other health care 

4 provider that receives payment through an in5 stitutional provider global budget under this 

6 paragraph shall be subject to the same report7 ing and disclosure requirements of the institu8 tional provider. 

9 (b) PAYMENT AMOUNT.— 

10 (1) IN GENERAL.—The amount of each pay11 ment to a provider described in subsection (a) shall 

12 be determined before the start of each fiscal year 

13 through negotiations between the provider and the 

14 regional director with jurisdiction over such pro15 vider. Such amount shall be based on factors speci16 fied in paragraph (2). 

17 (2) PAYMENT FACTORS.—Payments negotiated 

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

19 with respect to a provider— 

20 (A) the historical volume of services pro21 vided for each item and services in the previous 

22 3-year period; 

23 (B) the actual expenditures of such pro24 vider in such provider’s most recent cost report 


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1 under title XVIII of the Social Security Act for 

2 each item and service compared to— 

3 (i) such expenditures for other institu4 tional providers in the director’s jurisdic5 tion; and 

6 (ii) normative payment rates estab7 lished under comparative payment rate 

8 systems, including any adjustments, for 

9 such items and services; 

10 (C) projected changes in the volume and 

11 type of items and services to be furnished; 

12 (D) wages for employees, including any 

13 necessary increases mandatory minimum safe 

14 registered nurse-to-patient ratios and optimal 

15 staffing levels for physicians and other health 

16 care workers; 

17 (E) the provider’s maximum capacity to 

18 provide items and services; 

19 (F) education and prevention programs; 

20 (G) permissible adjustment to the pro21 vider’s operating budget due to factors such 

22 as— 

23 (i) an increase in primary or specialty 

24 care access; 


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1 (ii) efforts to decrease health care dis2 parities in rural or medically underserved 

3 areas; 

4 (iii) a response to emergent epidemic 

5 conditions; and 

6 (iv) proposed new and innovative pa7 tient care programs at the institutional 

8 level; and 

9 (H) any other factor determined appro10 priate by the Secretary. 

11 (3) LIMITATION.—Payment amounts negotiated 

12 pursuant to paragraph (1) may not— 

13 (A) take into account capital expenditures 

14 of the provider or any other expenditure not di15 rectly associated with the provision of items and 

16 services by the provider to an individual; 

17 (B) be used by a provider for capital ex18 penditures or such other expenditures; 

19 (C) exceed the provider’s capacity to pro20 vide care under this Act; or 

21 (D) be used to pay or otherwise com22 pensate any board member, executive, or ad23 ministrator of the institutional provider who 

24 has any interest or relationship prohibited 


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

2 under section 301 of this Act. 

3 (4) OPERATING EXPENSES.—For purposes of 

4 this subsection, ‘‘operating expenses’’ of a provider 

5 include the following: 

6 (A) The cost of all items and services asso7 ciated with the provision of inpatient care and 

8 outpatient care, including the following: 

9 (i) Wages and salary costs for physi10 cians, nurses, and other health care practi11 tioners employed by an institutional pro12 vider, including mandatory minimum safe 

13 registered nurse-to-patient staffing ratios 

14 and optimal staffing levels for physicians 

15 and other healthcare workers. 

16 (ii) Wages and salary costs for all an17 cillary staff and services. 

18 (iii) Costs of all pharmaceutical prod19 ucts administered by health care clinicians 

20 at the institutional provider’s facilities or 

21 through services provided in accordance 

22 with State licensing laws or regulations 

23 under which the institutional provider op24 erates. 


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1 (iv) Purchasing and maintenance of 

2 medical devices, supplies, and other health 

3 care technologies, including diagnostic test4 ing equipment. 

5 (v) Costs of all incidental services nec6 essary for safe patient care and handling. 

7 (vi) Costs of patient care, education, 

8 and prevention programs, including occu9 pational health and safety programs, public 

10 health programs, and necessary staff to 

11 implement such programs, for the contin12 ued education and health and safety of cli13 nicians and other individuals employed by 

14 the institutional provider. 

15 (B) Administrative costs for the institu16 tional provider. 

17 (5) 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 (6) 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 SEC. 612. PAYMENT TO INDIVIDUAL PROVIDERS THROUGH 

12 FEE-FOR-SERVICE. 

13 (a) IN GENERAL.—In the case of a provider not de14 scribed in section 611(a) (including those in group prac15 tices who are not receiving payment on a salaried basis 

16 described in section 611(a)(3)), payment for items and 

17 services furnished under this Act for which payment is not 

18 otherwise made under section 611 shall be made by the 

19 Secretary in amounts determined under the fee schedule 

20 established pursuant to subsection (b). Such payment 

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

22 and services, and a provider receiving such payment may 

23 not charge the individual receiving such item or service 

24 in any amount. 

25 (b) FEE SCHEDULE.— 


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

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

3 consultation with providers and regional office direc4 tors, the Secretary shall establish a national fee 

5 schedule for items and services payable under this 

6 Act. The Secretary shall evaluate the effectiveness of 

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

8 schedule annually. 

9 (2) AMOUNTS.—In establishing payment 

10 amounts for items and services under the fee sched11 ule established under paragraph (1), the Secretary 

12 shall take into account— 

13 (A) the amounts payable for such items 

14 and services under title XVIII of the Social Se15 curity Act; and 

16 (B) the expertise of providers and value of 

17 items and services furnished by such providers. 

18 (c) ELECTRONIC BILLING.—The Secretary shall es19 tablish a uniform national system for electronic billing for 

20 purposes of making payments under this subsection. 

21 (d) PHYSICIAN PRACTICE REVIEW BOARD.—Each di22 rector of a regional office, in consultation with representa23 tives of physicians practicing in that region, shall establish 

24 and appoint a physician practice review board to assure 

25 quality, cost effectiveness, and fair reimbursements for 


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1 physician-delivered items and services. The use of Quality2 Adjusted Life Years, Disability-Adjusted Life Years, or 

3 other similar mechanisms that discriminate against people 

4 with disabilities is prohibited for use in any value or cost5 effectiveness assessments. 

6 SEC. 613. ENSURING ACCURATE VALUATION OF SERVICES 

7 UNDER THE MEDICARE PHYSICIAN FEE 

8 SCHEDULE. 

9 (a) STANDARDIZED AND DOCUMENTED REVIEW

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

11 (42 U.S.C. 1395w–4(c)(2)) is amended by adding at the 

12 end the following new subparagraph: 

13 ‘‘(P) STANDARDIZED AND DOCUMENTED

14 REVIEW PROCESS.— 

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

16 year after the date of enactment of this 

17 subparagraph, the Secretary shall estab18 lish, document, and make publicly avail19 able, in consultation with the Office of Pri20 mary Health Care, a standardized process 

21 for reviewing the relative values of physi22 cians’ services under this paragraph. 

23 ‘‘(ii) MINIMUM REQUIREMENTS.—The 

24 standardized process shall include, at a 

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1 fying services for review, prioritizing the 

2 review of services, reviewing stakeholder 

3 recommendations, and identifying addi4 tional resources to be considered during 

5 the review process.’’. 

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

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

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

9 end the following new clause: 

10 ‘‘(x) PLANNED AND DOCUMENTED

11 USE OF FUNDS.—For each fiscal year (be12 ginning with the first fiscal year beginning 

13 on or after the date of enactment of this 

14 clause), the Secretary shall provide to Con15 gress a written plan for using the funds 

16 provided under clause (ix) to collect and 

17 use information on physicians’ services in 

18 the determination of relative values under 

19 this subparagraph.’’. 

20 (c) INTERNAL TRACKING OF REVIEWS.— 

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

22 the date of enactment of this Act, the Secretary 

23 shall submit to Congress a proposed plan for system24 atically and internally tracking the Secretary’s re25 view of the relative values of physicians’ services, 


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1 such as by establishing an internal database, under 

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

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

4 (2) MINIMUM REQUIREMENTS.—The proposal 

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

6 for achieving the ability to systematically and inter7 nally track the following: 

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

9 identified for review. 

10 (B) When services are reviewed or re11 viewed or when new services are added. 

12 (C) The resources, evidence, data, and rec13 ommendations used in reviews. 

14 (D) When relative values are adjusted. 

15 (E) The rationale for final relative value 

16 decisions. 

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

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

19 amended— 

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

21 inserting ‘‘4’’; and 

22 (2) in subparagraph (K)(i)(I), by striking ‘‘peri23 odically’’ and inserting ‘‘annually’’. 

24 (e) CONSULTATION WITH MEDICARE PAYMENT AD25 VISORY COMMISSION.— 


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

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

3 amended— 

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

5 ‘‘in consultation with the Medicare Payment 

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

7 and 

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

9 by subsection (d)(2), by inserting ‘‘, in coordi10 nation with the Medicare Payment Advisory 

11 Commission,’’ after ‘‘annually’’. 

12 (2) CONFORMING AMENDMENTS.—Section 1805 

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

14 amended— 

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

16 the following before the semicolon at the end: 

17 ‘‘and including coordinating with the Secretary 

18 in accordance with section 1848(c)(2) to sys19 tematically review the relative values established 

20 for physicians’ services, identify potentially 

21 misvalued services, and propose adjustments to 

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

23 (B) in subsection (e)(1), in the second sen24 tence, by inserting ‘‘or the Ranking Minority 

25 Member’’ after ‘‘the Chairman’’. 


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1 (f) PERIODIC AUDIT BY THE COMPTROLLER GEN2 ERAL.—Section 1848(c)(2) of the Social Security Act (42 

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

4 amended by adding at the end the following new subpara5 graph: 

6 ‘‘(Q) PERIODIC AUDIT BY THE COMP7 TROLLER GENERAL.— 

8 ‘‘(i) IN GENERAL.—The Comptroller 

9 General of the United States (in this sub10 section referred to as the ‘Comptroller 

11 General’) shall periodically audit the review 

12 by the Secretary of relative values estab13 lished under this paragraph for physicians’ 

14 services. 

15 ‘‘(ii) ACCESS TO INFORMATION.—The 

16 Comptroller General shall have unre17 stricted access to all deliberations, records, 

18 and data related to the activities carried 

19 out under this paragraph, in a timely man20 ner, upon request.’’. 

21 SEC. 614. PAYMENT PROHIBITIONS; CAPITAL EXPENDI22 TURES; SPECIAL PROJECTS. 

23 (a) SENSE OF CONGRESS.—It is the sense of Con24 gress that tens of millions of people in the United States 

25 do not receive healthcare services while billions of dollars 


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1 that could be spent on providing health care are diverted 

2 to profit. There is a moral imperative to correct the mas3 sive deficiencies in our current health system and to elimi4 nate profit from the provision of health care. 

5 (b) PROHIBITIONS.—Payments to providers under 

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

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

8 for— 

9 (1) marketing of the provider; 

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

11 increasing the profit or net revenue of the provider; 

12 (3) incentive payments, bonuses, or other com13 pensation based on patient utilization of items and 

14 services or any financial measure applied with re15 spect to the provider (or any group practice, inte16 grated health care delivery system, or other provider 

17 with which the provider contracts or has a pecuniary 

18 interest), including any value-based payment or em19 ployment-based compensation; 

20 (4) any agreement or arrangement described in 

21 section 203(a)(4) of the Labor-Management Report22 ing and Disclosure Act of 1959 (29 U.S.C. 

23 433(a)(4)); or 


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1 (5) political or contributions prohibited under 

2 section 317 of the Federal Elections Campaign Act 

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

4 (c) PAYMENTS FOR CAPITAL EXPENDITURES.— 

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

6 from amounts made available for capital expendi7 tures pursuant to section 601(a)(2)(B), such sums 

8 determined appropriate by the Secretary to providers 

9 who have submitted an application to the regional 

10 director of the region or regions in which the pro11 vider operates or seeks to operate in a time and 

12 manner specified by the Secretary for purposes of 

13 funding capital expenditures of such providers. 

14 (2) PRIORITY.—The Secretary shall prioritize 

15 allocation of funding under paragraph (1) to 

16 projects that propose to use such funds to improve 

17 service in a medically underserved area (as defined 

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

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

20 disparities among racial, income, or ethnic groups, 

21 or based on geographic regions. 

22 (3) LIMITATION.—The Secretary shall not 

23 grant funding for capital expenditures under this 

24 subsection for capital projects that are financed di25 rectly or indirectly through the diversion of private 


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1 or other non-Medicare for All Program funding that 

2 results in reductions in care to patients, including 

3 reductions in registered nursing staffing patterns 

4 and changes in emergency room or primary care 

5 services or availability. 

6 (4) CAPITAL PROJECTS FUNDED BY CHARI7 TABLE DONATIONS.—Operating expenses and funds 

8 shall not by used by an institutional provider receiv9 ing payment for capital expenditures under this sub10 section for a capital project funded by charitable do11 nations without the approval of the regional director 

12 or directors of the region or regions where the cap13 ital project is located. 

14 (d) PROHIBITION AGAINST CO-MINGLING OPER15 ATING AND CAPITAL FUNDS.—Providers that receive pay16 ment under this title shall be prohibited from using, with 

17 respect to funds made available under this Act— 

18 (1) funds designated for operating expenditures 

19 for capital expenditures or for profit; or 

20 (2) funds designated for capital expenditures 

21 for operating expenditures. 

22 (e) PAYMENTS FOR SPECIAL PROJECTS.— 

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

24 to each regional director, from amounts made avail25 able for special projects pursuant to section 


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1 601(a)(2)(C), such sums determined appropriate by 

2 the Secretary for purposes of funding projects de3 scribed in such section, including the construction, 

4 renovation, or staffing of health care facilities, in 

5 rural, underserved, or health professional or medical 

6 shortage areas within such region. Each regional di7 rector shall, prior to distributing such funds in ac8 cordance with paragraph (2), present a budget de9 scribing how such funds will be distributed to the 

10 Secretary. 

11 (2) DISTRIBUTION.—A regional director shall 

12 distribute funds to providers operating in the region 

13 of such director’s jurisdiction in a manner deter14 mined appropriate by the director. 

15 (f) PROHIBITION ON FINANCIAL INCENTIVE

16 METRICS IN PAYMENT DETERMINATIONS.—The Sec17 retary may not utilize any quality metrics or standards 

18 for the purposes of establishing provider payment meth19 odologies, programs, modifiers, or adjustments for pro20 vider payments under this title. 

21 SEC. 615. OFFICE OF PRIMARY HEALTH CARE. 

22 (a) IN GENERAL.—There is established within the 

23 Agency for Healthcare Research and Quality an Office of 

24 Primary Health Care, responsible for coordinating with 

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1 istration, and other offices in the Department as nec2 essary, in order to— 

3 (1) coordinate health professional education 

4 policies and goals, in consultation with the Secretary 

5 to achieve the national goals specified in subsection 

6 (b); 

7 (2) develop and maintain a system to monitor 

8 the number and specialties of individuals through 

9 their health professional education, any postgraduate 

10 training, and professional practice; 

11 (3) develop, coordinate, and promote policies 

12 that expand the number of primary care practi13 tioners, registered nurses, midlevel practitioners, and 

14 dentists; 

15 (4) recommend the appropriate training, tech16 nical assistance, and patient protection enhance17 ments of primary care health professionals, including 

18 registered nurses, to achieve uniform high quality 

19 and patient safety; and 

20 (5) consult with the Secretary on the allocation 

21 of the special projects budget under section 

22 601(a)(2)(C). 

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

24 the date of enactment of this Act, the Office of Primary 

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1 cess to high quality primary health care, particularly in 

2 underserved areas and for underserved populations. 

3 (c) CLARIFICATION.—Nothing in this— 

4 (1) section shall be construed to preempt any 

5 provision of State law establishing practice stand6 ards or guidelines for health care professionals, in7 cluding professional licensing or practice laws or reg8 ulations; and 

9 (2) Act shall be construed to require that any 

10 State impose additional educational standards or 

11 guidelines for health care professionals. 

12 SEC. 616. PAYMENTS FOR PRESCRIPTION DRUGS AND AP13 PROVED DEVICES AND EQUIPMENT. 

14 The prices to be paid for covered pharmaceuticals, 

15 medical supplies, medical technologies, and medically nec16 essary equipment covered under this Act shall be nego17 tiated annually by the Secretary. 

18 (1) IN GENERAL.—Notwithstanding any other 

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

20 beginning on or after the date of the enactment of 

21 this subsection, negotiate with pharmaceutical man22 ufacturers the prices (including discounts, rebates, 

23 and other price concessions) that may be charged to 

24 the Medicare for All Program during a negotiated 

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1 ered drugs for eligible individuals under the Medi2 care for All Program. In negotiating such prices 

3 under this section, the Secretary shall take into ac4 count the following factors: 

5 (A) The comparative clinical effectiveness 

6 and cost effectiveness, when available from an 

7 impartial source, of such drug. 

8 (B) The budgetary impact of providing 

9 coverage of such drug. 

10 (C) The number of similarly effective 

11 drugs or alternative treatment regimens for 

12 each approved use of such drug. 

13 (D) The total revenues from global sales 

14 obtained by the manufacturer for such drug 

15 and the associated investment in research and 

16 development of such drug by the manufacturer. 

17 (2) FINALIZATION OF NEGOTIATED PRICE.— 

18 The negotiated price of each covered drug for a ne19 gotiated price period shall be finalized not later than 

20 30 days before the first fiscal year in such nego21 tiated price period. 

22 (3) COMPETITIVE LICENSING AUTHORITY.— 

23 (A) IN GENERAL.—Notwithstanding any 

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

25 505(j)(5)(F) of the Federal Food, Drug, and 


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

2 505(c)(3)(E) of such Act, section 351(k)(7)(A) 

3 of the Public Health Service Act, or section 

4 527(a) of the Federal Food, Drug, and Cos5 metic Act, or by an extension of such exclusivity 

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

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

8 provides for market exclusivity (or extension of 

9 market exclusivity) with respect to a drug, in 

10 the case that the Secretary is unable to success 

11 fully negotiate an appropriate price for a cov12 ered drug for a negotiated price period, the Sec13 retary shall authorize the use of any patent, 

14 clinical trial data, or other exclusivity granted 

15 by the Federal Government with respect to such 

16 drug as the Secretary determines appropriate 

17 for purposes of manufacturing such drug for 

18 sale under Medicare for All Program. Any enti19 ty making use of a competitive license to use 

20 patent, clinical trial data, or other exclusivity 

21 under this section shall provide to the manufac22 turer holding such exclusivity reasonable com23 pensation, as determined by the Secretary 

24 based on the following factors: 


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1 (i) The risk-adjusted value of any 

2 Federal Government subsidies and invest3 ments in research and development used to 

4 support the development of such drug. 

5 (ii) The risk-adjusted value of any in6 vestment made by such manufacturer in 

7 the research and development of such 

8 drug. 

9 (iii) The impact of the price, including 

10 license compensation payments, on meeting 

11 the medical need of all patients at a rea12 sonable cost. 

13 (iv) The relationship between the 

14 price of such drug, including compensation 

15 payments, and the health benefits of such 

16 drug. 

17 (v) Other relevant factors determined 

18 appropriate by the Secretary to provide 

19 reasonable compensation. 

20 (B) REASONABLE COMPENSATION.—The 

21 manufacturer described in subparagraph (A) 

22 may seek recovery against the United States in 

23 the United States Court of Federal Claims. 

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

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1 proved under section 505(j) of the Federal 

2 Food, Drug, and Cosmetic Act or section 

3 351(k) of the Public Health Service Act and is 

4 provided under license issued by the Secretary 

5 under such subparagraph, the Medicare for All 

6 Program shall not pay more for such drug than 

7 the average of the prices available, during the 

8 most recent 12-month period for which data is 

9 available prior to the beginning of such nego10 tiated price period, from the manufacturer to 

11 any wholesaler, retailer, provider, health main12 tenance organization, nonprofit entity, or gov13 ernmental entity in the ten OECD (Organiza14 tion for Economic Cooperation and Develop15 ment) countries that have the largest gross do16 mestic product with a per capita income that is 

17 not less than half the per capita income of the 

18 United States. 

19 (D) AUTHORIZATION FOR SECRETARY TO

20 PROCURE DRUGS DIRECTLY.—The Secretary 

21 may procure a drug manufactured pursuant to 

22 a competitive license under subparagraph (A) 

23 for purposes of this Act. 

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1 plications under section 505(j) of the Federal Food, 

2 Drug, and Cosmetic Act for drugs licensed under 

3 paragraph (3)(A). 

4 (5) PROHIBITION OF ANTICOMPETITIVE BEHAV5 IOR.—No drug manufacturer may engage in anti6 competitive behavior with another manufacturer that 

7 may interfere with the issuance and implementation 

8 of a competitive license or run contrary to public 

9 policy. 

10 (6) REQUIRED REPORTING.—The Secretary 

11 may require pharmaceutical manufacturers to dis12 close to the Secretary such information that the Sec13 retary determines necessary for purposes of carrying 

14 out this subsection. 

15 TITLE VII—UNIVERSAL 

16 MEDICARE TRUST FUND 

17 SEC. 701. UNIVERSAL MEDICARE TRUST FUND. 

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

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

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

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

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

23 made and such amounts as may be deposited in, or appro24 priated to, such Trust Fund as provided in this Act. 

25 (b) APPROPRIATIONS INTO TRUST FUND.— 


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

2 Trust Fund for each fiscal year beginning with the 

3 fiscal year which includes the date on which benefits 

4 first become available as described in section 106, 

5 out of any moneys in the Treasury not otherwise ap6 propriated, amounts equivalent to 100 percent of the 

7 net increase in revenues to the Treasury which is at8 tributable to the amendments made by sections 801 

9 and 902. The amounts appropriated by the pre10 ceding sentence shall be transferred from time to 

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

12 general fund in the Treasury to the Trust Fund, 

13 such amounts to be determined on the basis of esti14 mates by the Secretary of the Treasury of the taxes 

15 paid to or deposited into the Treasury, and proper 

16 adjustments shall be made in amounts subsequently 

17 transferred to the extent prior estimates were in ex18 cess of or were less than the amounts that should 

19 have been so transferred. 

20 (2) CURRENT PROGRAM RECEIPTS.— 

21 (A) INITIAL YEAR.—Notwithstanding any 

22 other provision of law, there is appropriated to 

23 the Trust Fund for the fiscal year containing 

24 January 1 of the first year following the date 

25 of the enactment of this Act, an amount equal 


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1 to the aggregate amount appropriated for the 

2 preceding fiscal year for the following (in3 creased by the consumer price index for all 

4 urban consumers for the fiscal year involved): 

5 (i) The Medicare program under title 

6 XVIII of the Social Security Act (other 

7 than amounts attributable to any pre8 miums under such title). 

9 (ii) The Medicaid program under 

10 State plans approved under title XIX of 

11 such Act. 

12 (iii) The Federal Employees Health 

13 Benefits program, under chapter 89 of title 

14 5, United States Code. 

15 (iv) The TRICARE program, under 

16 chapter 55 of title 10, United States Code. 

17 (v) The maternal and child health 

18 program (under title V of the Social Secu19 rity Act), vocational rehabilitation pro20 grams, programs for drug abuse and men21 tal health services under the Public Health 

22 Service Act, programs providing general 

23 hospital or medical assistance, and any 

24 other Federal program identified by the 

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1 retary of the Treasury, to the extent the 

2 programs provide for payment for health 

3 services the payment of which may be 

4 made under this Act. 

5 (B) SUBSEQUENT YEARS.—Notwithstand6 ing any other provision of law, there is appro7 priated to the trust fund for the fiscal year con8 taining January 1 of the second year following 

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

10 each fiscal year thereafter, an amount equal to 

11 the amount appropriated to the Trust Fund for 

12 the previous year, adjusted for reductions in 

13 costs resulting from the implementation of this 

14 Act, changes in the consumer price index for all 

15 urban consumers for the fiscal year involved, 

16 and other factors determined appropriate by the 

17 Secretary. 

18 (3) RESTRICTIONS SHALL NOT APPLY.—Any 

19 other provision of law in effect on the date of enact20 ment of this Act restricting the use of Federal funds 

21 for any reproductive health service shall not apply to 

22 monies in the Trust Fund. 

23 (c) INCORPORATION OF PROVISIONS.—The provisions 

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

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


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1 Fund under this section in the same manner as such pro2 visions applied to the Federal Hospital Insurance Trust 

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

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

5 of Trustees of the Trust Fund’’ shall mean the ‘‘Sec6 retary’’. 

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

8 in the Federal Hospital Insurance Trust Fund under sec9 tion 1817 of the Social Security Act (42 U.S.C. 1395i) 

10 or the Federal Supplementary Medical Insurance Trust 

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

12 after the payment of claims for items and services fur13 nished under title XVIII of such Act have been completed, 

14 shall be transferred into the Universal Medicare Trust 

15 Fund under this section. 

16 TITLE VIII—CONFORMING 

17 AMENDMENTS TO THE EM18 PLOYEE RETIREMENT IN19 COME SECURITY ACT OF 1974 

20 SEC. 801. PROHIBITION OF EMPLOYEE BENEFITS DUPLICA21 TIVE OF BENEFITS UNDER THE MEDICARE 

22 FOR ALL PROGRAM; COORDINATION IN CASE 

23 OF WORKERS’ COMPENSATION. 

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

25 the Employee Retirement Income Security Act of 1974 


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1 (29 U.S.C. 1131 et seq.) is amended by adding at the end 

2 the following new section: 

3 ‘‘SEC. 522. PROHIBITION OF EMPLOYEE BENEFITS DUPLI4 CATIVE OF UNIVERSAL MEDICARE PROGRAM 

5 BENEFITS; COORDINATION IN CASE OF 

6 WORKERS’ COMPENSATION. 

7 ‘‘(a) IN GENERAL.—Subject to subsection (b), no em8 ployee benefit plan may provide benefits that duplicate 

9 payment for any items or services for which payment may 

10 be made under the Medicare for All Act of 2019. 

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

12 carrier that is liable for payment for workers compensa13 tion services furnished in a State shall reimburse the 

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

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

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

17 means an insurance company that underwrite work18 ers compensation medical benefits with respect to 

19 one or more employers and includes an employer or 

20 fund that is financially at risk for the provision of 

21 workers compensation medical benefits; 

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

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

24 an employee subject to the workers compensation 

25 laws of a State, the comprehensive medical benefits 


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1 for work-related injuries and illnesses provided for 

2 under such laws with respect to such an employee; 

3 and 

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

5 means items and services included in workers com6 pensation medical benefits and includes items and 

7 services (including rehabilitation services and long8 term care services) commonly used for treatment of 

9 work-related injuries and illnesses.’’. 

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

11 Employee Retirement Income Security Act of 1974 (29 

12 U.S.C. 1003(b)) is amended by adding at the end the fol13 lowing: ‘‘Paragraph (3) shall apply subject to section 

14 522(b) (relating to reimbursement of the Medicare for All 

15 Program by workers compensation carriers).’’. 

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

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

18 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.’’. 

19 SEC. 802. APPLICATION OF CONTINUATION COVERAGE RE20 QUIREMENTS UNDER ERISA AND CERTAIN 

21 OTHER REQUIREMENTS RELATING TO 

22 GROUP HEALTH PLANS. 

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

24 the Employee Retirement Income Security Act of 1974 


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1 (29 U.S.C. 1161 et seq.) shall apply only with respect to 

2 any employee health benefit plan that does not duplicate 

3 payments for any items or services for which payment may 

4 be made under the this Act. 

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

6 6 of subtitle B of title I of the Employee Retirement In7 come Security Act of 1974 (19 U.S.C. 1161) is amended 

8 by adding the following subsection at the end: 

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

10 plan that does not duplicate payments for any items or 

11 services for which payment may be made under the Uni12 versal Health Insurance Act of 2017.’’. 

13 SEC. 803. EFFECTIVE DATE OF TITLE. 

14 The provisions of and amendments made by this title 

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

16 TITLE IX—ADDITIONAL 

17 CONFORMING AMENDMENTS 

18 SEC. 901. RELATIONSHIP TO EXISTING FEDERAL HEALTH 

19 PROGRAMS. 

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

21 HEALTH INSURANCE PROGRAM (SCHIP).— 

22 (1) IN GENERAL.—Notwithstanding any other 

23 provision of law and with respect to an individual el24 igible to enroll under this Act, subject to paragraphs 

25 (2) and (3)— 


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1 (A) no benefits shall be available under 

2 title XVIII of the Social Security Act for any 

3 item or service furnished beginning on the date 

4 that is 2 years after the date of the enactment 

5 of this Act; 

6 (B) no individual is entitled to medical as7 sistance under a State plan approved under 

8 title XIX of such Act for any item or service 

9 furnished on or after such date; 

10 (C) no individual is entitled to medical as11 sistance under a State child health plan under 

12 title XXI of such Act for any item or service 

13 furnished on or after such date; and 

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

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

16 with respect to medical assistance or child 

17 health assistance for any item or service fur18 nished on or after such date. 

19 (2) TRANSITION.—In the case of inpatient hos20 pital services and extended care services during a 

21 continuous period of stay which began before the ef22 fective date of benefits under section 106, and which 

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

24 are provided under title XVIII of the Social Security 

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


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1 or under a State child health plan under title XXI 

2 of such Act, the Secretary shall provide for continu3 ation of benefits under such title or plan until the 

4 end of the period of stay. 

5 (3) SCHOOL PROGRAMS.—All school related 

6 health programs, centers, initiatives, services, or 

7 other activities or work provided under title XIX or 

8 title XXI of the Social Security Act as of January 

9 1, 2019, shall be continued and covered by the Medi10 care for All Program. 

11 (b) FEDERAL EMPLOYEES HEALTH BENEFITS PRO12 GRAM.—No benefits shall be made available under chapter 

13 89 of title 5, United States Code, with respect to items 

14 and services furnished to any individual eligible to enroll 

15 under this Act. 

16 (c) TRICARE.—No benefits shall be made available 

17 under sections 1079 and 1086 of title 10, United States 

18 Code, for items or services furnished to any individual eli19 gible to enroll under this Act. 

20 (d) TREATMENT OF BENEFITS FOR VETERANS AND

21 NATIVE AMERICANS.— 

22 (1) IN GENERAL.—Nothing in this Act shall af23 fect the eligibility of veterans for the medical bene24 fits and services provided under title 38, United 

25 States Code, or of Indians for the medical benefits 


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1 and services provided by or through the Indian 

2 Health Service. 

3 (2) REEVALUATION.—No reevaluation of the 

4 Indian Health Service shall be undertaken without 

5 consultation with tribal leaders and stakeholders. 

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

7 EXCHANGES. 

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

9 of the enactment of this Act, the Federal and State Ex10 changes established pursuant to title I of the Patient Pro11 tection and Affordable Care Act (Public Law 111–148) 

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

13 upon participation in or enrollment through such an Ex14 change, including such provisions of the Internal Revenue 

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

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

17 PERFORMANCE PROGRAMS. 

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

19 the Federal programs related to pay for performance pro20 grams and value-based purchasing shall terminate, and 

21 any other provision of law that relies upon participation 

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

23 or effect. Programs that shall terminate include— 

24 (1) the Merit-based Incentive Payment System 

25 established pursuant to subsection (q) of section 


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1 1848 of the Social Security Act (42 U.S.C. 1395w– 

2 4(q)); 

3 (2) the incentives for meaningful use of cer4 tified EHR technology established pursuant to sub5 section (a)(7) of section 1848 of the Social Security 

6 Act (42 U.S.C. 1395w–4(a)(7)); 

7 (3) the incentives for adoption and meaningful 

8 use of certified EHR technology established pursu9 ant to subsection (o) of section 1848 of the Social 

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

11 (4) alternative payment models established 

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

13 U.S.C. 1395(z)); and 

14 (5) the following programs as established pur15 suant to the following sections of the Patient Protec16 tion and Affordable Care Act: 

17 (A) Section 2701 (adult health quality 

18 measures). 

19 (B) Section 2702 (payment adjustments 

20 for health care acquired conditions). 

21 (C) Section 2706 (Pediatric Accountable 

22 Care Organization Demonstration Projects for 

23 the purposes of receiving incentive payments). 


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1 (D) Section 3002(b) (42 U.S.C. 1395w– 

2 4(a)(8)) (incentive payments for quality report3 ing). 

4 (E) Section 3001(a) (42 U.S.C. 

5 1395ww(o)) (Hospital Value-Based Purchas6 ing). 

7 (F) Section 3006 (value-based purchasing 

8 program for skilled nursing facilities and home 

9 health agencies). 

10 (G) Section 3007 (42 U.S.C. 1395w–4(p)) 

11 (value based payment modifier under physician 

12 fee schedule). 

13 (H) Section 3008 (42 U.S.C. 1395ww(p)) 

14 (payment adjustments for health care-acquired 

15 condition). 

16 (I) Section 3022 (42 U.S.C. 1395jjj) 

17 (Medicare shared savings programs). 

18 (J) Section 3023 (42 U.S.C. 1395cc–4) 

19 (National Pilot Program on Payment Bun20 dling). 

21 (K) Section 3024 (42 U.S.C. 1395cc–5) 

22 (Independence at home demonstration pro23 gram). 

24 (L) Section 3025 (42 U.S.C. 1395ww(q)) 

25 (hospital readmissions reduction program). 


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1 (M) Section 10301 (plans for value-based 

2 purchasing program for ambulatory surgical 

3 centers). 

4 TITLE X—TRANSITION 

5 Subtitle A—Medicare for All Tran6 sition Over 2 Years and Transi7 tional Buy-In Option 

8 SEC. 1001. MEDICARE FOR ALL TRANSITION OVER TWO 

9 YEARS. 

10 Title XVIII of the Social Security Act (42 U.S.C. 

11 1395c et seq.) is amended by adding at the end the fol12 lowing new section: 

13 ‘‘SEC. 1899C. MEDICARE FOR ALL TRANSITION OVER 2 

14 YEARS. 

15 ‘‘(a) TRANSITION.— 

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

17 the requirements described in paragraph (3) shall be 

18 eligible to enroll in the Medicare for All Program 

19 under this section during the transition period start20 ing one year after the date of enactment of the 

21 Medicare for All Act of 2019. 

22 ‘‘(2) BENEFITS.—An individual enrolled under 

23 this section is entitled to the benefits established 

24 under title II of the Medicare for All Act of 2019. 


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

2 requirements described in this paragraph are the fol3 lowing: 

4 ‘‘(A) The individual meets the eligibility re5 quirements established by the Secretary under 

6 title I of the Medicare for All Act of 2019. 

7 ‘‘(B) The individual has attained the appli8 cable year of age, or is currently enrolled in 

9 Medicare at the time of the transition to Medi10 care for All. 

11 ‘‘(4) APPLICABLE YEAR OF AGE DEFINED.— 

12 For purposes of this section, the term ‘applicable 

13 year of age’ means one year after the date of enact14 ment of the Medicare for All Act of 2019, the age 

15 of 55 or older, the age 18 or younger. 

16 ‘‘(b) ENROLLMENT; COVERAGE.—The Secretary shall 

17 establish enrollment periods and coverage under this sec18 tion consistent with the principles for establishment of en19 rollment periods and coverage for individuals under other 

20 provisions of this title. The Secretary shall establish such 

21 periods so that coverage under this section shall first begin 

22 on January 1 of the year on which an individual first be23 comes eligible to enroll under this section. 

24 ‘‘(c) SATISFACTION OF INDIVIDUAL MANDATE.—For 

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1 enue Code of 1986, the coverage provided under this sec2 tion constitutes minimum essential coverage under sub3 section (f)(1)(A)(i) of such section 5000A. 

4 ‘‘(d) CONSULTATION.—In promulgating regulations 

5 to implement this section, the Secretary shall consult with 

6 interested parties, including groups representing bene7 ficiaries, health care providers, employers, and insurance 

8 companies.’’. 

9 SEC. 1002. ESTABLISHMENT OF THE MEDICARE TRANSI10 TION BUY-IN. 

11 (a) IN GENERAL.—To carry out the purpose of this 

12 section, for the year beginning one year after the date of 

13 enactment of this Act and ending with the effective date 

14 described in section 106(a), the Secretary, acting through 

15 the Administrator of the Centers for Medicare & Medicaid 

16 (referred to in this section as the ‘‘Administrator’’), shall 

17 establish, and provide for the offering through the Ex18 changes, an option to buy in to the Medicare for All Pro19 gram (in this Act referred to as the ‘‘Medicare Transition 

20 buy-in’’). 

21 (b) ADMINISTERING THE MEDICARE TRANSITION

22 BUY-IN.— 

23 (1) ADMINISTRATOR.—The Administrator shall 

24 administer the Medicare Transition buy-in in accord25 ance with this section. 


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1 (2) APPLICATION OF ACA REQUIREMENTS.— 

2 Consistent with this section, the Medicare Transition 

3 buy-in shall comply with requirements under title I 

4 of the Patient Protection and Affordable Care Act 

5 (and the amendments made by that title) and title 

6 XXVII of the Public Health Service Act (42 U.S.C. 

7 300gg et seq.) that are applicable to qualified health 

8 plans offered through the Exchanges, subject to the 

9 limitation under subsection (e)(2). 

10 (3) OFFERING THROUGH EXCHANGES.—The 

11 Medicare Transition buy-in shall be made available 

12 only through the Exchanges, and shall be available 

13 to individuals wishing to enroll and to qualified em14 ployers (as defined in section 1312(f)(2) of the Pa15 tient Protection and Affordable Care Act (42 U.S.C. 

16 18032)) who wish to make such plan available to 

17 their employees. 

18 (4) ELIGIBILITY TO PURCHASE.—Any United 

19 States resident may enroll in the Medicare Transi20 tion buy-in. 

21 (c) BENEFITS; ACTUARIAL VALUE.—In carrying out 

22 this section, the Administrator shall ensure that the Medi23 care Transition buy-in provides— 

24 (1) coverage for the benefits required to be cov25 ered under title II of this Act; and 


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1 (2) coverage of benefits that are actuarially 

2 equivalent to 90 percent of the full actuarial value 

3 of the benefits provided under the plan. 

4 (d) PROVIDERS AND REIMBURSEMENT RATES.— 

5 (1) IN GENERAL.—With respect to the reim6 bursement provided to health care providers for cov7 ered benefits, as described in section 201, provided 

8 under the Medicare Transition buy-in, the Adminis9 trator shall reimburse such providers at rates deter10 mined for equivalent items and services under the 

11 Medicare for All fee-for-service schedule established 

12 in section 612(b) of this Act. 

13 (2) PRESCRIPTION DRUGS.—Any payment rate 

14 under this subsection for a prescription drug shall be 

15 at the prices negotiated under section 616 of this 

16 Act. 

17 (3) PARTICIPATING PROVIDERS.— 

18 (A) IN GENERAL.—A health care provider 

19 that is a participating provider of services or 

20 supplier under the Medicare program under 

21 title XVIII of the Social Security Act (42 

22 U.S.C. 1395 et seq.) or under a State Medicaid 

23 plan under title XIX of such Act (42 U.S.C. 

24 1396 et seq.) on the date of enactment of this 


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1 Act shall be a participating provider in the 

2 Medicare Transition buy-in. 

3 (B) ADDITIONAL PROVIDERS.—The Ad4 ministrator shall establish a process to allow 

5 health care providers not described in subpara6 graph (A) to become participating providers in 

7 the Medicare Transition buy-in. Such process 

8 shall be similar to the process applied to new 

9 providers under the Medicare program. 

10 (e) PREMIUMS.— 

11 (1) DETERMINATION.—The Administrator shall 

12 determine the premium amount for enrolling in the 

13 Medicare Transition buy-in, which— 

14 (A) may vary according to family or indi15 vidual coverage, age, and tobacco status (con16 sistent with clauses (i), (iii), and (iv) of section 

17 2701(a)(1)(A) of the Public Health Service Act 

18 (42 U.S.C. 300gg(a)(1)(A))); and 

19 (B) shall take into account the cost-shar20 ing reductions and premium tax credits which 

21 will be available with respect to the plan under 

22 section 1402 of the Patient Protection and Af23 fordable Care Act (42 U.S.C. 18071) and sec24 tion 36B of the Internal Revenue Code of 1986, 

25 as amended by subsection (g). 


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1 (2) LIMITATION.—Variation in premium rates 

2 of the Medicare Transition buy-in by rating area, as 

3 described in clause (ii) of section 2701(a)(1)(A)(iii) 

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

5 300gg(a)(1)(A)) is not permitted. 

6 (f) TERMINATION.—This section shall cease to have 

7 force or effect on the effective date described in section 

8 106(a). 

9 (g) TAX CREDITS AND COST-SHARING SUBSIDIES.— 

10 (1) PREMIUM ASSISTANCE TAX CREDITS.— 

11 (A) CREDITS ALLOWED TO MEDICARE

12 TRANSITION BUY-IN ENROLLEES IN NON-EX13 PANSION STATES.—Paragraph (1) of section 

14 36B(c) of the Internal Revenue Code of 1986 

15 is amended by redesignating subparagraphs (C) 

16 and (D) as subparagraphs (D) and (E), respec17 tively, and by inserting after subparagraph (B) 

18 the following new subparagraph: 

19 ‘‘(C) SPECIAL RULES FOR MEDICARE

20 TRANSITION BUY-IN ENROLLEES.— 

21 ‘‘(i) IN GENERAL.—In the case of a 

22 taxpayer who is covered, or whose spouse 

23 or dependent (as defined in section 152) is 

24 covered, by the Medicare Transition buy-in 

25 established under section 1002(a) of the 


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1 Medicare for All Act of 2019 for all 

2 months in the taxable year, subparagraph 

3 (A) shall be applied without regard to ‘but 

4 does not exceed 400 percent’. 

5 ‘‘(ii) ENROLLEES IN MEDICAID NON6 EXPANSION STATES.—In the case of a tax7 payer residing in a State which (as of the 

8 date of the enactment of the Medicare for 

9 All Act of 2019) does not provide for eligi10 bility under clause (i)(VIII) or (ii)(XX) of 

11 section 1902(a)(10)(A) of the Social Secu12 rity Act for medical assistance under title 

13 XIX of such Act (or a waiver of the State 

14 plan approved under section 1115) who is 

15 covered, or whose spouse or dependent (as 

16 defined in section 152) is covered, by the 

17 Medicare Transition buy-in established 

18 under section 1002(a) of the Medicare for 

19 All Act of 2019 for all months in the tax20 able year, subparagraphs (A) and (B) shall 

21 be applied by substituting ‘0 percent’ for 

22 ‘100 percent’ each place it appears.’’. 

23 (B) PREMIUM ASSISTANCE AMOUNTS FOR

24 TAXPAYERS ENROLLED IN MEDICARE TRANSI25 TION BUY-IN.— 


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1 (i) IN GENERAL.—Subparagraph (A) 

2 of section 36B(b)(3) of such Code is 

3 amended—(I) by redesignating clause (ii) 

4 as clause (iii), (II) by striking ‘‘clause (ii)’’ 

5 in clause (i) and inserting ‘‘clauses (ii) and 

6 (iii)’’, and (III) by inserting after clause (i) 

7 the following new clause: 

8 ‘‘(ii) SPECIAL RULES FOR TAXPAYERS

9 ENROLLED IN MEDICARE TRANSITION BUY10 IN.—In the case of a taxpayer who is cov11 ered, or whose spouse or dependent (as de12 fined in section 152) is covered, by the 

13 Medicare Transition buy-in established 

14 under section 1002(a) of the Medicare for 

15 All Act of 2019 for all months in the tax16 able year, the applicable percentage for 

17 any taxable year shall be determined in the 

18 same manner as under clause (i), except 

19 that the following table shall apply in lieu 

20 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.’’. 


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1 (ii) CONFORMING AMENDMENT.—Sub2 clause (I) of clause (iii) of section 

3 36B(b)(3) of such Code, as redesignated 

4 by subparagraph (A)(i), is amended by in5 serting ‘‘, and determined after the appli6 cation of clause (ii)’’ after ‘‘after applica7 tion of this clause’’. 

8 (2) COST-SHARING SUBSIDIES.—Subsection (b) 

9 of section 1402 of the Patient Protection and Af10 fordable Care Act (42 U.S.C. 18071(b)) is amend11 ed— 

12 (A) by inserting ‘‘, or in the Medicare 

13 Transition buy-in established under section 

14 1002(a) of the Medicare for All Act of 2019,’’ 

15 after ‘‘coverage’’ in paragraph (1); 

16 (B) by redesignating paragraphs (1) (as so 

17 amended) and (2) as subparagraphs (A) and 

18 (B), respectively, and by moving such subpara19 graphs 2 ems to the right; 

20 (C) by striking ‘‘INSURED.—In this sec21 tion’’ and inserting ‘‘INSURED.— 

22 ‘‘(1) IN GENERAL.—In this section’’; 

23 (D) by striking the flush language; and 

24 (E) by adding at the end the following new 

25 paragraph: 


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1 ‘‘(2) SPECIAL RULES.— 

2 ‘‘(A) INDIVIDUALS LAWFULLY PRESENT.— 

3 In the case of an individual described in section 

4 36B(c)(1)(B) of the Internal Revenue Code of 

5 1986, the individual shall be treated as having 

6 household income equal to 100 percent of the 

7 poverty line for a family of the size involved for 

8 purposes of applying this section. 

9 ‘‘(B) MEDICARE TRANSITION BUY-IN EN10 ROLLEES IN MEDICAID NON-EXPANSION

11 STATES.—In the case of an individual residing 

12 in a State which (as of the date of the enact13 ment of the Medicare for All Act of 2019) does 

14 not provide for eligibility under clause (i)(VIII) 

15 or (ii)(XX) of section 1902(a)(10)(A) of the So16 cial Security Act for medical assistance under 

17 title XIX of such Act (or a waiver of the State 

18 plan approved under section 1115) who enrolls 

19 in such Medicare Transition buy-in, the pre20 ceding sentence, paragraph (1)(B), and para21 graphs (1)(A)(i) and (2)(A) of subsection (c) 

22 shall each be applied by substituting ‘0 percent’ 

23 for ‘100 percent’ each place it appears.’’. 

24 (h) CONFORMING AMENDMENTS.— 


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1 (1) TREATMENT AS A QUALIFIED HEALTH

2 PLAN.—Section 1301(a)(2) of the Patient Protection 

3 and Affordable Care Act (42 U.S.C. 18021(a)(2)) is 

4 amended— 

5 (A) in the paragraph heading, by inserting 

6 ‘‘THE MEDICARE TRANSITION BUY-IN,’’ before 

7 ‘‘AND’’; and 

8 (B) by inserting ‘‘The Medicare Transition 

9 buy-in,’’ before ‘‘and a multi-State plan’’. 

10 (2) LEVEL PLAYING FIELD.—Section 1324(a) 

11 of the Patient Protection and Affordable Care Act 

12 (42 U.S.C. 18044(a)) is amended by inserting ‘‘the 

13 Medicare Transition buy-in,’’ before ‘‘or a multi14 State qualified health plan’’. 

15 Subtitle B—Transitional Medicare 

16 Reforms 

17 SEC. 1011. ELIMINATING THE 24-MONTH WAITING PERIOD 

18 FOR MEDICARE COVERAGE FOR INDIVID19 UALS WITH DISABILITIES. 

20 (a) IN GENERAL.—Section 226(b) of the Social Secu21 rity Act (42 U.S.C. 426(b)) is amended— 

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

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

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

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


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1 (3) in paragraph (2)(C)(ii), by striking ‘‘, in2 cluding the requirement that he has been entitled to 

3 the specified benefits for 24 months,’’; 

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

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

6 (II) the twenty-fifth month of his entitlement or sta7 tus as a qualified railroad retirement beneficiary de8 scribed in paragraph (2), and’’ and inserting ‘‘for 

9 each month for which the individual meets the re10 quirements of paragraph (2), beginning with the 

11 month following the month in which the individual 

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

13 and 

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

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

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

17 (b) CONFORMING AMENDMENTS.— 

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

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

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

21 (h); and 

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

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

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

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


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

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

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

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

5 is amended by striking ‘‘25th month of’’ and insert6 ing ‘‘month following the first month of’’. 

7 (4) RAILROAD RETIREMENT SYSTEM.—Section 

8 7(d)(2)(ii) of the Railroad Retirement Act of 1974 

9 (45 U.S.C. 231f(d)(2)(ii)) is amended— 

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

11 annuity’’ and inserting ‘‘is entitled to an annu12 ity’’; 

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

14 months’’; and 

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

16 for 24 calendar months, and’’. 

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

18 this section shall apply to insurance benefits under title 

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

20 services furnished in months beginning after December 1 

21 following the date of enactment of this Act, and before 

22 the date that is 2 years after the date of the enactment 

23 of such Act. 


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1 SEC. 1012. ENSURING CONTINUITY OF CARE. 

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

3 all persons enrolled or who seeks to enroll in a health plan 

4 during the transition period of the Medicare for All Pro5 gram are protected from disruptions in their care during 

6 the transition period, including continuity of care with 

7 such persons current health care provider teams. 

8 (b) CONTINUITY OF COVERAGE AND CARE IN GEN9 ERAL.—During the transition period of the Medicare for 

10 All Act, group health plans and health insurance issuers 

11 offering group or individual health insurance coverage 

12 shall not end coverage for an enrollee during the transition 

13 period described in the Act until all ages are eligible to 

14 enroll in the Medicare for All Program except as expressly 

15 agreed upon under the terms of the plan. 

16 (c) CONTINUITY OF COVERAGE AND CARE FOR PER17 SONS WITH COMPLEX MEDICAL NEEDS.— 

18 (1) The Secretary shall ensure that persons 

19 with disabilities, complex medical needs, or chronic 

20 conditions are protected from disruptions in their 

21 care during the transition period, including con22 tinuity of care with such persons current health care 

23 provider teams. 

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1 ance issuers offering group or individual health in2 surance coverage shall not— 

3 (A) end coverage for an enrollee who has 

4 a disability, complex medical need, or chronic 

5 condition during the transition period described 

6 in the Act until all ages are eligible to enroll in 

7 the Medicare for All Program; or 

8 (B) impose any exclusion with respect to 

9 such plan or coverage on the basis of a person’s 

10 disability, complex medical need, or chronic con11 dition during the transition period described 

12 under this Act until all ages are eligible to en13 roll in the Medicare for All Program. 

14 (d) PUBLIC CONSULTATION DURING TRANSITION.— 

15 The Secretary shall consult with communities and advo16 cacy organizations of persons living with disabilities as 

17 well as other patient advocacy organizations to ensure that 

18 the transition buy-in takes into account the continuity of 

19 care for persons with disabilities, complex medical needs, 

20 or chronic conditions. 

21 TITLE XI—MISCELLANEOUS 

22 SEC. 1101. DEFINITIONS. 

23 In this Act— 


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1 (1) the term ‘‘group practice’’ has the meaning 

2 given such term in section 1877(h)(4) of the Social 

3 Security Act (42 U.S.C. 1395nn(h)(4)); 

4 (2) the term ‘‘individual provider’’ means a sup5 plier (as defined for purposes of paragraph (4)); 

6 (3) the term ‘‘institutional provider’’ means— 

7 (A) providers of services described in sec8 tion 1861(u) of such Act (42 U.S.C. 1395x(u)); 

9 (B) hospitals as defined in section 1861(e) 

10 of the Social Security Act (42 U.S.C. 

11 1395x(e)), and any outpatient settings or clinics 

12 operating within a hospital license or any set13 ting or clinic that provides outpatient hospital 

14 services; 

15 (C) psychiatric hospitals (as defined in sec16 tion 1861(e) of the Social Security Act (42 

17 U.S.C. 1395x(f))); 

18 (D) rehabilitation hospitals (as defined by 

19 the Secretary of Health and Human Services 

20 under section 1886(d)(1)(B)(ii) of the Social 

21 Security Act (42 U.S.C. 1395ww(d)(1)(B)(ii))); 

22 (E) long-term care hospitals as defined in 

23 section 1861 of the Social Security Act (42 

24 U.S.C. 1395x(ccc)); and 


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1 (F) independent dialysis facilities and inde2 pendent end-stage renal disease facilities as de3 scribed in 42 CFR 413.174(b); 

4 (4) the term ‘‘medically necessary or appro5 priate’’ means the health care items and services or 

6 supplies are needed or appropriate to prevent, diag7 nose, or treat an illness, injury, condition, disease, or 

8 its symptoms for an individual and are determined 

9 to be necessary or appropriate for such individual by 

10 the physician or other health care professional treat11 ing such individual, after such professional performs 

12 an assessment of such individual’s condition, in a 

13 manner that meets— 

14 (A) the scope of practice, licensing, and 

15 other law of the State in which such items and 

16 services are to be furnished; and 

17 (B) appropriate standards established by 

18 the Secretary for purposes of carrying out this 

19 Act; 

20 (5) the term ‘‘provider’’ means an institutional 

21 provider or a supplier (as defined in section 1861(d) 

22 of such Act (42 U.S.C. 1395x(d)) if the reference to 

23 ‘‘this title’’ were a reference to the Medicare for All 

24 Program); 


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1 (6) the term ‘‘Secretary’’ means the Secretary 

2 of Health and Human Services; 

3 (7) the term ‘‘State’’ means a State, the Dis4 trict of Columbia, or a territory of the United 

5 States; and 

6 (8) the term ‘‘United States’’ shall include the 

7 States, the District of Columbia, and the territories 

8 of the United States. 

9 SEC. 1102. RULES OF CONSTRUCTION. 

10 (a) IN GENERAL.—A State or local government may 

11 set additional standards or apply other State or local laws 

12 with respect to eligibility, benefits, and minimum provider 

13 standards, only if such State or local standards— 

14 (1) provide equal or greater eligibility than is 

15 available under this Act; 

16 (2) provide equal or greater in-person access to 

17 benefits under this Act; 

18 (3) do not reduce access to benefits under this 

19 Act; 

20 (4) allow for the effective exercise of the profes21 sional judgment of physicians or other health care 

22 professionals; and 

23 (5) are otherwise consistent with this Act. 

24 (b) RELATION TO STATE LICENSING LAW.—Nothing 

25 in this Act shall be construed to preempt State licensing, 


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1 practice, or educational laws or regulations with respect 

2 to health care professionals and health care providers, for 

3 such professionals and providers who practice in that 

4 State. 

5 (c) APPLICATION TO STATE AND FEDERAL LAW ON

6 WORKPLACE RIGHTS.—Nothing in this Act shall be con7 strued to diminish or alter the rights, privileges, remedies, 

8 or obligations of any employee or employer under any Fed9 eral or State law or regulation or under any collective bar10 gaining agreement. 

11 (d) RESTRICTIONS ON PROVIDERS.—With respect to 

12 any individuals or entities certified to provide items and 

13 services covered under section 201(a)(7), a State may not 

14 prohibit an individual or entity from participating in the 

15 program under this Act for reasons other than the ability 

16 of the individual or entity to provide such services. 

Æ 


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