I 

116TH CONGRESS 

1ST SESSION H. R. 2452 

To amend the Social Security Act to establish a Medicare for America health 

program to provide for comprehensive health coverage for all Americans. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 1, 2019 

Ms. DELAURO (for herself, Ms. SCHAKOWSKY, Mr. KENNEDY, Mr. CLAY, Ms. 

NORTON, Mr. GRIJALVA, Mr. CARBAJAL, Mrs. TRAHAN, Mr. RYAN, Ms. 

JACKSON LEE, Mr. THOMPSON of Mississippi, Ms. ROYBAL-ALLARD, Ms. 

MCCOLLUM, Ms. MOORE, Mr. RUSH, and Mr. HIGGINS of New York) introduced the following bill; which was referred to the Committee on Ways 

and Means, and in addition to the Committees on Energy and Commerce, 

Education and Labor, the Judiciary, Natural Resources, and House Administration, 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 

A BILL 

To amend the Social Security Act to establish a Medicare 

for America health program to provide for comprehensive 

health coverage for all Americans. 

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 America Act of 2019’’. 


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

2 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—TRANSITIONING TO AND ESTABLISHING MEDICARE FOR 

AMERICA 

Subtitle A—Transitional Public Health Option 

Sec. 101. Establishment. 

Sec. 102. Eligibility. 

Sec. 103. Benefits. 

Sec. 104. Premiums. 

Sec. 105. Providers and reimbursement rates. 

Sec. 106. Account; funding. 

Subtitle B—Medicare for America 

Sec. 111. Establishment and administration of Medicare for America. 

Sec. 112. Modifications to and coordination with existing Federal health programs. 

Subtitle C—Targeted Reforms 

Sec. 121. No surprise billing. 

Sec. 122. Limitation on removal of Medicare Advantage providers by MA organizations. 

Sec. 123. Network adequacy. 

Sec. 124. Eliminating the 24-month waiting period for Medicare coverage for 

individuals with disabilities. 

Sec. 125. Eliminating the waiting period for individuals on State Medicaid 

waiting lists. 

Sec. 126. Employer health plan options. 

Sec. 127. Prohibition on step therapy and prior authorization under group 

health plans. 

Sec. 128. Medicare outpatient observation services. 

Sec. 129. Abortion coverage. 

Sec. 130. Applicability of mental health parity. 

Sec. 131. Student loan forgiveness for health care providers participating in 

Medicare for America. 

Sec. 132. Clarification of the definition of pediatric medical necessity in qualifying group coverage. 

Sec. 133. Safe staffing requirements. 

Sec. 134. Enhancements for reduced cost-sharing. 

Sec. 135. Repeal of bonus payments for Medicare Advantage plans. 

TITLE II—TAX PROVISIONS 

Sec. 201. Sunset of Public Law 115–97. 

Sec. 202. Surtax. 

Sec. 203. Basis of property acquired from a decedent. 

Sec. 204. Medicare payroll tax. 

Sec. 205. Net investment income tax. 

Sec. 206. Termination of deduction for contributions to health savings accounts. 


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Sec. 207. Increase in excise tax on small cigars and cigarettes and other tobacco products. 

Sec. 208. Excise tax on alcohol. 

Sec. 209. Tax on sugared drinks. 

Sec. 210. Repeal of excise tax on high-cost employer-sponsored health coverage. 

TITLE III—DRUG-RELATED PROVISIONS 

Sec. 301. Establishment of the Prescription Drug and Medical Device Review 

Board. 

Sec. 302. Membership; staff. 

Sec. 303. Prohibition against excessive price. 

Sec. 304. Enforcement provisions. 

Sec. 305. Authority. 

Sec. 306. Regulations. 

Sec. 307. Report to Federal agencies. 

Sec. 308. Definitions. 

Sec. 309. Moratorium on direct-to-consumer drug advertising. 

Sec. 310. Reporting on justification for drug price increases. 

TITLE IV—OUTCOMES AND REPORTING 

Sec. 401. Sense of Congress. 

Sec. 402. Evaluation of bill’s outcome. 

1 TITLE I—TRANSITIONING TO 

2 AND ESTABLISHING MEDI3 CARE FOR AMERICA 

4 Subtitle A—Transitional Public 

5 Health Option 

6 SEC. 101. ESTABLISHMENT. 

7 The Secretary of Health and Human Services (in this 

8 subtitle referred to as the ‘‘Secretary’’) shall establish a 

9 public health plan option that is offered in the individual 

10 market through the Federal and State Exchanges under 

11 title I of the Patient Protection and Affordable Care Act 

12 to eligible individuals for plan years 2021 and 2022 in 

13 accordance with this subtitle. 


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1 SEC. 102. ELIGIBILITY. 

2 Subject to subsection (b), an individual is eligible to 

3 enroll in such public health plan option if the individual 

4 is otherwise eligible to purchase individual health insur5 ance coverage through an Exchange and the individual re6 sides in a rating area in which the Secretary makes the 

7 public health plan option available. 

8 SEC. 103. BENEFITS. 

9 (a) IN GENERAL.—The public health plan option 

10 shall be a qualified health plan within the meaning of sec11 tion 1301(a) of the Patient Protection and Affordable 

12 Care Act (42 U.S.C. 18021(a)) that— 

13 (1) meets all requirements applicable to quali14 fied health plans under subtitle D of title I of the 

15 Patient Protection and Affordable Care Act (other 

16 than the requirement under section 

17 1301(a)(1)(C)(ii) of such Act (42 U.S.C. 

18 18021(a)(1)(C)(ii))) and title XXVII of the Public 

19 Health Service Act; 

20 (2) provides coverage of the essential health 

21 benefits described in section 1302(b) of the Patient 

22 Protection and Affordable Care Act (42 U.S.C. 

23 18022(b)); 

24 (3) provides silver and gold-level coverage de25 scribed in section 1302(d)(1)(C) of the Patient ProVerDate Sep 11 2014 20:58 May 08, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H2452.IH H2452

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1 tection and Affordable Care Act (42 U.S.C. 

2 18022(d)(1)(C)); and 

3 (4) provides coverage of comprehensive repro4 ductive health services, including abortion. 

5 (b) PREEMPTION.—Notwithstanding section 

6 1303(a)(1) of the Patient Protection and Affordable Care 

7 Act (42 U.S.C. 18023(a)(1))— 

8 (1) a State may not prohibit the public health 

9 plan option from offering the coverage described in 

10 subsection (a)(4); and 

11 (2) no State law that would prohibit such a 

12 plan from offering such coverage shall apply to such 

13 plan. 

14 SEC. 104. PREMIUMS. 

15 (a) IN GENERAL.—The Secretary shall establish pre16 mium rates for the public health plan option that— 

17 (1) are adjusted based on the applicable rating 

18 area; 

19 (2) are at a level sufficient to fully finance— 

20 (A) the costs of health benefits provided by 

21 such plans; and 

22 (B) administrative costs related to oper23 ating the plans; 


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1 (3) comply with the requirements under section 

2 2701 of the Public Health Service Act (42 U.S.C. 

3 300gg); and 

4 (4) ensure that no individual or household will 

5 pay more than 8 percent of adjusted gross monthly 

6 income toward the monthly premium. 

7 (b) FEDERAL SUBSIDIES.—Federal subsidies shall be 

8 provided to ensure that the premium shall be— 

9 (1) zero in the case of an individual whose an10 nual household income is below 200 percent of the 

11 poverty line; 

12 (2) determined by a linear sliding scale, in the 

13 case of an individual whose household income is at 

14 least 200 percent of the poverty line, but not more 

15 than 600 percent of the poverty line; and 

16 (3) no individual or household above 600 per17 cent of poverty level will pay more than 8 percent 

18 of adjusted gross monthly income toward such 

19 monthly premium. 

20 SEC. 105. PROVIDERS AND REIMBURSEMENT RATES. 

21 (a) IN GENERAL.—The Secretary shall establish a 

22 rate schedule for reimbursing types of health care pro23 viders furnishing items and services under the public 

24 health insurance plan option at rates based on rates ap25 plied for such items and services under title XVIII of the 


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1 Social Security Act, as of the date of the enactment of 

2 this Act, that are necessary to maintain network ade3 quacy. The Secretary shall establish a rate schedule for 

4 items and services not currently covered under title XVIII 

5 of the Social Security Act, such as dental, vision, and 

6 hearing benefits, well child visits, and reproductive health 

7 services, at a level to ensure adequate access to providers. 

8 (b) PARTICIPATING PROVIDERS.— 

9 (1) IN GENERAL.—A health care provider that 

10 is a participating provider of services or supplier 

11 under the Medicare program under title XVIII of 

12 the Social Security Act or under the Medicaid pro13 gram under title XIX of such Act on the date of en14 actment of this title shall be a participating provider 

15 for the public health insurance plan option. 

16 (2) ADDITIONAL PROVIDERS.—The Secretary 

17 shall establish a process to allow health care pro18 viders not described in paragraph (1) to become par19 ticipating providers for the public health insurance 

20 plan option. 

21 (3) CLARIFICATION.—Notwithstanding any 

22 other provision of law, health care providers may not 

23 be prohibited from participating in the public health 

24 insurance option for reasons other than their ability 

25 to provide covered services. Health care providers 


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1 and institutions are prohibited from denying covered 

2 individuals access to any covered benefits and serv3 ices because of their religious objections. 

4 (c) PRESCRIPTION DRUGS.—The Secretary shall 

5 apply the provisions of section 1860D–11(i) of the Social 

6 Security Act (42 U.S.C. 1395w–111(i)) to prescription 

7 drugs under the public health plan option in the same 

8 manner as such provisions apply with respect to applicable 

9 covered part D drugs under such section. 

10 SEC. 106. ACCOUNT; FUNDING. 

11 (a) ESTABLISHMENT.—There is established in the 

12 Treasury of the United States an account for the receipts 

13 and disbursements attributable to the operation of the 

14 public health plan option. 

15 (b) APPROPRIATION.—There is appropriated to the 

16 account established under subsection (a), out of any funds 

17 in the Treasury not otherwise obligated, such sums as may 

18 be necessary to be used by the Secretary for purposes of 

19 carrying out this part. 

20 (c) PROHIBITION OF STATE IMPOSITION OF

21 TAXES.—Section 1854(g) of the Social Security Act (42 

22 U.S.C. 1395w–24(g)) shall apply to receipts and disburse23 ments described in subsection (a) in the same manner as 

24 such section applies to payments or premiums described 

25 in such section. 


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1 (d) CLARIFICATION.—Any provision of law restricting 

2 the use of Federal funds with respect to any reproductive 

3 health service shall not apply to funds appropriated under 

4 subsection (b) or with respect to the account under sub5 section (a). 

6 Subtitle B—Medicare for America 

7 SEC. 111. ESTABLISHMENT AND ADMINISTRATION OF MEDI8 CARE FOR AMERICA. 

9 The Social Security Act is amended by adding at the 

10 end the following new title: 

11 ‘‘TITLE XXII—MEDICARE FOR 

12 AMERICA 

13 ‘‘PART A—COMPREHENSIVE HEALTH COVERAGE 

14 ‘‘SEC. 2201. ESTABLISHMENT. 

15 ‘‘The Secretary shall establish a public health insur16 ance program, to be known as ‘Medicare for America’, 

17 which shall for calendar year 2023 and each subsequent 

18 calendar year provide comprehensive health benefits in ac19 cordance with this part to individuals enrolled for coverage 

20 under this title. 

21 ‘‘SEC. 2202. ELIGIBILITY; AUTOMATIC ENROLLMENT. 

22 ‘‘(a) ELIGIBLE INDIVIDUALS.—For purposes of this 

23 title, every individual who is— 

24 ‘‘(1) a resident of the United States or a terri25 tory of the United States; 


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1 ‘‘(2) an individual who is lawfully present, as 

2 defined in section 152.2 of title 45 of the Code of 

3 Federal Regulations; or 

4 ‘‘(3) an individual who would be eligible for cov5 erage under a State Medicaid plan pursuant to sec6 tion 1903(v) (as such section was in effect as of the 

7 date of the enactment of this title), 

8 is entitled to benefits for health care services under this 

9 title. The Secretary shall promulgate a rule that provides 

10 criteria for applying this subsection, including determining 

11 residency for eligibility purposes under this title. Nothing 

12 in this title shall preclude a State from using State funds 

13 to provide for an individual’s health coverage who is not 

14 eligible under this subsection. 

15 ‘‘(b) ENROLLMENTS.—Subject to subsection (c): 

16 ‘‘(1) IN GENERAL.—Beginning in 2023, the 

17 Secretary shall provide a mechanism for the enroll18 ment of individuals entitled to benefits under this 

19 title and, in conjunction with such enrollment, the 

20 issuance of a Medicare for America card which may 

21 be used for purposes of identification and processing 

22 of claims for benefits under this title. The card shall 

23 not use the individual’s social security number as an 

24 identifier. As a condition of participation in the pro25 gram, participating providers shall facilitate enrollVerDate Sep 11 2014 20:58 May 08, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H2452.IH H2452

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1 ment as specified by the Secretary. The State enti2 ties responsible for enrolling individuals in the Med3 icaid program under title XIX and the Children’s 

4 Health Insurance Program under title XXI shall 

5 serve as the enrolling entity for Medicare for Amer6 ica within each State. 

7 ‘‘(2) AUTOMATIC ENROLLMENTS.—The mecha8 nism provided under paragraph (1) shall, subject to 

9 paragraph (4), provide, for plan years, for the fol10 lowing automatic enrollments under Medicare for 

11 America: 

12 ‘‘(A) ENROLLMENT AT BIRTH.—For plan 

13 years (beginning with plan year 2023), a proc14 ess, established by the Secretary in consultation 

15 with the Commissioner of Social Security, for 

16 the automatic enrollment of eligible individuals 

17 born during such plan year. 

18 ‘‘(B) CURRENT MEDICARE BENE19 FICIARIES.— 

20 ‘‘(i) CURRENT MEDICARE BENE21 FICIARIES.—For plan years (beginning 

22 with plan year 2023), a process established 

23 by the Secretary for the automatic enroll24 ment of all individuals who are enrolled for 

25 benefits under part A or B of title XVIII 


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1 (other than individuals who are enrolled 

2 for such benefits and receiving benefits 

3 under title XIX). 

4 ‘‘(ii) CONTINUING POPULATION.—For 

5 plan years (beginning with plan year 

6 2023), a process established by the Sec7 retary for the automatic enrollment of eli8 gible individuals who attain the age of 65 

9 during such plan year. 

10 ‘‘(iii) DUALS.—For plan years (begin11 ning with plan year 2025), a process estab12 lished by the Secretary for the automatic 

13 enrollment of eligible individuals who are 

14 enrolled for benefits under part A or B of 

15 title XVIII and receiving benefits under 

16 title XIX. 

17 ‘‘(C) OTHER INDIVIDUALS WITHOUT

18 QUALIFIED HEALTH COVERAGE.—For plan 

19 years (beginning with plan year 2023), a proc20 ess established by the Secretary for the auto21 matic enrollment of eligible individuals who are 

22 not enrolled in other qualified health coverage 

23 (as defined in paragraph (4)(B)) for such plan 

24 year. 


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1 ‘‘(3) OTHER ENROLLMENTS.—The mechanism 

2 provided under paragraph (1) shall provide for the 

3 following: 

4 ‘‘(A) IN GENERAL.—Enrollment periods 

5 and processes for each plan year (beginning 

6 with plan year 2023) for enrollment under 

7 Medicare for America of any eligible individual 

8 not otherwise described in paragraph (2). 

9 ‘‘(B) SMALL EMPLOYERS.— 

10 ‘‘(i) IN GENERAL.—For plan years 

11 (beginning with plan year 2023), a process 

12 and methodology under which a small em13 ployer, as defined in section 126(d)(3) of 

14 the Medicare for America Act, may provide 

15 for the enrollment of the employees of such 

16 employer under Medicare for America. For 

17 purposes of this subparagraph, the term 

18 ‘small employer’ means any employer for 

19 any calendar year if the annual payroll of 

20 such employer for the preceding calendar 

21 year does not exceed $2,000,000 or has 

22 fewer than 100 employees. 

23 ‘‘(ii) REQUIREMENT.—Small employ24 ers shall either provide coverage as defined 

25 within the meaning of section 2791(d)(8) 


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1 of the Public Health Service Act or facili2 tate the enrollment of their employees into 

3 Medicare for America. Small employers fa4 cilitating enrollment into Medicare for 

5 America will not be subject to a mandatory 

6 employer contribution. 

7 ‘‘(iii) AUTHORITY.—The Secretary 

8 may set standards for determining whether 

9 employers are undertaking any actions to 

10 affect the risk pool within Medicare for 

11 America by inducing individuals to decline 

12 coverage under a qualifying employer-spon13 sored plan and instead to enroll in Medi14 care for America. An employer violating 

15 such standards shall be treated as not 

16 meeting the requirements of qualified 

17 health coverage. 

18 ‘‘(C) LARGE EMPLOYERS.—For plan years 

19 (beginning with plan year 2027), the Secretary 

20 shall provide for a process and methodology 

21 under which a large employer may provide for 

22 the enrollment of the employees of such em23 ployer under Medicare for America. For pur24 poses of the preceding sentence, the term ‘large 

25 employer’ means an employer with at least 100 


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1 employees or whose annual payroll exceeds 

2 $2,000,000. 

3 ‘‘(D) MEMBERS OF CONGRESS AND THEIR

4 STAFF.—Beginning for plan year 2023, Mem5 bers of Congress and their staff, subject to 

6 paragraph (4), shall be enrolled in Medicare for 

7 America. 

8 ‘‘(4) OPT OUT FOR INDIVIDUALS ENROLLED

9 UNDER QUALIFIED HEALTH COVERAGE.— 

10 ‘‘(A) IN GENERAL.—The mechanism pro11 vided under paragraph (1) shall provide, with 

12 respect to a plan year, for a process that en13 ables individuals who are enrolled in qualified 

14 health coverage for such plan year to opt out of 

15 coverage under Medicare for America for such 

16 year. 

17 ‘‘(B) QUALIFIED HEALTH COVERAGE DE18 FINED.—For purposes of this section, the term 

19 ‘qualified health coverage’ means coverage 

20 under any of the following: 

21 ‘‘(i) For plan years 2023 and 2024: 

22 ‘‘(I) Qualified employer coverage, 

23 as defined in section 126 of the Medi24 care for America Act. 


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1 ‘‘(II) Medical coverage under 

2 chapter 55 of title 10, United States 

3 Code, including coverage under the 

4 TRICARE program. 

5 ‘‘(III) A health care program 

6 under chapter 17 or 18 of title 38, 

7 United States Code, as determined by 

8 the Secretary of Veterans Affairs, in 

9 coordination with the Secretary of 

10 Health and Human Services and the 

11 Secretary. 

12 ‘‘(IV) The health benefit program 

13 under chapter 89 of title 5, United 

14 States Code. 

15 ‘‘(V) Medical benefits and serv16 ices provided by or through the Indian 

17 Health Service. 

18 ‘‘(VI) The Medicaid program 

19 under title XIX of the Social Security 

20 Act. 

21 ‘‘(VII) The CHIP program under 

22 title XXI of the Social Security Act. 

23 ‘‘(ii) For plan years 2025 and 2026: 


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1 ‘‘(I) Coverage described in sub2 clause (I), (II), (III), (IV), or (V) of 

3 clause (i). 

4 ‘‘(II) Coverage described in sub5 clause (VI) of clause (i), but only with 

6 respect to coverage that is not for in7 dividuals described in subclause (VIII) 

8 of section 1902(a)(10)(A)(i) or who 

9 are also enrolled for benefits under 

10 title XVIII. 

11 ‘‘(iii) For each subsequent plan year, 

12 coverage described in subclause (I), (II), 

13 (III), (IV), or (V) of clause (i). 

14 ‘‘(c) WAIVER.—The Secretary shall establish a proc15 ess under which the Secretary may grant waivers to States 

16 for additional time before populations described in a pre17 vious subsection of this section of such State are automati18 cally enrolled under Medicare for America so long as the 

19 State can demonstrate substantial progress has been made 

20 in transitioning these populations. 

21 ‘‘SEC. 2203. BENEFITS. 

22 ‘‘(a) IN GENERAL.—Medicare for America shall, in 

23 accordance with this section, provide coverage for all the 

24 benefits, as determined to be medically necessary, as cov25 ered and defined under parts A and B of title XVIII and 


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1 title XIX as of the date of the enactment of this title, 

2 including the following: 

3 ‘‘(1) Ambulatory patient services. 

4 ‘‘(2) Emergency care and urgent care services. 

5 ‘‘(3) Hospitalization. 

6 ‘‘(4) Maternity and newborn care. 

7 ‘‘(5) Behavioral health services, including men8 tal health, substance use disorder services, and in9 tensive home and community based services. 

10 ‘‘(6) Prescription drugs approved by the Food 

11 and Drug Administration. 

12 ‘‘(7) Rehabilitative and habilitative services and 

13 devices, including the following: 

14 ‘‘(A) Physical therapy. 

15 ‘‘(B) Speech therapy. 

16 ‘‘(C) Occupational therapy. 

17 ‘‘(8) Laboratory services. 

18 ‘‘(9) Preventive and wellness services and 

19 chronic disease management. 

20 ‘‘(10) Pediatric services, all services that would 

21 otherwise be coverable under early and periodic 

22 screening, diagnostic, and treatment under the Med23 icaid program under title XIX and services otherwise 

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1 hood home visiting program under section 511, as of 

2 the date of the enactment of this title. 

3 ‘‘(11) Dental care, at a minimum the services 

4 necessary to prevent disease and promote oral 

5 health, restore oral structures to health and func6 tion, and treat emergency conditions, nightguards, 

7 mouthguards, and dentures. 

8 ‘‘(12) Hearing health services including aids 

9 and exams. 

10 ‘‘(13) Vision services. 

11 ‘‘(14) Home and community based long-term 

12 services and supports. 

13 ‘‘(15) Chiropractic services. 

14 ‘‘(16) Durable medical equipment (as defined 

15 for purposes of title XIX), including the following: 

16 ‘‘(A) Wheelchairs and accessories. 

17 ‘‘(B) Walking aides such as walkers, canes, 

18 and crutches. 

19 ‘‘(C) Bathroom equipment such as com20 modes and safety equipment. 

21 ‘‘(D) Inhalation therapy equipment such as 

22 nebulizers. 

23 ‘‘(E) Hospital beds and accessories. 


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1 ‘‘(F) Other devices such as Continuous 

2 Positive Airway Pressure (CPAP) machines, 

3 apnea monitors, and ventilators. 

4 ‘‘(G) Insulin pumps and glucometers. 

5 ‘‘(H) Breast pumps. 

6 ‘‘(I) Lymphedema compression treatment 

7 items. 

8 ‘‘(J) Wigs for medical conditions. 

9 ‘‘(K) Augmentative and alternative com10 munication devices, including dual-use devices. 

11 ‘‘(L) Oxygen. 

12 ‘‘(M) Orthotic and prosthetic devices. 

13 ‘‘(N) Disposable medical supplies. 

14 ‘‘(17) Family planning, including the following: 

15 ‘‘(A) Reproductive health exams. 

16 ‘‘(B) Patient counseling and education re17 lated to family planning. 

18 ‘‘(C) Abortion. 

19 ‘‘(D) Screening, testing, treatment, and 

20 pre- and post-test counseling for sexually trans21 mitted diseases and HIV. 

22 ‘‘(E) Contraceptives including pill, patch, 

23 medication, condom, implant, or other devices 

24 used to prevent pregnancy. 


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1 ‘‘(F) Voluntary sterilization for bene2 ficiaries over the age of 21. 

3 ‘‘(G) Infertility treatment. 

4 ‘‘(18) Gender-confirming medical procedures 

5 and treatment. 

6 ‘‘(19) Screening, testing, treatment, and pre7 and post-test counseling for sexually transmitted dis8 eases and HIV. 

9 ‘‘(20) Dietary and nutrition counseling. 

10 ‘‘(21) Medically necessary food and vitamins for 

11 digestive and inherited metabolic disorders. 

12 ‘‘(22) Nursing facilities. 

13 ‘‘(23) Acupuncture. 

14 ‘‘(24) Digital health therapeutics, as approved 

15 by the Center for Healthcare and the Center for 

16 Medicare and Medicaid Innovation. 

17 ‘‘(25) Telehealth. 

18 ‘‘(26) Non-emergency medical transportation. 

19 ‘‘(27) Care coordination, including services de20 fined in section 440.169 of title 42, Code of Federal 

21 Regulations. 

22 ‘‘(28) Palliative care. 

23 ‘‘(29) Any additional benefit or service not in24 cluded in this section that is coverable by any State 


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1 plan (or waiver of such State plan) under title XIX 

2 on the date of the enactment of this title. 

3 ‘‘(b) UPDATES.—Benefits coverable under Medicare 

4 for America shall be updated in accordance with the Na5 tional Coverage Determination process that had, as of the 

6 date before the date of the enactment of this title, applied 

7 with respect to benefits covered under title XVIII. 

8 ‘‘(c) IMPLEMENTING POLICIES.—The Secretary shall 

9 establish payment models, quality measures, and other im10 plementing policies that provide further access to the cov11 erage under this title. For purposes of the previous sen12 tence, the Secretary shall consult with stakeholders, in13 cluding those covering pediatrics, disabilities, and seniors. 

14 ‘‘(d) PROHIBITION AGAINST DUPLICATING COV15 ERAGE.— 

16 ‘‘(1) IN GENERAL.—It is unlawful for a private 

17 health insurer (other than an insurer with respect to 

18 a Medicare Advantage for America plan under part 

19 C of this title or qualified employer-based coverage) 

20 to sell health insurance coverage that duplicates the 

21 benefits provided under Medicare for America under 

22 this part. 

23 ‘‘(2) CONSTRUCTION.—Nothing in paragraph 

24 (1) shall be construed as prohibiting the sale of 

25 health insurance coverage for any additional benefits 


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1 not covered by this part, insofar as the coverage sat2 isfies the conditions of paragraphs (3) and (4). 

3 Nothing shall preclude employers meeting the re4 quirements under section 126 of the Medicare for 

5 America Act from providing supplemental coverage 

6 under this section to their employees. 

7 ‘‘(3) APPLICATION OF PROTECTIONS.—For pur8 poses of paragraph (2), health insurance coverage 

9 for any additional benefits must satisfy the following 

10 conditions: 

11 ‘‘(A) The provisions of section 2718 of the 

12 Public Health Service Act, relating to a medical 

13 loss ratio. 

14 ‘‘(B) The provisions of section 2702 of the 

15 Public Health Service Act, relating to guaran16 teed issue. 

17 ‘‘(C) The provisions of section 2701 of the 

18 Public Health Service Act, relating to commu19 nity rating. 

20 ‘‘(D) The provisions of section 2704 of the 

21 Public Health Service Act, relating to the ban 

22 on pre-existing conditions exclusions. 

23 ‘‘(4) NO FEES TO BROKERS.—For purposes of 

24 paragraph (2), the condition described in this para25 graph is that health insurance coverage described in 


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1 such paragraph does not pay fees to insurance bro2 kers. 

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

5 for the residents of such States at the expense of the 

6 State. 

7 ‘‘(f) PROHIBITION AGAINST STEP THERAPY AND

8 PRIOR AUTHORIZATION.—Items and services covered 

9 under Medicare for America shall be covered without any 

10 need for any prior authorization determination and with11 out any limitation applied through the use of step therapy 

12 protocols. 

13 ‘‘SEC. 2204. PREMIUMS. 

14 ‘‘(a) IN GENERAL.— 

15 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

16 each individual enrolled for benefits under this title 

17 for a year shall pay monthly community-rated pre18 miums for such year in an amount determined by 

19 the Secretary in accordance with subsection (b). 

20 ‘‘(2) GRANDFATHERED MEDICARE BENE21 FICIARIES.—In the case of an individual enrolled 

22 under part B of title XVIII as of the date of the en23 actment of this part, the premium applied under this 

24 section for such individual for benefits under this 

25 title shall be the lesser of— 


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1 ‘‘(A) the premium otherwise applicable to 

2 such individual under such title XVIII if this 

3 title had not been enacted; or 

4 ‘‘(B) the premium that would be applied to 

5 such individual under this title without the ap6 plication of this paragraph. 

7 ‘‘(b) PREMIUM CONTRIBUTION BASED ON INCOME.— 

8 The amount of a monthly premium, with respect to a plan 

9 year (beginning with 2023), under this section shall be 

10 established by the Secretary in accordance with the fol11 lowing: 

12 ‘‘(1) Such premium shall be determined such 

13 that the collective premiums for the plan year are 

14 with respect to the costs of health benefits provided 

15 under this title for such year and related administra16 tive costs. 

17 ‘‘(2) Premiums shall vary by family composition 

18 only. 

19 ‘‘(3) Federal subsidies shall be provided to en20 sure that the premium shall be— 

21 ‘‘(A) zero in the case of an individual 

22 whose annual household income is below 200 

23 percent of the poverty line; 

24 ‘‘(B) determined by a linear sliding scale, 

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1 come is at least 200 percent of the poverty line, 

2 but not more than 600 percent of the poverty 

3 line; and 

4 ‘‘(C) no individual or household will pay 

5 more than 8 percent of adjusted gross monthly 

6 income toward such premium. 

7 ‘‘(4) For an individual whose employer will be 

8 making a firm-wide contribution under this title in 

9 lieu of offering employer-sponsored insurance (as 

10 specified in section 126(b)(1)(B) of the Medicare for 

11 America Act), such individual shall pay a premium 

12 in accordance with this subsection. 

13 ‘‘(5) For an individual who has opted out of 

14 their employer-sponsored insurance in order to enroll 

15 in Medicare for America as specified in section 

16 126(c) of such Act, the individual shall pay the less17 er of— 

18 ‘‘(A) the premium described in this sub19 section; or 

20 ‘‘(B) the amount owed after the amount of 

21 employer contribution (as specified in section 

22 126(b)(1)(B) of the Medicare for America Act) 

23 is subtracted from the premium established by 

24 the Secretary of Health and Human Services as 

25 described in paragraph (1), whichever is less. 


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1 ‘‘(c) DEPOSITS.—Amounts paid under this section for 

2 coverage under this title shall be deposited in the Treasury 

3 to the credit of the Trust Fund established under section 

4 2206. 

5 ‘‘(d) APPEALS FOR CERTAIN MEDICARE GRAND6 FATHERED POPULATION.—In calculating premiums for 

7 purposes of subsection (a)(2): 

8 ‘‘(1) Any individual that was subject to a late 

9 enrollment penalty under part B of title XVIII shall 

10 have the right to appeal the assessment of the pen11 alty for good faith enrollment mistakes. 

12 ‘‘(2) The Secretary, in consultation with the 

13 Commissioner of Social Security, shall develop and 

14 publish a formal application for requesting an action 

15 of the Secretary under paragraph (1) to correct or 

16 eliminate the effects of an error, misrepresentation, 

17 or inaction described in such paragraph and deter18 mine and publish specific timelines for timely resolu19 tion of such a request. 

20 ‘‘(3) The Secretary shall also require that all 

21 such determinations with respect to such requests 

22 shall be reached within 15 business days of the sub23 mission of such application. All determinations shall 

24 be in writing through a standard decision notice 


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1 which shall include an explanation of the reasons for 

2 the determination. 

3 ‘‘(4) The Commissioner of Social Security shall 

4 enter into contracts with independent review organi5 zations in accordance with this subsection for the 

6 purpose of reviewing and determining individual ap7 peals of determinations under paragraph (3) with re8 spect to an application relating to enrollment under 

9 part A or part B. 

10 ‘‘(5) An individual who receives an adverse de11 termination under paragraph (3) may appeal to an 

12 independent review organization designated by the 

13 Commission. Any such appeal must be sent to the 

14 independent review organization within 90 days of 

15 the date the individual received the determination to 

16 be eligible for review. The independent review orga17 nization shall review and reach a determination of 

18 the review in writing within 45 days of the receipt 

19 of any such appeal. 

20 ‘‘(6) The Secretary of the Treasury may not 

21 enter into a contract under paragraph (4) with an 

22 independent review organization— 

23 ‘‘(A) unless the organization has staff that 

24 has the appropriate knowledge of, and experi25 ence with, the eligibility and coordination of 


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1 benefits rules and regulations under this title; 

2 and 

3 ‘‘(B) to the extent the organization is a fis4 cal intermediary under section 1816, a carrier 

5 under section 1842, or a Medicare administra6 tive contractor under section 1874A. 

7 ‘‘(7) The Secretary shall provide for access by 

8 independent review organizations conducting appeal 

9 determinations under this subsection, to the data10 base of the Coordination of Benefits Contractor of 

11 the Centers for Medicare & Medicaid Services as 

12 necessary in order to conduct the duties of such or13 ganizations to determine appeals pursuant to this 

14 subsection. 

15 ‘‘SEC. 2205. PAYMENT OF BENEFITS; COST-SHARING; OUT16 OF-POCKET LIMITS. 

17 ‘‘(a) PAYMENT OF BENEFITS; COST-SHARING.— 

18 There shall be paid, in the case of each individual who 

19 is enrolled under Medicare for America and incurs ex20 penses for items and services with respect to which bene21 fits are payable under this part, subject to subsection (c), 

22 80 percent of the reimbursement rates established pursu23 ant to section 2206 for such items and services, except 

24 that for the following services, the amounts paid under 

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1 ment rates established pursuant to section 2206 for such 

2 items and services: 

3 ‘‘(1) USPTF recommended preventive and 

4 chronic disease services. 

5 ‘‘(2) Long-term services and supports. 

6 ‘‘(3) Generic drugs, and prescription drugs if 

7 medically necessary. 

8 ‘‘(4) All services for individuals who are medi9 cally frail or otherwise have special medical needs, 

10 (including children with serious emotional disturb11 ance and adults with serious mental illness), individ12 uals with chronic substance use disorders, or individ13 uals with serious and complex medical conditions 

14 (such as epilepsy and HIV), individuals with a phys15 ical, intellectual or developmental disability that sig16 nificantly impairs their ability to perform one or 

17 more activities of daily living. 

18 ‘‘(5) Pregnancy related services. 

19 ‘‘(6) Emergency services. 

20 ‘‘(7) Services for children under age 21. 

21 The Secretary shall establish a default monthly payment 

22 plan under the Medicare for America benefits package to 

23 ensure the payment owed by the individual enrolled under 

24 Medicare for America is spread-out evenly throughout the 

25 year. 


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1 ‘‘(b) DEDUCTIBLE.—There shall be no deductible 

2 under Medicare for America. 

3 ‘‘(c) MAXIMUM OUT-OF-POCKET LIMIT.— 

4 ‘‘(1) IN GENERAL.—The coverage under Medi5 care shall provide benefits, after the eligible indi6 vidual has incurred out-of-pocket expenses for items 

7 and services with respect to which benefits are pay8 able under this part in a year equal to the annual 

9 out-of-pocket threshold specified in paragraph (2), 

10 with cost-sharing that is equal to $0. 

11 ‘‘(2) ANNUAL OUT-OF-POCKET THRESHOLD.— 

12 ‘‘(A) IN GENERAL.—For purposes of para13 graph (1), subject to subparagraphs (B) and 

14 (C), the annual out-of-pocket threshold speci15 fied in this paragraph is a threshold that shall 

16 be determined on a linear sliding scale for 

17 household income that is at least 200 percent of 

18 the poverty line, but not more than 600 percent 

19 of the poverty line, and that shall not exceed— 

20 ‘‘(i) with respect to an individual, 

21 $3,500; or 

22 ‘‘(ii) with respect to a household, 

23 $5,000. 

24 Individuals or households with income above 

25 600 percent of the Federal poverty line shall 


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1 have their annual out-of-pocket threshold 

2 capped at $3,500 and $5,000 respectively. 

3 ‘‘(B) INDEXING.—In the case of plan years 

4 beginning after 2021, the threshold described in 

5 subparagraph (A) (as in effect for the preceding 

6 plan year after application of this subpara7 graph) shall be increased by the percentage in8 crease over the previous year in the medical 

9 care expenditure category of the Consumer 

10 Price Index for All Urban Consumers (United 

11 States city average), published by the Bureau 

12 of Labor Statistics. 

13 ‘‘(C) EXCEPTION.—For purposes of para14 graph (1), the annual out-of-pocket threshold 

15 for individuals and households with annual in16 come below 200 percent of the Federal poverty 

17 line is $0. 

18 ‘‘(d) NO LIFETIME OR ANNUAL LIMITS.—There shall 

19 be no lifetime or annual limits for any services or benefits 

20 coverable under Medicare for America. 

21 ‘‘(e) NO BALANCE BILLING.—No provider may im22 pose a charge to an enrolled individual for coverable serv23 ices for which benefits are provided under this part in an 

24 amount higher than the reimbursement rate for such serv25 ices under section 2206 and may not impose a charge to 


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1 such individual for such service other than with respect 

2 to the other cost-sharing described in this section. 

3 ‘‘(f) NO PRIVATE CONTRACTING.—A health care pro4 vider or health care institution are prohibited from enter5 ing into a private contract with an individual enrolled 

6 under Medicare for America for any item or service 

7 coverable under Medicare for America. 

8 ‘‘(g) LIMITATIONS ON THE USE OF FLEXIBLE SAV9 INGS ACCOUNTS.—Flexible Savings Accounts shall only be 

10 used for benefits and services not covered by Medicare for 

11 America. 

12 ‘‘SEC. 2206. PROVIDERS NETWORK AND REIMBURSEMENT 

13 RATES. 

14 ‘‘(a) IN GENERAL.—The Secretary shall establish a 

15 rate schedule for reimbursing types of health care pro16 viders furnishing items and services under Medicare for 

17 America at rates that are consistent with subsection (b) 

18 and are necessary to maintain network adequacy. 

19 ‘‘(b) RATES.— 

20 ‘‘(1) IN GENERAL.—Except as provided in para21 graphs (2) and (3), the Secretary shall establish 

22 rates for benefits and services to be provided to 

23 health care providers and suppliers furnishing under 

24 Medicare for America based on rates that would be 

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1 justed) under title XVIII or title XIX, whichever is 

2 higher, for such type of health care providers and 

3 suppliers and item and service if such title remained 

4 in effect and, in the case of a type of provider and 

5 supplier or item or service coverable under Medicare 

6 for America but not otherwise coverable under title 

7 XVIII or title XIX, shall provide for rates that en8 sure adequate access to care. 

9 ‘‘(2) EXCEPTIONS.—For purposes of this sec10 tion, in applying paragraph (1) the Secretary shall 

11 ensure that rates to hospitals for inpatient services 

12 or outpatient services furnished under Medicare for 

13 America are at least 110 percent of such rates on 

14 average or in the aggregate for furnishing such inpa15 tient or outpatient services otherwise applied under 

16 title XVIII or title XIX, whichever is higher, except 

17 that for hospitals serving underserved areas as speci18 fied by the Secretary, such rates are increased as 

19 necessary to ensure adequate access to care. 

20 ‘‘(3) APPLICATION.—In applying rates under 

21 title XVIII and title XIX, as applicable, for purposes 

22 of this part, the following shall apply: 

23 ‘‘(A) The Secretary shall provide for site24 neutral payments for items and services fur25 nished in an outpatient hospital and physician 


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1 office, the rate of payment for such service shall 

2 be the same. 

3 ‘‘(B) The Secretary shall provide for a 

4 mechanism to provide payments for direct and 

5 indirect costs of graduate medical education 

6 programs without any cap on the number of 

7 residency positions for which payment may be 

8 made, including payments to hospitals for such 

9 programs and to eligible facilities for programs 

10 for population health-based residencies and for 

11 nurse practitioner post-licensure clinical train12 ing, residency, and fellowship programs. 

13 ‘‘(C) The Secretary shall increase the aver14 age relative value of primary care and other 

15 mental and behavioral health and cognitive 

16 services by not less than 30 percent in order to 

17 ensure adequate access to inpatient and out18 patient care. 

19 ‘‘(D) As a condition of participation in the 

20 program, participating providers shall accept 

21 Medicare for America rates paid by employer22 sponsored insurance plans and Medicare Advan23 tage for America plans. 

24 ‘‘(E) The Secretary shall semiannually re25 view if the rates paid by Medicare for America 


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1 are creating barriers to care. The Secretary 

2 shall have the authority to raise rates as nec3 essary to ensure adequate access to care. 

4 ‘‘(4) INCREASED FEDERAL MATCH FOR MED5 ICAID AND THE CHILDREN’S HEALTH INSURANCE

6 PROGRAM FOR YEARS 2023 THROUGH 2027.—The 

7 Secretary of Health and Human Services shall pay 

8 the difference between the Medicare for America 

9 rates and the Medicaid and CHIP rates during the 

10 period beginning on January 1, 2023, and ending on 

11 December 31, 2027. 

12 ‘‘(c) PARTICIPATING PROVIDERS.— 

13 ‘‘(1) IN GENERAL.—A health care provider that 

14 is a participating provider of services or supplier 

15 under the Medicare program under title XVIII or 

16 the Medicaid program under title XIX on the date 

17 of enactment of this title shall remain a partici18 pating provider for Medicare for America. 

19 ‘‘(2) ADDITIONAL PROVIDERS.—The Secretary 

20 shall establish a process to allow health care pro21 viders not described in paragraph (1) to become par22 ticipating providers for Medicare for America. 

23 ‘‘(d) PRESCRIPTION DRUGS.— 

24 ‘‘(1) IN GENERAL.—Notwithstanding any other 

25 provision of law, the Secretary shall, for plan years 


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1 beginning on or after the date of the enactment of 

2 this title, negotiate with pharmaceutical manufactur3 ers the prices (including discounts, rebates, and 

4 other price concessions) that may be charged to 

5 Medicare for America and MA for America organiza6 tions during a negotiated price period (as specified 

7 by the Secretary) for covered drugs for Medicare for 

8 America enrollees. In negotiating such prices under 

9 this section, the Secretary shall take into account 

10 the following factors: 

11 ‘‘(A) The comparative clinical effectiveness 

12 and cost effectiveness, when available from an 

13 impartial source, of such drug. 

14 ‘‘(B) The budgetary impact of providing 

15 coverage of such drug. 

16 ‘‘(C) The number of similarly effective 

17 drugs or alternative treatment regimens for 

18 each approved use of such drug. 

19 ‘‘(D) The associated financial burden on 

20 patients that utilize such drug. 

21 ‘‘(E) The associated unmet patient need 

22 for such drug. 

23 ‘‘(F) The total revenues from global sales 

24 obtained by the manufacturer for such drug 


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1 and the associated investment in research and 

2 development of such drug by the manufacturer. 

3 ‘‘(2) FINALIZATION OF NEGOTIATED PRICE.— 

4 The negotiated price of each covered drug for a ne5 gotiated price period shall be finalized not later than 

6 30 days before the first plan year in such negotiated 

7 price period. 

8 ‘‘(3) COMPETITIVE LICENSING AUTHORITY.— 

9 ‘‘(A) IN GENERAL.—Notwithstanding any 

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

11 505(j)(5)(F) of the Federal Food, Drug, and 

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

13 505(c)(3)(E) of such Act, section 351(k)(7)(A) 

14 of the Public Health Service Act, or section 

15 527(a) of the Federal Food, Drug, and Cos16 metic Act, or by an extension of such exclusivity 

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

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

19 provides for market exclusivity (or extension of 

20 market exclusivity) with respect to a drug, in 

21 the case that the Secretary is unable to success22 fully negotiate an appropriate price for a cov23 ered drug for a negotiated price period, the Sec24 retary shall authorize the use of any patent, 

25 clinical trial data, or other exclusivity granted 


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1 by the Federal Government with respect to such 

2 drug as the Secretary determines appropriate 

3 for purposes of manufacturing such drug for 

4 sale under Medicare for America. Any entity 

5 making use of a competitive license to use pat6 ent, clinical trial data, or other exclusivity 

7 under this section shall provide to the manufac8 turer holding such exclusivity reasonable com9 pensation, as determined by the Secretary 

10 based on the following factors: 

11 ‘‘(i) The risk-adjusted value of any 

12 Federal Government subsidies and invest13 ments in research and development used to 

14 support the development of such drug. 

15 ‘‘(ii) The risk-adjusted value of any 

16 investment made by such manufacturer in 

17 the research and development of such 

18 drug. 

19 ‘‘(iii) The impact of the price, includ20 ing license compensation payments, on 

21 meeting the medical need of all patients. 

22 ‘‘(iv) The relationship between the 

23 price of such drug, including compensation 

24 payments, and the health benefits of such 

25 drug. 


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1 ‘‘(v) Other relevant factors determined 

2 appropriate by the Secretary to provide 

3 reasonable compensation. 

4 ‘‘(B) REASONABLE COMPENSATION.—The 

5 manufacturer described in subparagraph (A) 

6 may seek recovery against the United States in 

7 the United States Court of Federal Claims. 

8 ‘‘(C) INTERIM PERIOD.— 

9 ‘‘(i) IN GENERAL.—Until 1 year after 

10 a drug described in subparagraph (A) is 

11 approved under section 505(j) of the Fed12 eral Food, Drug, and Cosmetic Act or sec13 tion 351(k) of the Public Health Service 

14 Act and is provided under license issued by 

15 the Secretary under such subparagraph, 

16 Medicare for America shall not pay more 

17 for such drug than the average of the 

18 prices available, during the most recent 12- 

19 month period for which data is available 

20 prior to the beginning of such negotiated 

21 price period, from the manufacturer to any 

22 wholesaler, retailer, provider, health main23 tenance organization, nonprofit entity, or 

24 governmental entity in the ten OECD (Or25 ganization for Economic Cooperation and 


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1 Development) countries that have the larg2 est gross domestic product with a per cap3 ita income that is not less than half the 

4 per capita income of the United States or 

5 the price established by the Prescription 

6 Drug and Medical Device Review Board 

7 established under title III of the Medicare 

8 for America Act of 2019. 

9 ‘‘(ii) FEDERAL PROGRAM LICENS10 ING.—If such drug is not made available 

11 at the price determined, the Secretary shall 

12 authorize such entities to use any patent, 

13 clinical trial data, or other exclusivity 

14 granted by the Federal Government with 

15 respect to such drug as the Secretary de16 termines appropriate for purposes of man17 ufacturing such drug for sale under any 

18 Federal program, including those provided 

19 by Medicare for America, Veterans Affairs, 

20 the Department of Defense, and the Coast 

21 Guard. 

22 ‘‘(D) AUTHORIZATION FOR SECRETARY TO

23 PROCURE DRUGS DIRECTLY.— 

24 ‘‘(i) IN GENERAL.—The Secretary 

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1 ant to a competitive license under subpara2 graph (A) for purposes of this part or pur3 suant to a Federal program license under 

4 subparagraph (C)(ii) for purposes of a 

5 Federal program directly from the entity 

6 manufacturing the drug pursuant to such 

7 a license. 

8 ‘‘(ii) CLARIFICATION REGARDING AP9 PLICATION OF BUY AMERICAN ACT.—In 

10 the case where the Secretary procures a 

11 drug under this subparagraph, the provi12 sions of chapter 83 of title 41, United 

13 States Code (commonly referred to as the 

14 ‘Buy American Act’), shall apply. 

15 ‘‘(E) PRIORITY FOR U.S. MANUFACTURERS

16 IN AUTHORIZING COMPETITIVE LICENSES.—In 

17 authorizing a competitive license under this 

18 paragraph, the Secretary— 

19 ‘‘(i) shall give preference to entities 

20 that the Secretary determines have the 

21 highest safety and security standards; and 

22 ‘‘(ii) may give priority to entities that 

23 will manufacture such drug in the United 

24 States. 


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1 ‘‘(4) FDA REVIEW OF LICENSED DRUG APPLI2 CATIONS.—The Secretary shall prioritize review of 

3 applications under section 505(j) of the Federal 

4 Food, Drug, and Cosmetic Act for drugs licensed 

5 under paragraph (3)(A). 

6 ‘‘(5) PROHIBITION OF ANTICOMPETITIVE BE7 HAVIOR.—No drug manufacturer may engage in 

8 anticompetitive behavior with another manufacturer 

9 that may interfere with the issuance and implemen10 tation of a competitive license or run contrary to 

11 public policy. 

12 ‘‘(6) REQUIRED REPORTING.—The Secretary 

13 may require pharmaceutical manufacturers to dis14 close to the Secretary such information that the Sec15 retary determines necessary for purposes of carrying 

16 out this subsection. 

17 ‘‘(7) CLARIFICATION.—Nothing in this sub18 section shall be construed as preventing Medicare for 

19 America obtaining a discount or reduction of the 

20 price for a covered drug below the price negotiated 

21 by the Secretary. 

22 ‘‘(8) VALUE OR COST-EFFECTIVENESS ASSESS23 MENTS.—The use of Quality-Adjusted Life Years, 

24 Disability-Adjusted Life Years, or other similar 

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1 fectiveness assessments for purposes of this sub2 section. 

3 ‘‘(9) CLARIFICATION.—There shall be no for4 mulary under Medicare for America. 

5 ‘‘SEC. 2207. TRUST FUND; FUNDING. 

6 ‘‘(a) TRUST FUND.—There shall be established a uni7 fied Medicare Trust Fund in which funds provided under 

8 this title are deposited and from which expenditures under 

9 this title are made. The Trust Fund shall consist of such 

10 gifts and bequests as may be made and such amounts as 

11 may be deposited in, or appropriated to, such Trust Fund 

12 as provided in this Act. 

13 ‘‘(b) FUNDING.— 

14 ‘‘(1) TAXES.—There are hereby appropriated to 

15 the Trust Fund for each fiscal year beginning with 

16 fiscal year 2023, out of any moneys in the Treasury 

17 not otherwise appropriated, amounts equivalent to 

18 100 percent of the net increase in revenues to the 

19 Treasury which is attributable to the amendments 

20 made by title II of the Medicare for America Act 

21 and premiums collected under this title. The 

22 amounts appropriated by the preceding sentence 

23 shall be transferred from time to time (but not less 

24 frequently than monthly) from the general fund in 

25 the Treasury to the Trust Fund, such amounts to be 


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1 determined on the basis of estimates by the Sec2 retary of the Treasury of the taxes paid to or depos3 ited into the Treasury; and proper adjustments shall 

4 be made in amounts subsequently transferred to the 

5 extent prior estimates were in excess of or were less 

6 than the amounts that should have been so trans7 ferred. 

8 ‘‘(2) CURRENT PROGRAM RECEIPTS.—Notwith9 standing any other provision of law, there are hereby 

10 appropriated to the Trust Fund for each fiscal year, 

11 beginning with fiscal year 2023, the amounts that 

12 would otherwise have been appropriated to carry out 

13 the following programs: 

14 ‘‘(A) The Medicare program under title 

15 XVIII. 

16 ‘‘(B) The Medicaid program under title 

17 XIX, beginning as of 2027. 

18 ‘‘(3) ADDITIONAL APPROPRIATIONS.—Addi19 tional sums are authorized to be appropriated annu20 ally as needed to maintain maximum quality, effi21 ciency, and access under this part. 

22 ‘‘(4) MEDICAID MAINTENANCE OF EFFORT PAY23 MENTS.—There shall be transferred to the Trust 

24 Fund the maintenance of effort payments made 

25 under section 2209. 


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1 ‘‘(c) RESTRICTIONS SHALL NOT APPLY.—Any other 

2 provision of law in effect on the date of enactment of this 

3 title restricting the use of Federal funds for any reproduc4 tive health service, including abortion, shall not apply to 

5 monies in the Trust Fund. 

6 ‘‘(d) INCORPORATION OF PROVISIONS.—The provi7 sions of subsections (b) through (i) of section 1817 shall 

8 apply to the Trust Fund under this section in the same 

9 manner as such provisions applied to the Federal Hospital 

10 Insurance Trust Fund under such section 1817, except 

11 that, for purposes of applying such subsections to this sec12 tion, the ‘Board of Trustees of the Trust Fund’ shall mean 

13 the ‘Secretary’. 

14 ‘‘(e) TRANSFER OF FUNDS.—Any amounts remain15 ing in the Federal Hospital Insurance Trust Fund under 

16 section 1817 or the Federal Supplementary Medical Insur17 ance Trust Fund under section 1841 after the payment 

18 of claims for items and services furnished under title 

19 XVIII have been completed, shall be transferred into the 

20 Trust Fund under this section. 

21 ‘‘SEC. 2208. ADMINISTRATIVE PROVISIONS. 

22 ‘‘(a) CENTER FOR HEALTH CARE.—Beginning 2023, 

23 the Centers for Medicare & Medicaid Services shall be re24 named the Center for Health Care and all references in 

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1 erence to such Center. All powers, duties, and responsibil2 ities of the Centers for Medicare & Medicaid Services shall 

3 be transferred to the Center for Health Care. 

4 ‘‘(b) AUTHORITY.—The Secretary shall have the au5 thority to issue interim final rules with respect to any pro6 vision in this part. 

7 ‘‘(c) ADMINISTRATIVE LAW JUDGES.— 

8 ‘‘(1) IN GENERAL.—The Center for Health 

9 Care is not authorized to appoint administrative law 

10 judges, in accordance with pages 11420 through 

11 11499 of title 70 of the Federal Register (March 8, 

12 2005). 

13 ‘‘(2) TIMING.—Under this title, administrative 

14 law judges must issue a decision within 90 days of 

15 receipt of a hearing request, as specified in sub16 sections (a) and (c) of section 405.1016 of title 2, 

17 Code of Federal Regulations. 

18 ‘‘(d) COVERAGE DETERMINATIONS APPEALS.— 

19 ‘‘(1) Individuals may appeal a coverage deter20 mination under this title before the individual ob21 tains the service or item that is the subject of the 

22 appeal. Individuals shall continue to receive the serv23 ice or item if an appeal is filed before the provision 

24 of the service or item is terminated. 


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1 ‘‘(2) The Secretary shall eliminate the redeter2 mination by a Medicare administrative contractor 

3 from the appeals process under the Medicare pro4 gram for beneficiaries. 

5 ‘‘(e) PRIVATE RIGHT OF ACTION.— 

6 ‘‘(1) IN GENERAL.—An applicant or recipient 

7 denied a right conferred by this title may bring a 

8 civil action seeking any remedy available in law or 

9 equity to remedy that violation. State courts and 

10 district courts of the United States shall have con11 current jurisdiction of such actions. 

12 ‘‘(2) RIGHT DEFINED.—Rights are created by 

13 any provision of this title that— 

14 ‘‘(A) prescribes, establishes, or confers a 

15 benefit or protection in favor of the individual 

16 or individuals seeking to enforce the provision; 

17 or 

18 ‘‘(B) prescribes, establishes, or imposes a 

19 duty or obligation on a person or entity to act 

20 or conduct operations in a manner that benefits 

21 the individual or individuals seeking to enforce 

22 the provision. 

23 ‘‘(3) REASONABLE ATTORNEY FEES.—In any 

24 action or proceeding to enforce this title, the court 

25 may award reasonable attorneys’ fees and litigation 


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1 costs (including expert fees) reasonably incurred 

2 against the defendant or defendants. 

3 ‘‘(4) APPEAL.—Any civil action brought under 

4 this section shall be subject to appeal as provided in 

5 sections 1291 and 1292 of title 28 of the United 

6 States Code. 

7 ‘‘(5) CONTINUED APPLICATION OF OTHER

8 LAWS.—Nothing in this title (or an amendment 

9 made by this title) shall be construed to invalidate 

10 or limit the rights, remedies, procedures, or legal 

11 standards available to individuals aggrieved under 

12 section 1979 of the Revised Statutes (42 U.S.C. 

13 1983), or to supersede State laws causes of action. 

14 ‘‘(f) NON-DISCRIMINATION.— 

15 ‘‘(1) IN GENERAL.—Except as otherwise pro16 vided for in this title, an individual shall not, on the 

17 ground prohibited under title VI of the Civil Rights 

18 Act of 1964 (42 U.S.C. 2000d et seq.), title IX of 

19 the Education Amendments of 1972 (20 U.S.C. 

20 1681 et seq.), the Age Discrimination Act of 1975 

21 (42 U.S.C. 6101 et seq.), section 504 of the Reha22 bilitation Act of 1973 (29 U.S.C. 794), or section 

23 1557 of the Affordable Care Act (42 U.S.C. 18116), 

24 be excluded from participation in, be denied the ben25 efits of, or be subjected to discrimination under, any 


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1 health program or activity, any part of which is re2 ceiving Federal financial assistance, including cred3 its, subsidies, or contracts of insurance, or under 

4 any program or activity that is administered by an 

5 Executive Agency or any entity established under 

6 this title (or amendments) or any employer-spon7 sored insurance. The enforcement mechanisms pro8 vided for and available under such title VI, title IX, 

9 section 794, Age Discrimination Act, or such section 

10 1557 shall apply for purposes of violations of this 

11 subsection. 

12 ‘‘(2) CONTINUED APPLICATION OF LAWS.— 

13 Nothing in this title (or an amendment made by this 

14 title) shall be construed to invalidate or limit the 

15 rights, remedies, procedures, or legal standards 

16 available to individuals aggrieved under title VI of 

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

18 seq.), title VII of the Civil Rights Act of 1964 (42 

19 U.S.C. 2000e et seq.), title IX of the Education 

20 Amendments of 1972 (20 U.S.C. 1681 et seq.), sec21 tion 504 of the Rehabilitation Act of 1973 (29 

22 U.S.C. 794), the Age Discrimination Act of 1975 

23 (42 U.S.C. 611 et seq.), or section 1557 of the Af24 fordable Care Act (42 U.S.C. 18116) or to super25 sede State laws that provide additional protections 


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1 against discrimination on any basis described in 

2 paragraph (1). 

3 ‘‘(3) HEALTH CARE PROVIDERS.—Health care 

4 providers may not be prohibited from participating 

5 in the Medicare for America for reasons other than 

6 their ability to provide covered services. Health care 

7 providers and institutions are prohibited from deny8 ing covered individuals access to covered benefits 

9 and services because of their religious objections. 

10 This subsection supercedes any provision of law that 

11 allows for conscience protection. 

12 ‘‘(4) REGULATIONS.—The Secretary may pro13 mulgate regulations to implement this subsection. 

14 ‘‘SEC. 2209. MAINTENANCE OF EFFORT REQUIREMENT. 

15 ‘‘(a) IN GENERAL.—A State is not eligible for pay16 ment under any program specified in subsection (c) for 

17 a calendar quarter in a plan year beginning after 2027 

18 unless the State makes to the Secretary for transfer to 

19 the unified Medicare Trust Fund under section 2207 the 

20 maintenance of effort payment applicable to such State 

21 and plan year under subsection (b). The Secretary shall 

22 extend such a waiver (including the availability of Federal 

23 financial participation under such waiver) for such period 

24 as may be required for a State to meet the requirement 

25 of the previous sentence. 


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1 ‘‘(b) MAINTENANCE OF EFFORT PAYMENTS.—For 

2 purposes of this section, a maintenance of effort payment 

3 with respect to a State and plan year is— 

4 ‘‘(1) for plan year 2028 and a State, a payment 

5 in an amount equal to the total amount of expendi6 tures of the State for medical assistance under title 

7 XIX and child health assistance under title XXI in8 cluding administrative costs for the plan year before 

9 the date of the enactment of this title; 

10 ‘‘(2) for plan year 2029 and each subsequent 

11 plan year before plan year 2033— 

12 ‘‘(A) in the case of a State that is a 

13 PPACA expansion State, the payment amount 

14 applied under this subsection for the previous 

15 plan year, increased by growth in GDP per cap16 ita plus 0.4 percent; and 

17 ‘‘(B) in the case of a State that is not a 

18 PPACA expansion State, the payment amount 

19 applied under this subsection for the previous 

20 plan year, increased by growth in GDP per cap21 ita plus 0.7 percent; and 

22 ‘‘(3) beginning in 2033, for each subsequent 

23 plan year, with respect to any State, the payment 

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1 vious year, increased by growth in GDP per capita 

2 plus 0.7 percent. 

3 ‘‘(c) PROGRAMS SPECIFIED.—For purposes of this 

4 section, the programs specified in this subsection are each 

5 of the following: 

6 ‘‘(1) Block grants for community mental health 

7 services under subpart I of part B of title XIX of 

8 the Public Health Service Act. 

9 ‘‘(2) Block grants and programs for social serv10 ices and elder justice under title XX. 

11 ‘‘(3) Maternal and child health services block 

12 grants under title V. 

13 ‘‘(4) Block grants for prevention and treatment 

14 of substance abuse under subpart II of part B of 

15 title XIX of the Public Health Service Act. 

16 ‘‘(5) State Targeted Response to Opioid Crisis 

17 Grant Community Services Block Grant. 

18 ‘‘(6) Grants under section 330 of the Public 

19 Health Service Act. 

20 ‘‘(7) Ryan White HIV/AIDS Program grants 

21 under title XXVI of the Public Health Service Act. 

22 ‘‘SEC. 2210. APPLICATION OF TITLE XVIII PROVISIONS. 

23 ‘‘Except as specified otherwise in this title, in imple24 menting Medicare for America, the Secretary shall to the 

25 greatest extent practicable apply the following provisions 


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1 of title XVIII to the program under this title, benefits cov2 ered under this title, individuals entitled to benefits under 

3 this title, and providers of services and suppliers partici4 pating under the program under this title in a similar 

5 manner as such provisions applied to the program under 

6 title XVIII, benefits covered under such title, individuals 

7 entitled to benefits or enrolled under such title, and pro8 viders of services and suppliers participating under the 

9 program under such title: 

10 ‘‘(1) Section 1801. 

11 ‘‘(2) Section 1805. 

12 ‘‘(3) Section 1806. 

13 ‘‘(4) Section 1807. 

14 ‘‘(5) Section 1809. 

15 ‘‘(6) Section 1814. 

16 ‘‘(7) Section 1815. 

17 ‘‘(8) Section 1816. 

18 ‘‘(9) Section 1818. 

19 ‘‘(10) Section 1818A. 

20 ‘‘(11) Section 1819. 

21 ‘‘(12) Section 1820. 

22 ‘‘(13) Section 1834. 

23 ‘‘(14) Section 1834A. 

24 ‘‘(15) Section 1843. 

25 ‘‘(16) Section 1846. 


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1 ‘‘(17) Section 1847. 

2 ‘‘(18) Section 1851. 

3 ‘‘(19) Section 1852. 

4 ‘‘(20) Section 1855. 

5 ‘‘(21) Section 1856. 

6 ‘‘(22) Section 1857. 

7 ‘‘(23) Section 1858. 

8 ‘‘(24) Section 1861. 

9 ‘‘(25) Section 1863. 

10 ‘‘(26) Section 1864. 

11 ‘‘(27) Section 1866B. 

12 ‘‘(28) Section 1866C. 

13 ‘‘(29) Section 1866E. 

14 ‘‘(30) Section 1867. 

15 ‘‘(31) Section 1868. 

16 ‘‘(32) Section 1869. 

17 ‘‘(33) Section 1871. 

18 ‘‘(34) Section 1874A. 

19 ‘‘(35) Section 1880. 

20 ‘‘(36) Section 1881. 

21 ‘‘(37) Section 1881A. 

22 ‘‘(38) Section 1891. 

23 ‘‘(39) Section 1894. 

24 ‘‘(40) Section 1895. 

25 ‘‘(41) Section 1896. 


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1 ‘‘PART B—HOME AND COMMUNITY BASED LONG2 TERM SERVICES AND SUPPORTS 

3 ‘‘SEC. 2231. HOME AND COMMUNITY BASED LONG-TERM 

4 SERVICES AND SUPPORTS BENEFIT. 

5 ‘‘All individuals enrolled under Medicare for America 

6 under this title shall have coverage for home and commu7 nity based long-term services and supports benefits. Noth8 ing in this part shall be construed to limit an enrollee’s 

9 entitlement to any other benefit that is covered pursuant 

10 to section 2203, including nursing facility benefits. 

11 ‘‘SEC. 2232. ELIGIBILITY. 

12 ‘‘(a) ELIGIBLE INDIVIDUALS.—An individual who is 

13 eligible for home and community based long-term services 

14 and supports benefits under this part is an individual who 

15 satisfies each of the following: 

16 ‘‘(1) The individual is eligible for Medicare for 

17 America. 

18 ‘‘(2) The individual is determined by a licensed 

19 health care practitioner to be unable to perform, 

20 without substantial assistance, at least one Activity 

21 of Daily Living as described in section 

22 7702B(c)(2)(B) of the Internal Revenue Code of 

23 1986, or to require substantial assistance with one 

24 or more of the following areas: 

25 ‘‘(A) Communication. 

26 ‘‘(B) Social interaction. 


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1 ‘‘(C) Learning. 

2 ‘‘(D) Self-care. 

3 ‘‘(E) Self-management. 

4 ‘‘(F) Impairments that affect the person’s 

5 capacity for social or economic participation. 

6 ‘‘(b) CLARIFICATION.—Under this part, in the case 

7 of an individual described in subsection (a) who experi8 ences periods in which their functional capacity changes 

9 or improves, such individual shall continue to have access 

10 to benefits under this part as needed. If such an individ11 ual’s functional capacity improves to a point in which the 

12 individual no longer requires home and community based 

13 long-term services and supports, or requires fewer serv14 ices, the individual shall be able to immediately and 

15 seamlessly resume receiving all needed services if and 

16 when their functional needs recur. Eligibility for services 

17 shall be maintained if, without the services, the individual 

18 would have reduced functional capacity. When assessing 

19 functional impairment, the individual will be assessed 

20 without regard to any current services or the ameliorative 

21 effects of other mitigating measures described in section 

22 3(4)(E)(i)(I) of the Americans With Disabilities Act of 

23 1990. 

24 ‘‘(c) BENEFITS.— 


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1 ‘‘(1) DEFINITION.—For purposes of this title, 

2 the term ‘home and community based long-term 

3 services and supports benefit’ means the daily living 

4 supports needed by eligible individuals in order to 

5 live, work, and participate in their communities, and 

6 includes all home and community based services and 

7 supports coverable as of the date of the enactment 

8 of this title, under any State plan or waiver under 

9 title XIX, including— 

10 ‘‘(A) home health aides and homemakers; 

11 ‘‘(B) direct support professionals and per12 sonal attendant care services; 

13 ‘‘(C) hospice; 

14 ‘‘(D) nursing care; 

15 ‘‘(E) medical social services; 

16 ‘‘(F) care coordination, including case 

17 management, fiscal intermediary, and support 

18 brokerage services; 

19 ‘‘(G) short-term inpatient care, including 

20 respite care and care for pain control; 

21 ‘‘(H) behavioral health home and commu22 nity based long-term services and supports, in23 cluding assertive community treatment; peer 

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1 cluding case management; supported employ2 ment; and supported housing wraparound; 

3 ‘‘(I) private-duty nursing; 

4 ‘‘(J) respite services provided in the indi5 vidual’s home or broader community; and 

6 ‘‘(K) transitional services to support an in7 dividual’s transition from an institutional set8 ting to the community. 

9 ‘‘(2) NON-APPLICATION.—The provisions of sec10 tions 424.22(a)(1)(i) and 424.22(a)(1)(ii) of title 42 

11 of the Code of Federal Regulations does not apply 

12 in the case of the benefit described in paragraph 

13 (1)(A). 

14 ‘‘(d) HOME AND COMMUNITY BASED LONG-TERM

15 SERVICES AND SUPPORTS WORKFORCE DEVELOP16 MENT.— 

17 ‘‘(1) IN GENERAL.—The Secretary shall ensure 

18 that the number of individuals in the home and com19 munity based long-term services and supports work20 force is adequate to ensure community integration 

21 for all beneficiaries under Medicare for America. In 

22 so doing, the Secretary may consider a wide range 

23 of factors, including payment rates for direct care 

24 workers, career pipelines and credentialing, worker 

25 rights, and the impact of national labor policies. 


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1 ‘‘(2) SELF-DIRECTED MODEL.—All eligible indi2 viduals shall be defaulted into a self-directed care 

3 option (as defined by the Secretary). The Secretary 

4 must consult with eligible individuals, caregivers, 

5 workers and their representatives, including unions, 

6 and state entities responsible for administering the 

7 LTSS benefit to establish this model. 

8 ‘‘(3) COMMUNITY FIRST.—The benefit under 

9 this part shall be arranged for and provided with a 

10 community first presumption and eligible individuals 

11 shall be provided home and community based long12 term services and support available under this sec13 tion, regardless of type or level of disability or serv14 ice need. No eligible individual may be referred to an 

15 institution without first being offered and, if chosen, 

16 provided home and community based long-term serv17 ices and supports. Individuals in an institution on 

18 the effective date of the bill, and at least annually 

19 or upon any change in condition thereafter, shall be 

20 informed of, and if chosen, provided with home and 

21 community based long-term services and supports. 

22 ‘‘(e) ADMINISTRATION OF SERVICES AND SUP23 PORTS.—State entities responsible for administering home 

24 and community based long-term services and support ben25 efits under any State plan or waiver under title XIX as 


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1 of the date of the enactment of this title shall continue 

2 to administer the benefits and services coverable under 

3 this section. 

4 ‘‘(f) COORDINATION WITH OTHER FEDERAL BENE5 FITS.— 

6 ‘‘(1) RULE OF CONSTRUCTION.—Nothing in 

7 this part shall be construed as prohibiting benefits 

8 paid under this part from being used to compensate 

9 a caregiver who provides community living assistance 

10 services and supports to a dependent relative for 

11 providing community living assistance services and 

12 supports to an eligible individual under this part. 

13 ‘‘(2) DEPENDENT RELATIVE DEFINED.—The 

14 term ‘dependent relative’ means a child, grandchild, 

15 niece, nephew, parent, grandparent, sibling, aunt, or 

16 uncle (of such caregiver or his or her spouse or do17 mestic partner); such caregiver’s spouse or domestic 

18 partner, if such child, grandchild, niece, nephew, 

19 parent, grandparent, sibling, aunt, uncle, spouse, or 

20 domestic partner is an eligible individual. 

21 ‘‘(3) SUPPLEMENT NOT SUPPLANT.—Benefits 

22 received under this part by a caregiver shall supple23 ment, but not supplant, other benefits for which the 

24 individual is eligible under any other federally fund25 ed program that provides benefits or assistance. 


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1 ‘‘(4) DISREGARD.—The benefit paid under this 

2 part shall be disregarded for purposes of deter3 mining or continuing the eligibility of the individual 

4 or the spouse of the individual for receipt of benefits 

5 under any other Federal, State, or locally funded as6 sistance program, including benefits paid under title 

7 II or XVI, under the laws administered by the Sec8 retary of Veterans Affairs, under low-income hous9 ing assistance programs, under the supplemental nu10 trition assistance program established under the 

11 Food and Nutrition Act of 2008, or under programs 

12 administered by State vocational rehabilitation agen13 cies. 

14 ‘‘(5) REGULATIONS.—Not later than one year 

15 after the date of the enactment of this section, the 

16 Secretary shall promulgate such regulations as are 

17 necessary to carry out this part and to prevent fraud 

18 and abuse with respect to the benefits under this 

19 part. 

20 ‘‘PART C—MEDICARE ADVANTAGE FOR AMERICA 

21 ‘‘SEC. 2221. ALL PRIVATE PLANS. 

22 ‘‘(a) IN GENERAL.—For plan years beginning with 

23 plan year 2023, a health insurance issuer may offer health 

24 insurance coverage in the individual market only if such 


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1 issuer has entered into a contract with the Secretary 

2 under subsection (b) to offer such coverage. 

3 ‘‘(b) AGREEMENTS.—The Secretary shall enter into 

4 an agreement with an MA for America sponsor to offer 

5 MA for America plans under this part for the coverage 

6 of individuals enrolled under Medicare for America who 

7 elect to receive benefits under part A through such a plan. 

8 ‘‘(c) MA FOR AMERICA PLAN; MA FOR AMERICA

9 SPONSOR.—For purposes of this part: 

10 ‘‘(1) MA FOR AMERICA PLAN.—An MA for 

11 America plan is a Medicare Advantage plan under 

12 part C of title XVIII, except such plan shall provide 

13 coverage for individuals enrolled under Medicare for 

14 America under part A of this title, with respect to 

15 at least the benefits covered under such part A. 

16 ‘‘(2) MA FOR AMERICA SPONSOR.—An MA for 

17 America sponsor is a sponsor of an MA for America 

18 plan. 

19 ‘‘SEC. 2222. APPLICATION OF MEDICARE ADVANTAGE PRO20 VISIONS. 

21 ‘‘For purposes of applying this part, except as other22 wise specified under this part, the provisions of part C 

23 of title XVIII, as in effect as of the date of the enactment 

24 of this title shall apply with respect to an MA for America 

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1 erage under this part, individuals enrolled under such 

2 plan, and benefits covered under part A in a similar man3 ner and to a similar extent as such provisions applied to 

4 an MA organization, MA plan, individuals eligible for 

5 under part C of such title, individuals enrolled under an 

6 MA plan, and benefits covered under fee-for-service Medi7 care as of such date. 

8 ‘‘SEC. 2223. MEDICARE ADVANTAGE FOR AMERICA PAY9 MENT RATES. 

10 ‘‘The rates for Medicare Advantage for America 

11 plans shall be equal to the rates paid by Medicare for 

12 America. The Administrator of the Center for Healthcare 

13 shall pay Medicare Advantage for America plans 95 per14 cent of average Medicare for America costs in each county. 

15 ‘‘SEC. 2224. SEPARATE PREMIUM FOR MEDICARE ADVAN16 TAGE FOR AMERICA PLANS FURNISHING 

17 SUPPLEMENTAL BENEFITS. 

18 ‘‘Nothing in this part shall preclude an individual 

19 from choosing a Medicare Advantage for America plan 

20 which requires the individual to pay an additional, sepa21 rate amount because of supplemental benefits or because 

22 it is a more expensive plan. In such case the individual 

23 enrolled under such plan would be responsible for a sepa24 rate monthly premium. 


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1 ‘‘SEC. 2225. PRESCRIPTION DRUG PRICING UNDER MEDI2 CARE ADVANTAGE FOR AMERICA PLANS. 

3 ‘‘Medicare Advantage for America plans, for prescrip4 tion drugs, shall pay no more than the price negotiated 

5 under Medicare for America. 

6 ‘‘SEC. 2226. BAN ON PAYING BROKERS’ FEES. 

7 ‘‘Medicare Advantage for America plans may not pay 

8 fees to insurance brokers. 

9 ‘‘SEC. 2227. CLARIFICATION ON MEDICARE ADVANTAGE EM10 PLOYER GROUP WAIVER PLANS AND THE 

11 MEDICARE SECONDARY PAYER REQUIRE12 MENT. 

13 ‘‘Such plans shall be exempt from the MSP Require14 ment, and nothing in this section shall be construed as 

15 prohibiting such plans from contributing to the payment 

16 of premiums and cost-sharing. 

17 ‘‘SEC. 2228. REFERENCES. 

18 ‘‘Beginning in 2023, all references in law and regula19 tion to Medicare Advantage shall be deemed a reference 

20 to Medicare Advantage for America.’’. 

21 SEC. 112. MODIFICATIONS TO AND COORDINATION WITH 

22 EXISTING FEDERAL HEALTH PROGRAMS. 

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

24 HEALTH INSURANCE PROGRAM (SCHIP).— 

25 (1) IN GENERAL.—Notwithstanding any other 

26 provision of law, subject to paragraphs (2) and (3) 


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1 and section 2202(c) of the Social Security Act, as 

2 added by section 111— 

3 (A) no benefits shall be available under 

4 title XVIII of the Social Security Act for any 

5 item or service furnished— 

6 (i) beginning on or after January 1, 

7 2023 (except in the case of an individual 

8 enrolled under such title and title XIX of 

9 such Act); and 

10 (ii) beginning on or after January 1, 

11 2025, with respect to all individuals, in12 cluding individuals enrolled under such 

13 title and title XIX of such Act; 

14 (B) no individual is entitled to medical as15 sistance under a State plan approved under 

16 title XIX of such Act— 

17 (i) for any item or service furnished 

18 on or after January 1, 2025, in the case 

19 of an individual enrolled under such title 

20 and title XVIII of the Social Security Act 

21 or an individual described in subclause 

22 (VIII) of section 1902(a)(10)(A)(i); and 

23 (ii) for any item or service furnished 

24 on or after January 1, 2027; 


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1 (C) no individual is entitled to medical as2 sistance under a State child health plan under 

3 title XXI of such Act for any item or service 

4 furnished on or after January 1, 2025; and 

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

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

7 with respect to medical assistance or child 

8 health assistance— 

9 (i) for any item or service furnished 

10 on or after January 1, 2025, in the case 

11 of an individual enrolled under such title 

12 and title XVIII of the Social Security Act 

13 or an individual described in subclause 

14 (VIII) of section 1902(a)(10)(A)(i); and 

15 (ii) for any item or service furnished 

16 on or after January 1, 2027. 

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

19 continuous period of stay which began before Janu20 ary 1, 2025, for Medicare and 2027 for Medicaid or 

21 CHIP, and which had not ended as of such date, for 

22 which benefits are provided under title XVIII of the 

23 Social Security Act, under a State plan under title 

24 XIX of such Act, or under a State child health plan 

25 under title XXI such Act, the Secretary of Health 


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1 and Human Services shall provide for continuation 

2 of benefits under such title or plan until the end of 

3 the period of stay. 

4 (b) OTHER FEDERAL HEALTH PROGRAMS.— 

5 (1) FEDERAL EMPLOYEES HEALTH BENEFITS

6 PROGRAM.—Nothing in this Act, or the amendments 

7 made by this Act, shall affect benefits made avail8 able under chapter 89 of title 5, United States Code. 

9 (2) TRICARE.—Nothing in this Act, or the 

10 amendments made by this Act, shall affect benefits 

11 made available under sections 1079 and 1086 of 

12 title 10, United States Code. 

13 (3) TREATMENT OF BENEFITS FOR VETERANS

14 AND NATIVE AMERICANS.— 

15 (A) IN GENERAL.—Nothing in this Act, or 

16 the amendments made by this Act, shall affect 

17 the eligibility of veterans for the medical bene18 fits and services provided under title 38, United 

19 States Code, or of Indians for the medical bene20 fits and services provided by or through the In21 dian Health Service. 

22 (B) REEVALUATION.—No reevaluation of 

23 the Indian Health Service shall be undertaken 

24 without consultation with tribal leaders and 

25 stakeholders. 


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1 (C) SUPPLEMENTAL INDIAN HEALTH

2 SERVICES ALLOCATION.—The Secretary shall 

3 annually determine the need to provide an allot4 ment of supplemental funds to Indian Health 

5 Services, including payments to providers, 

6 health professional education, administrative ex7 penses, and prevention and public health activi8 ties. 

9 (4) ENROLLEE CHOICE.—Nothing in this Act 

10 shall preclude individuals enrolled in the Federal 

11 Employees Health Benefits Program or TRICARE 

12 or individuals receiving benefits provided under title, 

13 38, United States Code or the Indian Health Service 

14 from enrolling in Medicare for America. Enrollees 

15 shall be entitled to the employer contribution as es16 tablished under section 126(c) of such Act. 

17 (c) SUNSET OF PROVISIONS RELATED TO THE STATE

18 EXCHANGES.—Effective January 1, 2022, the Federal 

19 and State Exchanges established pursuant to title I of the 

20 Patient Protection and Affordable Care Act (Public Law 

21 111–148) shall terminate, and any other provision of law 

22 that relies upon participation in or enrollment through 

23 such an Exchange, including such provisions of the Inter24 nal Revenue Code of 1986, shall cease to have force or 

25 effect. 


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1 (d) SEVERABILITY.—Every provision in this Act and 

2 every application of the provisions in this Act are severable 

3 from each other as a matter of Federal law. If any applica4 tion of any provision in this Act to any person or group 

5 of persons or circumstances is found by a court to be in6 valid, the remainder of this Act and the application of the 

7 Act’s provisions to all other persons and circumstances 

8 may not be affected. 

9 Subtitle C—Targeted Reforms 

10 SEC. 121. NO SURPRISE BILLING. 

11 (a) SURPRISE BILL DEFINED.—For purposes of this 

12 section the term ‘‘surprise bill’’— 

13 (1) means a bill for health care services, other 

14 than emergency services, received by an insured for 

15 services rendered by an out-of-network health care 

16 provider, where such services were rendered by such 

17 out-of-network provider at an in-network facility, 

18 during a service or procedure performed by an in19 network provider or during a service or procedure 

20 previously approved or authorized by the health car21 rier and the insured did not knowingly elect to ob22 tain such services from such out-of-network provider; 

23 and 

24 (2) does not include a bill for health care serv25 ices received by an insured when an in-network 


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1 health care provider was available to render such 

2 services and the insured knowingly elected to obtain 

3 such services from another health care provider who 

4 was out-of-network. 

5 (b) No non-participating health care provider shall 

6 require prior authorization for rendering emergency serv7 ices to an insured. 

8 (c) No health carrier shall impose, for emergency 

9 services rendered to an insured by an out-of-network 

10 health care provider, a coinsurance, copayment, deductible 

11 or other out-of-pocket expense that is greater than the co12 insurance, copayment, deductible or other out-of-pocket 

13 expense that would be imposed if such emergency services 

14 were rendered by an in-network health care provider. 

15 (d) PAYMENT AMOUNT.—If emergency services were 

16 rendered to an insured by an out-of-network health care 

17 provider, such health care provider may bill the health car18 rier directly and the health carrier shall reimburse such 

19 health care provider the greatest of the following amounts: 

20 (1) The amount payable under Medicare for 

21 America for such services if rendered by a health 

22 care provider participating in Medicare for America. 

23 (2) The arbitrated amount between the quali24 fying health plan and the non-participating provider. 


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1 (e) Nothing in this section shall be construed to pro2 hibit the qualifying health plan and the non-participating 

3 health care provider from agreeing to a greater reimburse4 ment amount. 

5 (f) NON-EMERGENCY SERVICES.—With respect to a 

6 surprise bill, the following applies: 

7 (1) An individual enrolled in the qualifying 

8 health plan shall only be required to pay the applica9 ble coinsurance that would be imposed for such 

10 health care services if such services were rendered by 

11 a participating health care provider. 

12 (2) The qualifying health plan shall reimburse 

13 the non-participating health care provider or indi14 vidual enrolled in such health plan, as applicable, for 

15 health care services rendered at the qualifying health 

16 plane rate as payment in full, unless the health plan 

17 and the non-participating health care provider agree 

18 otherwise. 

19 (g) If health care services were rendered to an indi20 vidual enrolled in qualifying health coverage by a non-par21 ticipating health care provider and the qualifying health 

22 plan failed to inform such enrollee, if such enrollee was 

23 required to be informed, of the network status of such 

24 non-participating health care provider, the qualifying 

25 health plan shall not impose coinsurance expense that is 


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1 greater than the maximum out-of-pocket expense that 

2 would be imposed if such services were rendered by a 

3 qualifying health care provider. 

4 (h) EMERGENCY SERVICES.— 

5 (1) NO PRIOR AUTHORIZATION.—A health care 

6 provider not participating in Medicare for America 

7 may not require prior authorization for rendering 

8 emergency services to an individual enrolled under 

9 Medicare for America. 

10 (2) OUT-OF-POCKET EXPENSES.—A health care 

11 provider not participating in Medicare for America 

12 may not impose, for emergency services rendered to 

13 an individual enrolled in Medicare for America, a co14 insurance, copayment, or other out-of-pocket expense 

15 that is greater than the coinsurance or maximum 

16 out-of-pocket expense that would be imposed if such 

17 emergency services were rendered by a Medicare for 

18 America participating provider. 

19 (3) PAYMENT AMOUNT.—If emergency services 

20 are rendered to an individual enrolled in Medicare 

21 for America by a health care provider not partici22 pating in Medicare for America, such health care 

23 provider may bill Medicare for America directly and 

24 Medicare for America shall reimburse such health 

25 care provider the greatest of the following amounts: 


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1 (A) The amount payable under Medicare 

2 for America for such services if rendered by a 

3 health care provider participating in Medicare 

4 for America. 

5 (B) The arbitrated amount between the 

6 Secretary of Health and Human Services and 

7 the provider, determined by an arbitration proc8 ess established by the Secretary. 

9 (i) NON-EMERGENCY SERVICES.—With respect to a 

10 surprise bill, the following applies: 

11 (1) An individual enrolled in qualifying coverage 

12 (as defined in section 2202(b)(4)(B) of the Social 

13 Security Act) shall only be required to pay the appli14 cable coinsurance that would be imposed for such 

15 health care services if such services were rendered by 

16 a health care provider participating in Medicare for 

17 America. 

18 (2) The Secretary of Health and Human Serv19 ices shall reimburse the non-participating health 

20 care provider or individual enrolled in such health 

21 plan, as applicable, for health care services rendered 

22 at rate payable under Medicare for America as pay23 ment in full, unless the Secretary and the non-par24 ticipating health care provider agree otherwise. 


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1 (3) If health care services were rendered to an 

2 individual enrolled in Medicare for America by a 

3 health care provider not participating in Medicare 

4 for America and the Secretary of Health and 

5 Human Services failed to inform such enrollee, if 

6 such enrollee was required to be informed, of the 

7 network status of such non-participating health care 

8 provider, the Secretary shall not impose a coinsur9 ance expense that is greater than the maximum out10 of-pocket expense that would be imposed if such 

11 services were rendered by a provider participating in 

12 Medicare for America. 

13 SEC. 122. LIMITATION ON REMOVAL OF MEDICARE ADVAN14 TAGE PROVIDERS BY MA ORGANIZATIONS. 

15 (a) LIMITATION.—Section 1852(d) of the Social Se16 curity Act (42 U.S.C. 1395w–22(d)) is amended by adding 

17 at the end the following: 

18 ‘‘(7) LIMITATION ON REMOVAL OF PROVIDERS

19 FROM MA PLANS BY MA ORGANIZATIONS.— 

20 ‘‘(A) REMOVAL OF PROVIDERS WITH

21 CAUSE.—Beginning with plan year 2020, except 

22 as provided in subparagraph (C), an MA orga23 nization offering an MA plan may only remove 

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1 work of such plan if the organization has cause 

2 to remove such provider or supplier. 

3 ‘‘(B) CAUSE TO REMOVE PROVIDERS.— 

4 ‘‘(i) IN GENERAL.—An MA organiza5 tion offering an MA plan has cause to re6 move a provider of services or a supplier 

7 from a network of such plan if the Sec8 retary determines that the provider or sup9 plier is— 

10 ‘‘(I) medically negligent; 

11 ‘‘(II) in violation of any legal or 

12 contractual requirement applicable to 

13 the provider or supplier acting within 

14 the lawful scope of practice, including 

15 any participation or other requirement 

16 applicable to such provider or supplier 

17 under this title or under any contrac18 tual term for such plan; or 

19 ‘‘(III) otherwise unfit to furnish 

20 items and services in accordance with 

21 requirements of this title. 

22 ‘‘(ii) CONSIDERATION OF COST TO MA

23 ORGANIZATIONS.—For purposes of sub24 paragraph (A), cost to an MA organization 

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1 tion of a provider of services or supplier in 

2 a network of such plan does not constitute 

3 cause for the MA organization to remove 

4 such provider or supplier from the network 

5 mid-year, and such cost may not be consid6 ered as a factor in favor of a determination 

7 that such organization has cause to remove 

8 the provider. 

9 ‘‘(C) EXCEPTION.—With respect to each 

10 upcoming plan year, beginning with plan year 

11 2020 an MA organization offering an MA plan 

12 may only remove a provider of services or sup13 plier from a network of such plan for reasons 

14 not specified in subparagraph (B)(i) before the 

15 date that is 60 days before the first day of the 

16 annual coordinated election period for such plan 

17 year under section 1851(e)(3). 

18 ‘‘(D) NOTICE AND APPEAL PROCESS.— 

19 ‘‘(i) IN GENERAL.—Any removal of a 

20 provider of services or supplier from a net21 work of an MA plan may occur only after 

22 the completion of a fair notice and appeal 

23 process that the Secretary shall establish 

24 by regulation. Such process shall require 

25 the MA organization to provide to such 


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1 provider or supplier and to the Secretary 

2 an explanation of the reason or reasons for 

3 the removal. The Secretary shall make this 

4 information publicly available. 

5 ‘‘(ii) APPLICATION.— 

6 ‘‘(I) APPLICATION OF NEW PROC7 ESS.—In the case of a removal of a 

8 provider of services or supplier from a 

9 network of an MA plan occurring on 

10 or after the effective date published in 

11 a final rule for such fair notice and 

12 appeal process, such process shall 

13 apply in lieu of the process for the 

14 termination or suspension of a pro15 vider contract under section 

16 422.202(a) of title 42, Code of Fed17 eral Regulations. 

18 ‘‘(II) CONTINUATION OF OLD

19 PROCESS.—In the case of a removal of 

20 a provider of services or supplier from 

21 a network of an MA plan occurring 

22 before such effective date, the process 

23 for the termination or suspension of a 

24 provider contract under section 


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1 422.202(a) of title 42, Code of Fed2 eral Regulations, shall apply. 

3 ‘‘(E) PARTICIPANT NOTICE AND PROTEC4 TION.— 

5 ‘‘(i) NOTICE TO PARTICIPANTS OF

6 PROVIDER REMOVAL.—Not less than 60 

7 days before the date on which a provider 

8 of services or supplier is removed from a 

9 network of an MA plan, the MA organiza10 tion offering such plan shall provide writ11 ten notification of the removal to each in12 dividual enrolled in such plan receiving 

13 items or services from the provider or sup14 plier during the plan year in effect on the 

15 date of removal or during the previous 

16 plan year. Such notification shall include 

17 at the minimum— 

18 ‘‘(I) the names and telephone 

19 numbers of available in-network pro20 viders of services and suppliers offer21 ing items and services that are the 

22 same or similar to the items and serv23 ices offered by the removed provider 

24 or supplier; 


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1 ‘‘(II) information regarding the 

2 options available to an individual en3 rolled in such plan to request the con4 tinuation of medical treatment or 

5 therapy with the removed provider or 

6 supplier; and 

7 ‘‘(III) one or more customer serv8 ice telephone numbers that an indi9 vidual enrolled in such plan may ac10 cess to obtain information regarding 

11 changes to the network of the plan. 

12 ‘‘(ii) ANNUAL NOTICE OF CHANGE.— 

13 In addition to providing the notification of 

14 removal as required under clause (i), the 

15 MA organization offering such MA plan 

16 shall include such notification in the an17 nual notice of change for the MA plan for 

18 the upcoming plan year. 

19 ‘‘(iii) CONTINUITY OF CARE.—In any 

20 case in which a provider of services or sup21 plier is removed from a network of an MA 

22 plan, such plan shall ensure that the re23 moval satisfies the continuity of care re24 quirements under paragraph (1)(A) with 

25 respect to each individual enrolled in such 


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1 plan receiving items or services from the 

2 provider or supplier during the plan year 

3 in effect on the date of removal or during 

4 the previous plan year. 

5 ‘‘(F) RULE OF CONSTRUCTION.—Nothing 

6 in this paragraph shall be construed as affect7 ing the ability of a provider of services or sup8 plier to decline to participate in a network of an 

9 MA plan. 

10 ‘‘(8) TRANSPARENCY IN MEASURES USED BY

11 MA ORGANIZATIONS TO ESTABLISH OR MODIFY PRO12 VIDER NETWORKS.— 

13 ‘‘(A) IN GENERAL.—Beginning with plan 

14 year 2020, an MA organization offering an MA 

15 plan shall publish and make accessible the in16 formation described in subparagraph (B)— 

17 ‘‘(i) in the annual bid information 

18 submitted by the MA organization with re19 spect to the MA plan under section 1854; 

20 and 

21 ‘‘(ii) on the Internet Web Site for the 

22 MA plan. 

23 ‘‘(B) INFORMATION DESCRIBED.—The in24 formation described in this subparagraph is the 

25 following: 


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1 ‘‘(i) Information regarding the meas2 ures used by the MA organization to estab3 lish or modify the provider network of the 

4 MA plan, including measures of the quality 

5 and efficiency of providers. Such informa6 tion shall include the specifications, meth7 odology, and sample size of such measures. 

8 ‘‘(ii) Other information related to the 

9 establishment or modification of such pro10 vider network that the Secretary deter11 mines appropriate. 

12 ‘‘(C) LIMITATION.—The information de13 scribed in subparagraph (B) shall not include 

14 any individually identifiable information of any 

15 provider or supplier of services.’’. 

16 (b) ENFORCEMENT.— 

17 (1) SANCTIONS FOR NONCOMPLIANCE.—Section 

18 1857(g)(1) of the Social Security Act (42 U.S.C. 

19 1395w–27(g)(1)) is amended— 

20 (A) in subparagraph (J), by striking ‘‘or’’; 

21 (B) by redesignating subparagraph (K) as 

22 subparagraph (L); 

23 (C) by inserting after subparagraph (J) 

24 the following new subparagraph: 


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1 ‘‘(K) fails to comply with section 

2 1852(d)(7) or 1852(d)(8); or’’; and 

3 (D) in subparagraph (L) (as so redesig4 nated), by striking ‘‘through (J)’’ and inserting 

5 ‘‘through (K)’’. 

6 (2) SANCTIONS NOT APPLICABLE TO PART D.— 

7 Title XVIII of the Social Security Act is amended— 

8 (A) in section 1860D–12(b)(3)(E) (42 

9 U.S.C. 1395w–112(b)(3)(E)), by striking 

10 ‘‘paragraph (1)(F)’’ and inserting ‘‘paragraphs 

11 (1)(F) and (1)(K)’’; and 

12 (B) in section 1894(e)(6)(B) (42 U.S.C. 

13 1395eee(e)(6)(B)), by inserting ‘‘(other than 

14 paragraph (1)(K) of such section)’’ after 

15 ‘‘1857(g)(1)’’. 

16 (c) MEDICARE ADVANTAGE PLAN COMPARE TOOL.— 

17 Not later than one year after the date of enactment of 

18 this Act, the Secretary of Health and Human Services 

19 shall take such measures as are necessary to ensure that 

20 the Medicare Advantage Compare Tool takes into account 

21 the preferences and utilization needs of such individuals. 

22 SEC. 123. NETWORK ADEQUACY. 

23 (a) IN GENERAL.—Section 1852(d) of the Social Se24 curity Act (42 U.S.C. 1395w–22(d)) is amended by adding 

25 at the end the following: 


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1 ‘‘(9) NETWORK ADEQUACY REQUIREMENTS.— 

2 Beginning in plan year 2019, notwithstanding any 

3 other provision of law, the following shall apply: 

4 ‘‘(A) PROVIDER AVAILABILITY.—When es5 tablishing a plan network, a Medicare Advan6 tage organization offering an MA plan shall, 

7 among other factors determined by the Sec8 retary, consider the following: 

9 ‘‘(i) The anticipated enrollment in the 

10 plan. 

11 ‘‘(ii) The expected types of services 

12 provided and utilization of services by en13 rollees under the plan. 

14 ‘‘(iii) The number and types of pro15 viders needed to provide such services. 

16 ‘‘(iv) The number of network pro17 viders who are not accepting new patients. 

18 ‘‘(v) The location of providers and en19 rollees, taking into account geographic dis20 bursement. 

21 ‘‘(vi) The full-time equivalent avail22 ability of a provider to provide such serv23 ices. 

24 ‘‘(B) PROVISION OF CARE IN A TIMELY

25 MANNER.—A Medicare Advantage organization 


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1 offering an MA plan shall ensure that providers 

2 are able to provide services in a timely manner, 

3 as defined by the Secretary, under the plan. 

4 ‘‘(C) APPLICATION OF NETWORK ACCESS

5 ADEQUACY STANDARDS.—In applying the net6 work access adequacy standards pursuant to 

7 paragraph (1), the Secretary shall seek input 

8 from patient advocacy groups, providers of serv9 ices and suppliers, and MA plans under this 

10 part. 

11 ‘‘(D) CERTIFICATION.—Each plan year, a 

12 Medicare Advantage organization shall certify 

13 to the Secretary, with respect to each MA plan 

14 offered by the organization, that the providers, 

15 including specialists and subspecialists, in the 

16 plan network are able to provide the services re17 quired under the organization’s contract with 

18 the Secretary under section 1857 with respect 

19 to the offering of such plan and to meet the 

20 needs of the enrollees within the plan service 

21 area during the year. 

22 ‘‘(E) ANNUAL REPORTING.—Each plan 

23 year, a Medicare Advantage organization shall 

24 report to the Secretary, and make public the 


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1 following with respect to each MA plan offered 

2 by the organization: 

3 ‘‘(i) AVERAGE WAIT TIME.—The aver4 age wait time for primary and specialty 

5 care for enrollees under the plan. 

6 ‘‘(ii) UTILIZATION OF OUT OF NET7 WORK PROVIDERS.—The utilization of out8 of-network providers under the plan. 

9 ‘‘(iii) AVERAGE COST PER PATIENT.— 

10 The average annual spending per patient 

11 for primary and specialty care for enrollees 

12 under the plan. 

13 ‘‘(F) CERTIFICATION.—In advance of the 

14 annual, coordinated election period under sec15 tion 1851(e)(3), a Medicare Advantage organi16 zation shall certify to the Secretary the accu17 racy of provider directories for each plan of18 fered by the organization. 

19 ‘‘(G) NETWORK REVIEW.—The Secretary 

20 shall ensure that the network of each MA plan 

21 offered by a Medicare Advantage organization 

22 meets the network adequacy guidelines estab23 lished under this paragraph and under section 

24 422.112(a)(4) of title 42, Code of Federal Reg25 ulations (or any successor regulation to such 


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1 section) at least once every 3 years or when a 

2 material change in network occurs. 

3 ‘‘(H) AUTHORITY.—The Secretary shall 

4 have the authority to stop any further enroll5 ment in a Medicare Advantage plan if there is 

6 a pattern of excessive violations of this para7 graph.’’. 

8 (b) ENFORCEMENT.—Section 1857(g)(1)(K) of the 

9 Social Security Act (42 U.S.C. 1395w–27(g)(1)(K)), as 

10 added by section 2(b), is amended by striking ‘‘or 

11 1852(d)(8)’’ and inserting ‘‘, 1852(d)(8), or 1852(d)(9)’’. 

12 SEC. 124. ELIMINATING THE 24-MONTH WAITING PERIOD 

13 FOR MEDICARE COVERAGE FOR INDIVID14 UALS WITH DISABILITIES. 

15 (a) IN GENERAL.—Section 226(b) of the Social Secu16 rity Act (42 U.S.C. 426(b)) is amended— 

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

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

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

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

21 (3) in paragraph (2)(C)(ii), by striking ‘‘, in22 cluding the requirement that he has been entitled to 

23 the specified benefits for 24 months,’’; 

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

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


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1 (II) the twenty-fifth month of his entitlement or sta2 tus as a qualified railroad retirement beneficiary de3 scribed in paragraph (2), and’’ and inserting ‘‘for 

4 each month for which the individual meets the re5 quirements of paragraph (2), beginning with the 

6 month following the month in which the individual 

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

8 and 

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

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

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

12 (b) CONFORMING AMENDMENTS.— 

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

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

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

16 (h); and 

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

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

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

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

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

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

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

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


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1 is amended by striking ‘‘25th month of’’ and insert2 ing ‘‘month following the first month of’’. 

3 (4) RAILROAD RETIREMENT SYSTEM.—Section 

4 7(d)(2)(ii) of the Railroad Retirement Act of 1974 

5 (45 U.S.C. 231f(d)(2)(ii)) is amended— 

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

7 annuity’’ and inserting ‘‘is entitled to an annu8 ity’’; 

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

10 months’’; and 

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

12 for 24 calendar months, and’’. 

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

14 this section shall apply to insurance benefits under title 

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

16 services furnished in months beginning after the date of 

17 enactment of this Act. 

18 SEC. 125. ELIMINATING THE WAITING PERIOD FOR INDI19 VIDUALS ON STATE MEDICAID WAITING 

20 LISTS. 

21 The Secretary of Health and Human Services is ap22 propriated such sums as are necessary to facilitate enroll23 ment, not later than 90 days after the date of the enact24 ment of this Act, all eligible individuals who, as of the 


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1 date of the enactment of this Act, are on State Medicaid 

2 waiting lists or State Medicaid waiver waiting lists. 

3 SEC. 126. EMPLOYER HEALTH PLAN OPTIONS. 

4 (a) DEFINITION.—A qualifying employer-sponsored 

5 plan is— 

6 (1) a governmental plan (within the meaning of 

7 section 2791(d)(8) of the Public Health Service 

8 Act); or 

9 (2) any other plan or coverage that meets the 

10 criteria under subsection (b), includes vision, dental, 

11 and hearing benefits, and provides health coverage 

12 that is equivalent to an actuarial value of at least 80 

13 percent of the coverage provided under title XXII of 

14 the Social Security Act and makes a premium con15 tribution of at least 70 percent. 

16 Such plan shall require a premium contribution from the 

17 employer of at least 70 percent regardless of whether cov18 erage is for single, spousal, or dependent care. 

19 (b) OBLIGATION.—Large employers shall, with re20 spect to any full-time employee of such employer— 

21 (1) offer a qualifying employer-sponsored plan 

22 to such employee, in accordance with subsection (a); 

23 or 


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1 (2) make a contribution of 8 percent of their 

2 annual payroll to the Medicare Trust Fund under 

3 title XXII of the Social Security Act. 

4 (c) EMPLOYEE CHOICE.—An employee may opt out 

5 of a qualifying employer-sponsored plan as satisfied by 

6 subsection (b)(1) in order to enroll in Medicare for Amer7 ica. The employer shall make a contribution equal to the 

8 contribution it shall make in order to meet the require9 ments established by subsection (a)(1) or (a)(2). The Sec10 retary of Health and Human Services shall have authority 

11 to set standards for determining whether employers or in12 surers are undertaking any actions to affect the risk pool 

13 within Medicare for America by inducing individuals to de14 cline coverage under a qualifying employer-sponsored plan 

15 and instead to enroll in Medicare for America. An em16 ployer violating such standards shall be treated as not 

17 meeting the requirements of subsection (a). 

18 (d) EMPLOYEE EDUCATION ON HEALTH COVERAGE

19 OPTIONS.—Large employers shall disseminate to employ20 ees such publicly available information on coverage options 

21 under Medicare for America as the Secretary deems ap22 propriate, including contact information for assistance. 

23 (e) SPECIAL RULES.— 

24 (1) ANNUAL PAYROLL.—For purposes of this 

25 paragraph, the term ‘‘annual payroll’’ means, with 


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1 respect to any employer for any calendar year, the 

2 aggregate wages paid by the employer during such 

3 calendar year. 

4 (2) AGGREGATION RULES.—Related employers 

5 and predecessors shall be treated as a single em6 ployer for purposes of this subsection. 

7 (3) REDUCTION FOR PART-TIME EMPLOYEES.— 

8 In the case of a part-time employee, the employer 

9 contribution requirements of paragraph (1) shall be 

10 treated as satisfied if the employer contribution with 

11 respect to such employee is not less than the part12 time employment ratio of the contribution required 

13 under paragraph (1). 

14 (4) RULES RELATED TO PART-TIME EMPLOY15 MENT.—For purposes of this subsection— 

16 (A) PART-TIME EMPLOYEE.—The term 

17 ‘‘part-time employee’’ means, with respect to 

18 any month, an employee who works on average 

19 fewer than 30 hours per week. 

20 (B) PART-TIME EMPLOYMENT RATIO.— 

21 The term ‘‘part-time employment ratio’’ means, 

22 with respect to a part-time employee of an em23 ployer in a month, a fraction— 


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1 (i) the numerator of which is the 

2 number of hours in the employee’s normal 

3 work week; and 

4 (ii) the denominator of which is 30 

5 hours. 

6 (C) SPECIAL RULES.—Under rules pre7 scribed by the Secretary of Health and Human 

8 Services, in consultation with the Secretary of 

9 the Treasury, in the case of an employee for an 

10 employer whose defined work week for full-time 

11 employees is less than 30 hours, any reference 

12 in this subsection to 30 hours is deemed a ref13 erence to the number of hours in the work week 

14 so defined. 

15 (D) CONVERSION TO HOURS OF EMPLOY16 MENT.—The Secretary of Health and Human 

17 Services, in consultation with the Secretary of 

18 the Treasury, shall establish rules for the con19 version of compensation to hours of employ20 ment, for purposes of this subsection in the 

21 case of employees that receive compensation on 

22 a salaried basis, or on the basis of a commis23 sion, or other contingent or bonus basis, rather 

24 than based on an hourly wage. 


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1 (f) TIMING AND MANNER.—Each employer that 

2 makes a financial contribution under subsection (b)(2) 

3 and (c) under this section (other than with respect to cov4 erage under a group health plan) shall pay such contribu5 tion in a form and manner, specified by the Secretary of 

6 the Treasury, based upon the form and manner in which 

7 employer excise taxes are required to be paid under section 

8 3111 of the Internal Revenue Code of 1986. 

9 (g) NON-DISCRIMINATION.— 

10 (1) IN GENERAL.—Except as otherwise pro11 vided for in this title (or an amendment made by 

12 this title), an individual shall not, on the ground 

13 prohibited under title VI of the Civil Rights Act of 

14 1964 (42 U.S.C. 2000d et seq.), title IX of the Edu15 cation Amendments of 1972 (20 U.S.C. 1681 et 

16 seq.), the Age Discrimination Act of 1975 (42 

17 U.S.C. 6101 et seq.), or section 504 of the Rehabili18 tation Act of 1973 (29 U.S.C. 794), be excluded 

19 from participation in, be denied the benefits of, or 

20 be subjected to discrimination under, any health pro21 gram or activity, any part of which is receiving Fed22 eral financial assistance, including credits, subsidies, 

23 or contracts of insurance, or under any program or 

24 activity that is administered by an Executive Agency 


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1 or any entity established under this title (or amend2 ments) or any employer-sponsored insurance. 

3 (2) CONTINUED APPLICATION OF LAWS.—Noth4 ing in this title (or an amendment made by this 

5 title) shall be construed to invalidate or limit the 

6 rights, remedies, procedures, or legal standards 

7 available to individuals aggrieved under title VI of 

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

9 seq.), title VII of the Civil Rights Act of 1964 (42 

10 U.S.C. 2000e et seq.), title IX of the Education 

11 Amendments of 1972 (20 U.S.C. 1681 et seq.), sec12 tion 504 of the Rehabilitation Act of 1973 (29 

13 U.S.C. 794), or the Age Discrimination Act of 1975 

14 (42 U.S.C. 611 et seq.), or to supersede State laws 

15 that provide additional protections against discrimi16 nation on any basis described in paragraph (1). 

17 (3) LIMITATION.—A group health plan may not 

18 establish rules relating to the health insurance cov19 erage eligibility (including continued eligibility) or 

20 contribution requirements of any full-time employee 

21 under the terms of the plan that have the effect of 

22 discriminating in favor of higher-wage employees. 

23 (4) REGULATIONS.—The Secretary of Health 

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1 retary of Labor, may promulgate regulations to im2 plement this subsection. 

3 SEC. 127. PROHIBITION ON STEP THERAPY AND PRIOR AU4 THORIZATION UNDER GROUP HEALTH 

5 PLANS. 

6 Section 2719A of the Public Health Service Act (42 

7 U.S.C. 300gg–19a) is amended by adding at the end the 

8 following new subsection: 

9 ‘‘(e) PROHIBITION AGAINST STEP THERAPY AND

10 PRIOR AUTHORIZATION.—Beginning with the first plan 

11 year following the date of the enactment of this subsection, 

12 a group health plan may not require a prior authorization 

13 determination for coverage of any benefit under such plan 

14 and may not apply treatment limitations through the use 

15 of step therapy protocols.’’. 

16 SEC. 128. MEDICARE OUTPATIENT OBSERVATION SERV17 ICES. 

18 Section 1861(i) of the Social Security Act (42 U.S.C. 

19 1395x(i)) is amended by adding at the end the following: 

20 ‘‘For purposes of this subsection, an individual receiving 

21 outpatient observation services shall be deemed to be an 

22 inpatient during such period, and the date such individual 

23 ceases receiving such services shall be deemed the hospital 

24 discharge date (unless such individual is admitted as a 

25 hospital inpatient at the end of such period)’’. 


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1 SEC. 129. ABORTION COVERAGE. 

2 Notwithstanding any other provision of law, Federal 

3 funds may be used to provide for abortion services under 

4 any health program or activity. 

5 SEC. 130. APPLICABILITY OF MENTAL HEALTH PARITY. 

6 Section 2726 of the Public Health Service Act shall 

7 apply to all health coverage in the same manner and to 

8 the same extent as such section applies to health insurance 

9 issuers and group health plans under title XXVII of such 

10 Act. 

11 SEC. 131. STUDENT LOAN FORGIVENESS FOR HEALTH CARE 

12 PROVIDERS PARTICIPATING IN MEDICARE 

13 FOR AMERICA. 

14 (a) IN GENERAL.—Beginning on the date after the 

15 date of the enactment of this Act, after the conclusion of 

16 each plan year, the Secretary of Health and Human Serv17 ices, in conjunction with the Secretary of Education, shall 

18 cancel the applicable percent specified in subsection (b) 

19 of the total amount due on any eligible Federal Loan made 

20 20 years prior to date of enactment and any date after 

21 the date of enactment of this Act for a borrower who is 

22 a Medicare for America participating provider and sub23 mits an employment certification form described in sub24 section (d). 

25 (b) APPLICABLE PERCENT.—For purposes of sub26 section (a), the applicable percent is 10 percent of any 


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1 eligible Federal Loan for each year the health care pro2 vider participates in Medicare for America. 

3 (c) DEFINITIONS.—In this section: 

4 (1) ELIGIBLE FEDERAL LOAN.—The term ‘‘eli5 gible Federal loan’’ means any loan made under part 

6 D of title IV of the Higher Education Act of 1965 

7 (20 U.S.C. 1087a). 

8 (2) HEALTH CARE PROVIDER.—The term 

9 ‘‘health care provider’’ means a physician, physician 

10 assistant, registered nurse, nurse practitioner, ad11 vanced practice nurse, licensed practical nurse, psy12 chologist, mental health counselor, marriage and 

13 family therapist, direct care worker, health social 

14 worker, dentist, dental hygienist, pharmacist, phys15 ical therapist, occupational therapist, or any other 

16 health care provider specified by the Secretary of 

17 Health and Human Services if the Secretary deter18 mines such specification for purposes of this section 

19 is necessary to ensure workforce adequacy. 

20 (3) MEDICARE FOR AMERICA PARTICIPATING

21 PROVIDER.—The term ‘‘Medicare for America par22 ticipating provider’’ means a health care provider 

23 that meets the definition of such term under section 

24 105 or works at a participating provider or entity as 

25 defined under section 105. 


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1 (d) EMPLOYMENT CERTIFICATION FORM.— 

2 (1) IN GENERAL.—In order to receive loan can3 cellation under this paragraph, a borrower shall sub4 mit to the Secretary of Education an employment 

5 certification form that is developed by the Secretary 

6 of Education and includes self-certification of em7 ployment and a separate part for employer certifi8 cation that indicates the dates of employment. 

9 (2) DEFERMENT.—If a borrower submits to the 

10 Secretary of Education the employment certification 

11 form described in paragraph (1), during the period 

12 in which the borrower is employed as a Medicare for 

13 America participating provider for which loan can14 cellation is eligible under this section, the borrower’s 

15 eligible Federal Direct Loan shall be placed in 

16 deferment. 

17 (e) INTEREST CANCELED.—If a portion of a loan is 

18 canceled under this section for any year, the entire amount 

19 of interest on such loan that accrues for such year shall 

20 be canceled. 

21 (f) REGULATIONS.—The Secretary of Health and 

22 Human Services and Secretary of Education may promul23 gate regulations to implement this section. 


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1 SEC. 132. CLARIFICATION OF THE DEFINITION OF PEDI2 ATRIC MEDICAL NECESSITY IN QUALIFYING 

3 GROUP COVERAGE. 

4 (a) DEFINITION.—The following definition of pedi5 atric medical necessity shall be incorporated into benefit 

6 standards of all plans subject to the requirements of sec7 tion 1302 of the Patient Protection and Affordable Care 

8 Act (42 U.S.C. 18022) and all group plans by 2023. 

9 (b) DEVELOPMENT OF DEFINITION.—Pediatric med10 ical necessity, or pediatric medically necessary care, shall 

11 be defined as health care interventions that are evidence 

12 based, evidence informed, or based on consensus advisory 

13 opinion and that are recommended by recognized health 

14 care professionals, to promote optimal growth and devel15 opment in a child and to prevent, detect, diagnose, treat, 

16 ameliorate, or palliate the effects of physical, genetic, con17 genital, developmental, behavioral, or mental conditions, 

18 injuries, or disabilities. 

19 (c) UPDATES TO DEFINITION.—The Secretary of 

20 Health and Human Services, in consultation with experts 

21 in the field of pediatric care and key stakeholders, includ22 ing patient and family groups, shall review and update this 

23 definition on a biennial basis, consistent with up-to-date 

24 standards of pediatric healthcare practice that are based 

25 on— 


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1 (1) the views of pediatric healthcare providers 

2 and experts practicing in relevant clinical areas; 

3 (2) recommendations of medical-specialty soci4 eties, other pediatric healthcare provider organiza5 tions, and family and patient groups, and 

6 (3) credible scientific evidence published in 

7 peer-reviewed literature that is generally recognized 

8 by the relevant health care provider community. 

9 SEC. 133. SAFE STAFFING REQUIREMENTS. 

10 (a) MINIMUM DIRECT CARE REGISTERED NURSE

11 STAFFING REQUIREMENTS.—The Public Health Service 

12 Act (42 U.S.C. 201 et seq.) is amended by adding at the 

13 end the following new title: 

14 ‘‘TITLE XXXIV—MINIMUM DI15 RECT CARE REGISTERED 

16 NURSE STAFFING REQUIRE17 MENT 

18 ‘‘SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT. 

19 ‘‘(a) STAFFING PLAN.— 

20 ‘‘(1) IN GENERAL.—A hospital shall implement 

21 a staffing plan that— 

22 ‘‘(A) provides adequate, appropriate, and 

23 quality delivery of health care services and pro24 tects patient safety; and 


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1 ‘‘(B) is consistent with the requirements of 

2 this title. 

3 ‘‘(2) EFFECTIVE DATES.— 

4 ‘‘(A) IMPLEMENTATION OF STAFFING

5 PLAN.—Subject to subparagraph (B), the re6 quirements under paragraph (1) shall take ef7 fect on a date to be determined by the Sec8 retary, but not later than 1 year after the date 

9 of the enactment of this title. 

10 ‘‘(B) APPLICATION OF MINIMUM DIRECT

11 CARE REGISTERED NURSE-TO-PATIENT RA12 TIOS.—The requirements under subsection (b) 

13 shall take effect as soon as practicable, as de14 termined by the Secretary, but not later than— 

15 ‘‘(i) 2023; and 

16 ‘‘(ii) in the case of a hospital in a 

17 rural area (as defined in section 

18 1886(d)(2)(D) of the Social Security Act), 

19 2025. 

20 ‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE21 TO-PATIENT RATIOS.— 

22 ‘‘(1) IN GENERAL.—Except as provided in para23 graph (4) and other provisions of this section, a hos24 pital’s staffing plan shall provide that, at all times 

25 during each shift within a unit of the hospital, and 


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1 with a full complement of ancillary and support 

2 staff, a direct care registered nurse may be assigned 

3 to not more than the following number of patients 

4 in that unit: 

5 ‘‘(A) One patient in trauma emergency 

6 units. 

7 ‘‘(B) One patient in operating room units, 

8 provided that a minimum of 1 additional person 

9 serves as a scrub assistant in such unit. 

10 ‘‘(C) Two patients in critical care units, in11 cluding neonatal intensive care units, emer12 gency critical care and intensive care units, 

13 labor and delivery units, coronary care units, 

14 acute respiratory care units, postanesthesia 

15 units, and burn units. 

16 ‘‘(D) Three patients in emergency room 

17 units, pediatrics units, stepdown units, telem18 etry units, antepartum units, and combined 

19 labor, deliver, and postpartum units. 

20 ‘‘(E) Four patients in medical-surgical 

21 units, intermediate care nursery units, acute 

22 care psychiatric units, and other specialty care 

23 units. 

24 ‘‘(F) Five patients in rehabilitation units 

25 and skilled nursing units. 


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1 ‘‘(G) Six patients in postpartum (3 cou2 plets) units and well-baby nursery units. 

3 ‘‘(2) SIMILAR UNITS WITH DIFFERENT

4 NAMES.—The Secretary may apply minimum direct 

5 care registered nurse-to-patient ratios established in 

6 paragraph (1) for a hospital unit referred to in such 

7 paragraph to a type of hospital unit not referred to 

8 in such paragraph if such type of hospital unit pro9 vides a level of care to patients whose needs are 

10 similar to the needs of patients cared for in the hos11 pital unit referred to in such paragraph. 

12 ‘‘(3) APPLICATION OF RATIOS TO HOSPITAL

13 NURSING PRACTICE STANDARDS.— 

14 ‘‘(A) IN GENERAL.—A patient assignment 

15 may be included in the calculation of the direct 

16 care registered nurse-to-patient ratios required 

17 in this subsection only if care is provided by a 

18 direct care registered nurse and the provision of 

19 care to the particular patient is within that di20 rect care registered nurse’s competence. 

21 ‘‘(B) DEMONSTRATION OF UNIT-SPECIFIC

22 COMPETENCE.—A hospital shall not assign a di23 rect care registered nurse to a hospital unit un24 less that hospital determines that the direct 

25 care registered nurse has demonstrated current 


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1 competence in providing care in that unit, and 

2 has also received orientation to that hospital’s 

3 unit sufficient to provide competent care to pa4 tients in that unit. 

5 ‘‘(C) DUTIES OF THE ASSIGNED DIRECT

6 CARE REGISTERED NURSE.—Each patient shall 

7 be assigned to a direct care registered nurse 

8 who shall directly provide the assessment, plan9 ning, supervision, implementation, and evalua10 tion of the nursing care provided to the patient 

11 at least every shift and has the responsibility 

12 for the provision of care to a particular patient 

13 within his or her scope of practice. 

14 ‘‘(D) NURSE ADMINISTRATORS AND SU15 PERVISORS.—A registered nurse who is a nurse 

16 administrator, nurse supervisor, nurse manager, 

17 charge nurse, case manager, or any other hos18 pital administrator or supervisor, shall not be 

19 included in the calculation of the direct care 

20 registered nurse-to-patient ratio unless that 

21 nurse has a current and active direct patient 

22 care assignment and provides direct patient 

23 care in compliance with the requirements of this 

24 section, including competency requirements. 

25 The exemption in this subsection shall apply 


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1 only during the hours in which the individual 

2 registered nurse has the principal responsibility 

3 of providing direct patient care and has no ad4 ditional job duties as would a direct care reg5 istered nurse. 

6 ‘‘(E) OTHER PERSONNEL.—Other per7 sonnel may perform patient care tasks based on 

8 their training and demonstrated skill but may 

9 not perform or assist in direct care registered 

10 nurse functions unless authorized to do in ac11 cordance with State scope of practice laws and 

12 regulations. 

13 ‘‘(F) TEMPORARY NURSING PERSONNEL.— 

14 A hospital shall not assign any nursing per15 sonnel from temporary nursing agencies patient 

16 care to any hospital unit without such personnel 

17 having demonstrated competence on the as18 signed unit and received orientation to that hos19 pital’s unit sufficient to provide competent care 

20 to patients in that unit. 

21 ‘‘(G) ANCILLARY AND ADDITIONAL STAFF22 ING.—The need for additional staffing of direct 

23 care registered nurses, licensed vocational or 

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1 ants, or other licensed or unlicensed ancillary 

2 staff above the minimum registered nurse-to-pa3 tient ratios shall be based on the assessment of 

4 the individual patient’s nursing care require5 ment, the individual patient’s nursing care plan, 

6 and acuity level. 

7 ‘‘(4) RESTRICTIONS.— 

8 ‘‘(A) PROHIBITION AGAINST AVERAGING.— 

9 A hospital shall not average the number of pa10 tients and the total number of direct care reg11 istered nurses assigned to patients in a hospital 

12 unit during any 1 shift or over any period of 

13 time for purposes of meeting the requirements 

14 under this subsection. 

15 ‘‘(B) PROHIBITION AGAINST IMPOSITION

16 OF MANDATORY OVERTIME REQUIREMENTS.—A 

17 hospital shall not impose mandatory overtime 

18 requirements to meet the hospital unit direct 

19 care registered nurse-to-patient ratios required 

20 under this subsection. 

21 ‘‘(C) RELIEF DURING ROUTINE AB22 SENCES.—A hospital shall ensure that only a 

23 direct care registered nurse who has dem24 onstrated current competence to the hospital in 

25 providing care on a particular unit and has also 


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1 received orientation to that hospital’s unit suffi2 cient to provide competent care to patients in 

3 that unit may relieve another direct care reg4 istered nurse during breaks, meals, and other 

5 routine, expected absences from a hospital unit. 

6 ‘‘(D) APPLICATION OF DIRECT CARE REG7 ISTERED NURSE-TO-PATIENT RATIOS IN PA8 TIENT-ACUITY ADJUSTABLE UNITS.—Patients 

9 shall be cared for only on units or patient care 

10 areas where the direct care registered nurse-to11 patient ratios meet the level of intensity, type 

12 of care, and the individual requirements and 

13 needs of each patient. Notwithstanding para14 graph (2), hospitals that provide patient care in 

15 units or patient care areas that are acuity 

16 adaptable or acuity adjustable shall apply the 

17 direct care registered nurse-to-patient ratio re18 quired in this section for the highest patient 

19 acuity level or level of care in that unit or pa20 tient care area, and shall comply with all other 

21 requirements of this section. 

22 ‘‘(E) USE OF VIDEO MONITORS.—A hos23 pital shall not employ video monitors or any 

24 form of electronic visualization of a patient as 

25 a substitute for the direct observation required 


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1 for patient assessment by the direct care reg2 istered nurse or required for patient protection. 

3 Video monitors or any form of electronic visual4 ization of a patient shall not be included in the 

5 calculation of the direct care registered nurse6 to-patient ratio required in this subsection and 

7 shall not replace the requirement of paragraph 

8 (3)(D) that each patient shall be assigned to a 

9 direct care registered nurse who shall directly 

10 provide the assessment, planning, supervision, 

11 implementation, and evaluation of the nursing 

12 care provided to the patient at least every shift 

13 and have the responsibility for the provision of 

14 care to a particular patient within his or her 

15 scope of practice. 

16 ‘‘(F) USE OF OTHER TECHNOLOGY.—A 

17 hospital shall not employ technology that sub18 stitutes for the assigned registered nurse’s pro19 fessional judgment in assessment, planning, im20 plementation, and evaluation of care. 

21 ‘‘(5) ADJUSTMENT OF RATIOS.— 

22 ‘‘(A) IN GENERAL.—If necessary to protect 

23 patient safety, the Secretary may prescribe reg24 ulations that— 


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1 ‘‘(i) increase minimum direct care reg2 istered nurse-to-patient ratios under this 

3 subsection to reduce the number of pa4 tients that may be assigned to each direct 

5 care nurse; or 

6 ‘‘(ii) add minimum direct care reg7 istered nurse-to-patient ratios for units not 

8 referred to in paragraphs (1) and (2). 

9 ‘‘(B) CONSULTATION.—Such regulations 

10 shall be prescribed after consultation with af11 fected hospitals and registered nurses. 

12 ‘‘(6) ANCILLARY AND ADDITIONAL STAFFING.— 

13 ‘‘(A) IN GENERAL.—The Secretary may 

14 prescribe regulations requiring additional staff15 ing of direct care registered nurses, licensed vo16 cational or practice nurses, licensed psychiatric 

17 technicians, certified nursing or patient care as18 sistants, or other licensed or unlicensed ancil19 lary staff above the minimum registered nurse20 to-patient ratios that is based on the assess21 ment of the individual patient’s nursing care 

22 needs, the individual patient’s nursing care 

23 plan, and acuity level. 

24 ‘‘(B) CONSULTATION.—Such regulations 

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1 fected hospitals, registered nurses, and ancillary 

2 staff. 

3 ‘‘(7) RELATIONSHIP TO STATE-IMPOSED RA4 TIOS.—Nothing in this title shall preempt State 

5 standards that the Secretary determines to be as 

6 stringent as Federal requirements for a staffing plan 

7 established under this title. Minimum direct care 

8 registered nurse-to-patient ratios established under 

9 this subsection shall not preempt State requirements 

10 that the Secretary determines are as stringent as to 

11 Federal requirements for direct care registered 

12 nurse-to-patient ratios established under this title. 

13 ‘‘(8) EXEMPTION IN EMERGENCIES.—The re14 quirements established under this subsection shall 

15 not apply during a state of emergency if a hospital 

16 is requested or expected to provide an exceptional 

17 level of emergency or other medical services. If a 

18 hospital seeks to apply the exemption under this 

19 paragraph in response to a complaint filed against 

20 the hospital for a violation of the provisions of this 

21 title, the hospital must demonstrate that prompt and 

22 diligent efforts were made to maintain required 

23 staffing levels. The Secretary shall issue guidance to 

24 hospitals that describes situations that constitute a 

25 state of emergency for purposes of the exemption 


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1 under this paragraph and shall establish necessary 

2 penalties for violations of this paragraph consistent 

3 with section 3406. 

4 ‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF5 ING PLAN.— 

6 ‘‘(1) CONSIDERATIONS IN DEVELOPMENT OF

7 PLAN.—In developing the staffing plan, a hospital 

8 shall provide for direct care registered nurse-to-pa9 tient ratios above the minimum direct care reg10 istered nurse-to-patient ratios required under sub11 section (b) if appropriate based upon consideration 

12 of, at a minimum, the following factors: 

13 ‘‘(A) The number of patients on a par14 ticular unit on a shift-by-shift basis. 

15 ‘‘(B) The acuity level and nursing care 

16 plan of patients on a particular unit on a shift17 by-shift basis. 

18 ‘‘(C) The anticipated admissions, dis19 charges, and transfers of patients during each 

20 shift that impacts direct patient care. 

21 ‘‘(D) Specialized experience required of di22 rect care registered nurses on a particular unit. 

23 ‘‘(E) Staffing levels and services provided 

24 by licensed vocational or practical nurses, li25 censed psychiatric technicians, certified nurse 


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1 assistants, or other ancillary staff in meeting 

2 direct patient care needs not required by a di3 rect care registered nurse. 

4 ‘‘(F) The level of familiarity with hospital 

5 practices, policies, and procedures by temporary 

6 agency direct care registered nurses used dur7 ing a shift. 

8 ‘‘(G) Obstacles to efficiency in the delivery 

9 of patient care presented by physical layout. 

10 ‘‘(2) DOCUMENTATION OF STAFFING.—A hos11 pital shall specify the system used to document ac12 tual staffing in each unit for each shift. 

13 ‘‘(3) ANNUAL REEVALUATION OF PLAN.— 

14 ‘‘(A) IN GENERAL.—A hospital shall annu15 ally evaluate its staffing plan in each unit in re16 lation to actual patient care requirements. 

17 ‘‘(B) UPDATE.—A hospital shall update its 

18 staffing plan to the extent appropriate based on 

19 such evaluation. 

20 ‘‘(4) TRANSPARENCY.— 

21 ‘‘(A) IN GENERAL.—Any staffing plan or 

22 method used to create and evaluate acuity-level 

23 and adopted by a hospital under this section 

24 shall be transparent in all respects, including 

25 disclosure of detailed documentation of the 


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1 methodology used to determine nursing staff2 ing, identifying each factor, assumption, and 

3 value used in applying such methodology. 

4 ‘‘(B) PUBLIC AVAILABILITY.—The Sec5 retary shall establish procedures to provide that 

6 the documentation submitted under subsection 

7 (d) is available for public inspection in its en8 tirety. 

9 ‘‘(5) REGISTERED NURSE PARTICIPATION.—A 

10 staffing plan of a hospital— 

11 ‘‘(A) shall be developed and subsequent re12 evaluations shall be conducted under this sub13 section on the basis of input from direct care 

14 registered nurses at the hospital from each unit 

15 or patient care area; and 

16 ‘‘(B) where such nurses are represented 

17 through collective bargaining, shall require bar18 gaining with the applicable recognized or cer19 tified collective bargaining representative of 

20 such nurses. 

21 Nothing in this title shall be construed to permit 

22 conduct prohibited under the National Labor Rela23 tions Act or chapter 71 of title 5, United States 

24 Code. 


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1 ‘‘(6) STAFFING COMMITTEES.—If a hospital 

2 maintains a staffing committee, then the committee 

3 shall include at least one registered nurse from each 

4 hospital unit and shall be composed of at least 50 

5 percent direct care registered nurses. The staffing 

6 committee shall include meaningful representation of 

7 other direct care nonmanagement staff. Direct care 

8 registered nurses who serve on the committee shall 

9 be selected by other direct care registered nurses 

10 from their unit. Other direct care nonmanagement 

11 staff shall be selected by other direct care non12 management staff. Participation on staffing commit13 tees shall be considered a part of the employee’s reg14 ularly scheduled workweek. 

15 ‘‘(d) SUBMISSION OF PLAN TO SECRETARY.—A hos16 pital shall submit to the Secretary its staffing plan and 

17 any annual updates under subsection (c)(3)(B). A feder18 ally operated hospital may submit its staffing plan 

19 through the department or agency operating the hospital. 

20 ‘‘SEC. 3402. POSTING, RECORDS, AND AUDITS. 

21 ‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos22 pital shall post a uniform notice in a form specified by 

23 the Secretary in regulation that— 

24 ‘‘(1) explains requirements imposed under sec25 tion 3401; 


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1 ‘‘(2) includes actual direct care registered 

2 nurse-to-patient ratios during each shift; 

3 ‘‘(3) includes the actual number and titles of di4 rect care registered nurses assigned during each 

5 shift; and 

6 ‘‘(4) is visible, conspicuous, and accessible to 

7 staff, patients, and the public. 

8 ‘‘(b) RECORDS.— 

9 ‘‘(1) MAINTENANCE OF RECORDS.—Each hos10 pital shall maintain accurate records of actual direct 

11 care registered nurse-to-patient ratios in each unit 

12 for each shift for no less than 3 years. Such records 

13 shall include— 

14 ‘‘(A) the number of patients in each unit; 

15 ‘‘(B) the identity and duty hours of— 

16 ‘‘(i) each direct care registered nurse 

17 assigned to each patient in each unit in 

18 each shift; and 

19 ‘‘(ii) ancillary staff who are under the 

20 coordination of the direct care registered 

21 nurse; 

22 ‘‘(C) certification that each nurse received 

23 rest and meal breaks and the identity and duty 

24 hours of each direct care registered nurse who 

25 provided such relief; and 


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1 ‘‘(D) a copy of each notice posted under 

2 subsection (a). 

3 ‘‘(2) AVAILABILITY OF RECORDS.—Each hos4 pital shall make its records maintained under para5 graph (1) available to— 

6 ‘‘(A) the Secretary; 

7 ‘‘(B) registered nurses and their collective 

8 bargaining representatives (if any); and 

9 ‘‘(C) the public under regulations estab10 lished by the Secretary, or in the case of a fed11 erally operated hospital, under section 552 of 

12 title 5, United States Code (commonly known 

13 as the Freedom of Information Act). 

14 ‘‘(c) AUDITS.—The Secretary shall conduct periodic 

15 audits to ensure— 

16 ‘‘(1) implementation of the staffing plan in ac17 cordance with this title; and 

18 ‘‘(2) accuracy in records maintained under this 

19 section. 

20 ‘‘SEC. 3403. MINIMUM DIRECT CARE LICENSED PRACTICAL 

21 NURSE STAFFING REQUIREMENTS. 

22 ‘‘(a) ESTABLISHMENT.—A hospital’s staffing plan 

23 shall comply with minimum direct care licensed practical 

24 nurse staffing requirements that the Secretary establishes 

25 for units in hospitals. Such staffing requirements shall be 


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1 established not later than 18 months after the date of the 

2 enactment of this title, and shall be based on the study 

3 conducted under subsection (b). 

4 ‘‘(b) STUDY.—Not later than 1 year after the date 

5 of the enactment of this title, the Secretary, acting 

6 through the Director of the Agency for Healthcare Re7 search and Quality, shall complete a study of licensed 

8 practical nurse staffing and its effects on patient care in 

9 hospitals. The Director may contract with a qualified enti10 ty or organization to carry out such study under this para11 graph. The Director shall consult with licensed practical 

12 nurses and organizations representing licensed practical 

13 nurses regarding the design and conduct of the study. 

14 ‘‘(c) APPLICATION OF REGISTERED NURSE PROVI15 SIONS TO LICENSED PRACTICAL NURSE STAFFING RE16 QUIREMENTS.—Paragraphs (2), (4)(A), (4)(B), (4)(C), 

17 and (6) of section 3401(b), paragraphs (1), (2), (3), and 

18 (4) of section 3401(c), and section 3402 shall apply to 

19 the establishment and application of direct care licensed 

20 practical nurse staffing requirements under this section 

21 pursuant to the additional staffing requirements under 

22 subsection (b)(3)(G) of section 3401 and in the same man23 ner that they apply to the establishment and application 

24 of direct care registered nurse-to-patient ratios under sec25 tions 3401 and 3402. 


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1 ‘‘(d) EFFECTIVE DATE.—The requirements of this 

2 section shall take effect as soon as practicable, as deter3 mined by the Secretary, but not later than— 

4 ‘‘(1) 2 years after the date of the enactment of 

5 this title; and 

6 ‘‘(2) in the case of a hospital in a rural area 

7 (as defined in section 1886(d)(2)(D) of the Social 

8 Security Act), 4 years after the date of the enact9 ment of this title. 

10 ‘‘(e) STUDY.—Not later than 1 year after the date 

11 of the enactment of this title, the Secretary, acting 

12 through the Director of the Agency for Healthcare Re13 search and Quality shall complete a study of registered 

14 and practical nurse staffing requirements in clinics and 

15 other outpatient settings, and its effects on patient care 

16 in outpatient settings. The Director may contract with a 

17 qualified entity or organization to carry out such study 

18 under this subsection. The Director shall consult with reg19 istered nurses and licensed practice nurses working in out20 patient settings, including professional nursing associa21 tions and labor organizations representing both registered 

22 and practice nurses working in outpatient settings regard23 ing the design and conduct of the study. 


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1 ‘‘SEC. 3404. WHISTLEBLOWER AND PATIENT PROTECTIONS. 

2 ‘‘(a) PROFESSIONAL OBLIGATION AND RIGHTS.—All 

3 nurses have a duty and right to act based on their profes4 sional judgment in accordance with State nursing laws 

5 and regulations of the State in which the direct nursing 

6 care is being performed and to provide care in the exclu7 sive interests of the patients and to act as the patient’s 

8 advocate. 

9 ‘‘(b) ACCEPTANCE OF PATIENT CARE ASSIGN10 MENTS.—The nurse is responsible for providing com11 petent, safe, therapeutic, and effective nursing care to as12 signed patients. Before accepting a patient assignment, a 

13 nurse shall— 

14 ‘‘(1) have the necessary professional knowledge, 

15 judgment, skills, and ability to provide the required 

16 care; 

17 ‘‘(2) determine using professional judgment in 

18 accordance with State nursing laws and regulations 

19 of the State in which the direct nursing care is being 

20 performed whether the nurse is competent to per21 form the nursing care required; and 

22 ‘‘(3) determine whether acceptance of a patient 

23 assignment would expose the patient or nurse to risk 

24 of harm. 

25 ‘‘(c) OBJECTION TO OR REFUSAL OF ASSIGNMENT.— 

26 A nurse may object to, or refuse to participate in, any 


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1 activity, policy, practice, assignment, or task if in good 

2 faith— 

3 ‘‘(1) the nurse reasonably believes it to be in 

4 violation of section 3401 or 3403; or 

5 ‘‘(2) the nurse is not prepared by education, 

6 training, or experience to fulfill the assignment with7 out compromising the safety of any patient or jeop8 ardizing the license of the nurse. 

9 ‘‘(d) RETALIATION FOR OBJECTION TO OR REFUSAL

10 OF ASSIGNMENT BARRED.— 

11 ‘‘(1) NO DISCHARGE, DISCRIMINATION, OR RE12 TALIATION.—No hospital shall discharge, retaliate, 

13 discriminate, or otherwise take adverse action in any 

14 manner with respect to any aspect of a nurse’s em15 ployment (as defined in section 3407), including dis16 charge, promotion, compensation, or terms, condi17 tions, or privileges of employment, based on the 

18 nurse’s refusal of a work assignment under sub19 section (c). 

20 ‘‘(2) NO FILING OF COMPLAINT.—No hospital 

21 shall file a complaint or a report against a nurse 

22 with a State professional disciplinary agency because 

23 of the nurse’s refusal of a work assignment under 

24 subsection (c). 


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1 ‘‘(e) CAUSE OF ACTION.—Any nurse, collective bar2 gaining representative, or legal representative of any nurse 

3 who has been discharged, discriminated against, or retali4 ated against in violation of subsection (d)(1) or against 

5 whom a complaint or report has been filed in violation of 

6 subsection (d)(2) may (without regard to whether a com7 plaint has been filed under subsection (f) of this section 

8 or subsection (b) of section 3406) bring a cause of action 

9 in a United States district court. A nurse who prevails 

10 on the cause of action shall be entitled to one or more 

11 of the following: 

12 ‘‘(1) Reinstatement. 

13 ‘‘(2) Reimbursement of lost wages, compensa14 tion, and benefits. 

15 ‘‘(3) Attorneys’ fees. 

16 ‘‘(4) Court costs. 

17 ‘‘(5) Other damages. 

18 ‘‘(f) COMPLAINT TO SECRETARY.—A nurse, patient, 

19 collective bargaining representative, or other individual 

20 may file a complaint with the Secretary against a hospital 

21 that violates the provisions of this title. For any complaint 

22 filed, the Secretary shall— 

23 ‘‘(1) receive and investigate the complaint; 

24 ‘‘(2) determine whether a violation of this title 

25 as alleged in the complaint has occurred; and 


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1 ‘‘(3) if such a violation has occurred, issue an 

2 order that the complaining nurse or individual shall 

3 not suffer any discharge, retaliation, discrimination, 

4 or other adverse action prohibited by subsection (d) 

5 or subsection (h). 

6 ‘‘(g) TOLL-FREE TELEPHONE NUMBER.— 

7 ‘‘(1) IN GENERAL.—The Secretary shall provide 

8 for the establishment of a toll-free telephone hotline 

9 to provide information regarding the requirements 

10 under sections 3401 through 3403 and to receive re11 ports of violations of such section. 

12 ‘‘(2) NOTICE TO PATIENTS.—A hospital shall 

13 provide each patient admitted to the hospital for in14 patient care with the hotline described in paragraph 

15 (1), and shall give notice to each patient that such 

16 hotline may be used to report inadequate staffing or 

17 care. 

18 ‘‘(h) PROTECTION FOR REPORTING.— 

19 ‘‘(1) PROHIBITION ON RETALIATION OR DIS20 CRIMINATION.—A hospital shall not discriminate or 

21 retaliate in any manner against any patient, em22 ployee, or contract employee of the hospital, or any 

23 other individual, on the basis that such individual, in 

24 good faith, individually or in conjunction with an25 other person or persons, has presented a grievance 


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1 or complaint, or has initiated or cooperated in any 

2 investigation or proceeding of any governmental en3 tity, regulatory agency, or private accreditation 

4 body, made a civil claim or demand, or filed an ac5 tion relating to the care, services, or conditions of 

6 the hospital or of any affiliated or related facilities. 

7 ‘‘(2) GOOD FAITH DEFINED.—For purposes of 

8 this subsection, an individual shall be deemed to be 

9 acting in good faith if the individual reasonably be10 lieves— 

11 ‘‘(A) the information reported or disclosed 

12 is true; and 

13 ‘‘(B) a violation of this title has occurred 

14 or may occur. 

15 ‘‘(i) PROHIBITION ON INTERFERENCE WITH

16 RIGHTS.— 

17 ‘‘(1) EXERCISE OF RIGHTS.—It shall be unlaw18 ful for any hospital to— 

19 ‘‘(A) interfere with, restrain, or deny the 

20 exercise, or attempt to exercise, by any person 

21 of any right provided or protected under this 

22 title; or 

23 ‘‘(B) coerce or intimidate any person re24 garding the exercise or attempt to exercise such 

25 right. 


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1 ‘‘(2) OPPOSITION TO UNLAWFUL POLICIES OR

2 PRACTICES.—It shall be unlawful for any hospital to 

3 discriminate or retaliate against any person for op4 posing any hospital policy, practice, or actions which 

5 are alleged to violate, breach, or fail to comply with 

6 any provision of this title. 

7 ‘‘(3) PROHIBITION ON INTERFERENCE WITH

8 PROTECTED COMMUNICATIONS.—A hospital (or an 

9 individual representing a hospital) shall not make, 

10 adopt, or enforce any rule, regulation, policy, or 

11 practice which in any manner directly or indirectly 

12 prohibits, impedes, or discourages a direct care 

13 nurse from, or intimidates, coerces, or induces a di14 rect care nurse regarding, engaging in free speech 

15 activities or disclosing information as provided under 

16 this title. 

17 ‘‘(4) PROHIBITION ON INTERFERENCE WITH

18 COLLECTIVE ACTION.—A hospital (or an individual 

19 representing a hospital) shall not in any way inter20 fere with the rights of nurses to organize, bargain 

21 collectively, and engage in concerted activity under 

22 section 7 of the National Labor Relations Act (29 

23 U.S.C. 157). 


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1 ‘‘(j) NOTICE.—A hospital shall post in an appropriate 

2 location in each unit a conspicuous notice in a form speci3 fied by the Secretary that— 

4 ‘‘(1) explains the rights of nurses, patients, and 

5 other individuals under this section; 

6 ‘‘(2) includes a statement that a nurse, patient, 

7 or other individual may file a complaint with the 

8 Secretary against a hospital that violates the provi9 sions of this title; and 

10 ‘‘(3) provides instructions on how to file such a 

11 complaint. 

12 ‘‘(k) EFFECTIVE DATE.— 

13 ‘‘(1) REFUSAL; RETALIATION; CAUSE OF AC14 TION.— 

15 ‘‘(A) IN GENERAL.—Subsections (c) 

16 through (e) shall apply to objections and refus17 als occurring on or after the effective date of 

18 the provision of this title to which the objection 

19 or refusal relates. 

20 ‘‘(B) EXCEPTION.—Subsection (c)(2) shall 

21 not apply to objections or refusals in any hos22 pital before the requirements of section 3401(a) 

23 or 3403(a), as applicable, apply to that hos24 pital. 


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1 ‘‘(2) PROTECTIONS FOR REPORTING.—Sub2 section (h)(1) shall apply to actions occurring on or 

3 after the effective date of the provision to which the 

4 violation relates, except that such subsection shall 

5 apply to initiation, cooperation, or participation in 

6 an investigation or proceeding on or after the date 

7 of enactment of this title. 

8 ‘‘(3) NOTICE.—Subsection (j) shall take effect 

9 18 months after the date of enactment of this title. 

10 ‘‘SEC. 3405. ENFORCEMENT. 

11 ‘‘(a) IN GENERAL.—The Secretary shall enforce the 

12 requirements and prohibitions of this title in accordance 

13 with this section. 

14 ‘‘(b) PROCEDURES FOR RECEIVING AND INVES15 TIGATING COMPLAINTS.—The Secretary shall establish 

16 procedures under which— 

17 ‘‘(1) any person may file a complaint alleging 

18 that a hospital has violated a requirement or a pro19 hibition of this title; and 

20 ‘‘(2) such complaints shall be investigated by 

21 the Secretary. 

22 ‘‘(c) REMEDIES.—If the Secretary determines that a 

23 hospital has violated a requirement of this title, the Sec24 retary— 


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1 ‘‘(1) shall require the facility to establish a cor2 rective action plan to prevent the recurrence of such 

3 violation; and 

4 ‘‘(2) may impose civil money penalties, as de5 scribed in subsection (d). 

6 ‘‘(d) CIVIL PENALTIES.— 

7 ‘‘(1) IN GENERAL.—In addition to any other 

8 penalties prescribed by law, the Secretary may im9 pose civil penalties as follows: 

10 ‘‘(A) HOSPITAL LIABILITY.—The Secretary 

11 may impose on a hospital found to be in viola12 tion of this title a civil money penalty of— 

13 ‘‘(i) not more than $25,000 for the 

14 first knowing violation of this title by such 

15 hospital; and 

16 ‘‘(ii) not more than $50,000 for any 

17 subsequent knowing violation of this title 

18 by such hospital. 

19 ‘‘(B) INDIVIDUAL LIABILITY.—The Sec20 retary may impose on an individual who— 

21 ‘‘(i) is employed by a hospital found 

22 by the Secretary to have violated this title; 

23 and 

24 ‘‘(ii) knowingly violates this title, 


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1 a civil money penalty of not more than $20,000 

2 for each such violation by the individual. 

3 ‘‘(2) PROCEDURES.—The provisions of section 

4 1128A of the Social Security Act (other than sub5 sections (a) and (b)) shall apply with respect to a 

6 civil money penalty or proceeding under this sub7 section in the same manner as such provisions apply 

8 with respect to a civil money penalty or proceeding 

9 under such section 1128A. 

10 ‘‘(e) PUBLIC NOTICE OF VIOLATIONS.— 

11 ‘‘(1) INTERNET WEBSITE.—The Secretary shall 

12 publish on the internet website of the Department of 

13 Health and Human Services the names of hospitals 

14 on which a civil money penalty has been imposed 

15 under this section, the violation for which such pen16 alty was imposed, and such additional information 

17 as the Secretary determines appropriate. 

18 ‘‘(2) CHANGE OF OWNERSHIP.—With respect to 

19 a hospital that had a change of ownership, as deter20 mined by the Secretary, penalties imposed on the 

21 hospital while under previous ownership shall no 

22 longer be published by the Secretary pursuant to 

23 paragraph (1) after the 1-year period beginning on 

24 the date of change of ownership. 


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1 ‘‘(f) USE OF FUNDS.—Funds collected by the Sec2 retary pursuant to this section are authorized to be appro3 priated to carry out this title. 

4 ‘‘SEC. 3406. DEFINITIONS. 

5 ‘‘For purposes of this title: 

6 ‘‘(1) ACUITY LEVEL.—The term ‘acuity level’ 

7 means the determination, using a hospital acuity 

8 measurement tool that has been developed and es9 tablished in coordination with direct care registered 

10 nurses and made transparent pursuant to section 

11 3401(c)(4), of nursing care requirements, based on 

12 the assigned direct care registered nurse’s profes13 sional judgment of— 

14 ‘‘(A) the severity and complexity of an in15 dividual patient’s illness or injury; 

16 ‘‘(B) the need for specialized equipment; 

17 and 

18 ‘‘(C) the intensity of nursing interventions 

19 required. 

20 ‘‘(2) COMPETENCE.—The term ‘competence’ or 

21 ‘competent’ means the satisfactory application of the 

22 duties and responsibilities of a registered nurse in 

23 providing nursing care to specific patient popu24 lations and for acuity levels for each patient care 

25 unit or area pursuant to the State nursing laws and 


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1 regulations of the State in which the direct nursing 

2 care is being performed. 

3 ‘‘(3) DIRECT CARE LICENSED PRACTICAL

4 NURSE.—The term ‘direct care licensed practical 

5 nurse’ means an individual who has been granted a 

6 license by at least one State to practice as a licensed 

7 practical nurse or a licensed vocational nurse and 

8 who provides bedside care for one or more patients. 

9 ‘‘(4) DIRECT CARE REGISTERED NURSE.—The 

10 term ‘direct care registered nurse’ means an indi11 vidual who has been granted a license by at least 

12 one State to practice as a registered nurse and who 

13 provides bedside care for one or more patients. 

14 ‘‘(5) EMPLOYMENT.—The term ‘employment’ 

15 includes the provision of services under a contract or 

16 other arrangement. 

17 ‘‘(6) HOSPITAL.—The term ‘hospital’ has the 

18 meaning given that term in section 1861(e) of the 

19 Social Security Act. 

20 ‘‘(7) NURSE.—The term ‘nurse’ means any di21 rect care registered nurse or direct care licensed 

22 practice nurse (as the case may be), regardless of 

23 whether or not the nurse is an employee. 

24 ‘‘(8) NURSING CARE PLAN.—The term ‘nursing 

25 care plan’ means a plan developed by the assigned 


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1 direct care registered nurse (in accordance with 

2 nursing law in the State in which the nursing care 

3 is performed) that indicates the nursing care to be 

4 given to individual patients that— 

5 ‘‘(A) considers the acuity level of the pa6 tient; 

7 ‘‘(B) is developed in coordination with the 

8 patient, the patient’s family, or other represent9 atives when appropriate, and staff of other dis10 ciplines involved in the care of the patient; 

11 ‘‘(C) reflects all elements of the nursing 

12 process; and 

13 ‘‘(D) recommends the number and skill 

14 mix of additional licensed and unlicensed direct 

15 care staff needed to fully implement the nursing 

16 care plan. 

17 ‘‘(9) PROFESSIONAL JUDGMENT.—The term 

18 ‘professional judgment’ means, in accordance with 

19 State nursing laws and regulations of the State in 

20 which the direct nursing care is being performed, the 

21 direct care registered nurse’s application of knowl22 edge, expertise, and experience in conducting a com23 prehensive nursing assessment of each patient and 

24 in making independent decisions about patient care 

25 including the need for additional staff. 


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1 ‘‘(10) STAFFING PLAN.—The term ‘staffing 

2 plan’ means a staffing plan required under section 

3 3401. 

4 ‘‘(11) STATE OF EMERGENCY.—The term ‘state 

5 of emergency’— 

6 ‘‘(A) means a state of emergency that is 

7 an unpredictable or unavoidable occurrence at 

8 an unscheduled or unpredictable interval, relat9 ing to health care delivery and requiring imme10 diate medical interventions and care; and 

11 ‘‘(B) does not include a state of emergency 

12 that results from a labor dispute in the health 

13 care industry or consistent understaffing. 

14 ‘‘SEC. 3407. RULE OF CONSTRUCTION. 

15 ‘‘Nothing in this title shall be construed to authorize 

16 disclosure of private and confidential patient information, 

17 if such disclosure is not authorized or required by other 

18 applicable law.’’. 

19 (b) RECOMMENDATIONS TO CONGRESS.—Not later 

20 than 1 year after the date of enactment of this Act, the 

21 Secretary of Health and Human Services shall submit to 

22 Congress a report containing recommendations for ensur23 ing that sufficient numbers of nurses are available to meet 

24 the requirements imposed by title XXXIV of the Public 

25 Health Service Act, as added by subsection (a). 


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1 (c) REPORT BY HRSA.— 

2 (1) IN GENERAL.—Not later than 2 years after 

3 the date of enactment of this Act, the Administrator 

4 of the Health Resources and Services Administra5 tion, in consultation with the National Health Care 

6 Workforce Commission, shall submit to Congress a 

7 report regarding the relationship between nurse 

8 staffing levels and nurse retention in hospitals. 

9 (2) UPDATED REPORT.—Not later than 5 years 

10 after the date of enactment of this Act, the Adminis11 trator of the Health Resources and Services Admin12 istration, in consultation with the National Health 

13 Care Workforce Commission, shall submit to Con14 gress an update of the report submitted under para15 graph (1). 

16 (d) ENFORCEMENT OF REQUIREMENTS THROUGH

17 FEDERAL PROGRAMS.— 

18 (1) MEDICARE PROGRAM.—Section 1866(a)(1) 

19 of the Social Security Act (42 U.S.C. 1395cc(a)(1)) 

20 is amended— 

21 (A) in subparagraph (X), by striking ‘‘, 

22 and’’ and inserting a comma; 

23 (B) in subparagraph (Y), by striking the 

24 period at the end and inserting ‘‘, and’’; and 


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1 (C) by inserting after subparagraph (Y) 

2 the following new subparagraph: 

3 ‘‘(Z) in the case of a hospital, to comply 

4 with the provisions of title XXXIV of the Public 

5 Health Service Act.’’. 

6 (2) MEDICAID PROGRAM.—Section 1902(a) of 

7 the Social Security Act (42 U.S.C. 1396a(a)) is 

8 amended— 

9 (A) by striking ‘‘and’’ at the end of para10 graph (82); 

11 (B) by striking the period at the end of 

12 paragraph (83) and inserting ‘‘; and’’; and 

13 (C) by inserting after paragraph (83) the 

14 following new paragraph: 

15 ‘‘(84) provide that any hospital that receives a 

16 payment under such plan comply with the provisions 

17 of title XXXIV of the Public Health Service Act (re18 lating to minimum direct care registered nurse staff19 ing requirements).’’. 

20 (e) NURSING HOMES.—No later than one year after 

21 enactment of this Act, the Secretary of Health and 

22 Human Services shall promulgate a rule for minimum 

23 staffing standards for skilled nursing facilities under the 

24 Medicare program and for nursing facilities under the 


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1 Medicaid program that align with the standards set in this 

2 section. 

3 SEC. 134. ENHANCEMENTS FOR REDUCED COST-SHARING. 

4 (a) IN GENERAL.—Section 1402 of the Patient Pro5 tection and Affordable Care Act (42 U.S.C. 18071) is 

6 amended— 

7 (1) in subsection (b)(1), by striking ‘‘silver’’ 

8 and inserting ‘‘gold’’; 

9 (2) by amending subsection (c)(1)(B) to read as 

10 follows: 

11 ‘‘(B) COORDINATION WITH ACTUARIAL

12 LIMITS.—The Secretary shall ensure the reduc13 tion under this paragraph shall not result in the 

14 plan’s share of the total allowed costs of bene15 fits provided under the plan becoming less 

16 than— 

17 ‘‘(i) 95 percent in the case of an eligi18 ble insured described in paragraph (2)(A); 

19 ‘‘(ii) 90 percent in the case of an eli20 gible insured described in paragraph 

21 (2)(B); and 

22 ‘‘(iii) 85 percent in the case of an eli23 gible insured described in paragraph 

24 (2)(C).’’; and 


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1 (3) by amending subsection (c)(2) to read as 

2 follows: 

3 ‘‘(2) ADDITIONAL REDUCTION.—The Secretary 

4 shall establish procedures under which the issuer of 

5 a qualified health plan to which this section applies 

6 shall further reduce cost-sharing under the plan in 

7 a manner sufficient to— 

8 ‘‘(A) in the case of an eligible insured 

9 whose household income is not less than 100 

10 percent but not more than 200 percent of the 

11 poverty line for a family of the size involved, in12 crease the plan’s share of the total allowed 

13 costs of benefits provided under the plan to 95 

14 percent of such costs; 

15 ‘‘(B) in the case of an eligible insured 

16 whose household income is more than 200 per17 cent but not more than 300 percent of the pov18 erty line for a family of the size involved, in19 crease the plan’s share of the total allowed 

20 costs of benefits provided under the plan to 90 

21 percent of such costs; and 

22 ‘‘(C) in the case of an eligible insured 

23 whose household income is more than 300 per24 cent but not more than 400 percent of the pov25 erty line for a family of the size involved, inVerDate Sep 11 2014 20:58 May 08, 2019 Jkt 089200 PO 00000 Frm 00137 Fmt 6652 Sfmt 6201 E:\BILLS\H2452.IH H2452

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1 crease the plan’s share of the total allowed 

2 costs of benefits provided under the plan to 85 

3 percent of such costs.’’. 

4 (b) EFFECTIVE DATE.—The amendments made by 

5 this subsection shall apply to plan years beginning after 

6 December 31, 2019. 

7 (c) FUNDING.—Section 1402 of the Patient Protec8 tion and Affordable Care Act (42 U.S.C. 18071) is amend9 ed by adding at the end the following new subsection: 

10 ‘‘(g) FUNDING.—Out of any funds in the Treasury 

11 not otherwise appropriated, there are appropriated to the 

12 Secretary such sums as may be necessary for payments 

13 under this section.’’. 

14 SEC. 135. REPEAL OF BONUS PAYMENTS FOR MEDICARE 

15 ADVANTAGE PLANS. 

16 Section 1853(o) of the Social Security Act (42 U.S.C. 

17 1395w–23(o)) is repealed. 

18 TITLE II—TAX PROVISIONS 

19 SEC. 201. SUNSET OF PUBLIC LAW 115–97. 

20 (a) IN GENERAL.—All provisions of, and amend21 ments made by, Public Law 115–97 shall not apply to cal22 endar, taxable, plan, or limitation years beginning after 

23 December 31, 2019. 

24 (b) APPLICATION OF CERTAIN LAWS.—The Internal 

25 Revenue Code of 1986 shall be applied and administered 


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1 to years described in subsection (a) as if the provisions 

2 and amendments described in subsection (a) had never 

3 been enacted. 

4 SEC. 202. SURTAX. 

5 There is hereby imposed a tax of 5 percent on the 

6 adjusted gross income of each taxpayer to the extent such 

7 income exceeds $500,000. 

8 SEC. 203. BASIS OF PROPERTY ACQUIRED FROM A DECE9 DENT. 

10 (a) IN GENERAL.—Section 1014 of the Internal Rev11 enue Code of 1986 is amended by striking ‘‘person, be’’ 

12 and all that follows through the period at the end and 

13 inserting the following: ‘‘person, be the basis in the hands 

14 of the decedent.’’. 

15 (b) EFFECTIVE DATE.—The amendments made by 

16 this section to property acquired or passed after the date 

17 of enactment of this Act. 

18 SEC. 204. MEDICARE PAYROLL TAX. 

19 (a) IN GENERAL.—Section 3101(b)(2) of the Internal 

20 Revenue Code of 1986 is amended by striking ‘‘0.9 per21 cent’’ and inserting ‘‘4 percent’’. 

22 (b) EFFECTIVE DATE.—The amendments made by 

23 this section shall apply with respect to taxable years begin24 ning after the date of the enactment of this Act. 


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1 SEC. 205. NET INVESTMENT INCOME TAX. 

2 (a) IN GENERAL.—Section 1411(a) of the Internal 

3 Revenue Code of 1986 is amended by striking ‘‘3.8 per4 cent’’ each place such term appears and inserting ‘‘6.9 

5 percent’’. 

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

7 this section shall apply with respect to taxable years begin8 ning after the date of the enactment of this Act. 

9 SEC. 206. TERMINATION OF DEDUCTION FOR CONTRIBU10 TIONS TO HEALTH SAVINGS ACCOUNTS. 

11 Section 223(b) of the Internal Revenue Code of 1986 

12 is amended by adding at the end the following new para13 graph: 

14 ‘‘(9) TERMINATION OF DEDUCTION.—Notwith15 standing any other provision of this subsection, the 

16 monthly limitation for any month beginning after 

17 December 31, 2023, is zero.’’. 

18 SEC. 207. INCREASE IN EXCISE TAX ON SMALL CIGARS AND 

19 CIGARETTES AND OTHER TOBACCO PROD20 UCTS. 

21 (a) SMALL CIGARS.—Section 5701(a)(1) of the Inter22 nal Revenue Code of 1986 is amended by striking 

23 ‘‘$50.33’’ and inserting ‘‘$100.66’’. 

24 (b) CIGARETTES.—Section 5701(b) of such Code is 

25 amended— 


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1 (1) by striking ‘‘$50.33’’ in paragraph (1) and 

2 inserting ‘‘$100.66’’; and 

3 (2) by striking ‘‘$105.69’’ in paragraph (2) and 

4 inserting ‘‘$211.38’’. 

5 (c) PIPE TOBACCO.—Section 5701(f) of the Internal 

6 Revenue Code of 1986 is amended by striking ‘‘$2.8311 

7 cents’’ and inserting ‘‘$50.00’’. 

8 (d) ROLL-YOUR-OWN TOBACCO.—Section 5701(g) of 

9 such Code is amended by striking ‘‘$24.78’’ and inserting 

10 ‘‘$49.56’’. 

11 (e) LARGE CIGARS.—Paragraph (2) of section 

12 5701(a) of the Internal Revenue Code of 1986 is amended 

13 by striking ‘‘52.75 percent’’ and all that follows through 

14 the period and inserting ‘‘$24.78 per pound (and a propor15 tionate tax at the like rate on all fractional parts of a 

16 pound) but not less than 5.033 cents per cigar.’’. 

17 (f) SMOKELESS TOBACCO.— 

18 (1) IN GENERAL.—Section 5701(e) of the Inter19 nal Revenue Code of 1986 is amended— 

20 (A) in paragraph (1), by striking ‘‘$1.51’’ 

21 and inserting ‘‘$28.04’’; 

22 (B) in paragraph (2), by striking ‘‘50.33 

23 cents’’ and inserting ‘‘$12.42’’; and 

24 (C) by adding at the end the following: 


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1 ‘‘(3) SMOKELESS TOBACCO SOLD IN DISCRETE

2 SINGLE-USE UNITS.—On discrete single-use units, 

3 $107.65 per each 1,000 single-use units.’’. 

4 (2) DISCRETE SINGLE-USE UNIT.—Section 

5 5702(m) of such Code is amended— 

6 (A) in paragraph (1), by striking ‘‘or chew7 ing tobacco’’ and inserting ‘‘chewing tobacco, 

8 discrete single-use unit’’; 

9 (B) in paragraphs (2) and (3), by inserting 

10 ‘‘that is not a discrete single-use unit’’ before 

11 the period in each such paragraph; and 

12 (C) by adding at the end the following: 

13 ‘‘(4) DISCRETE SINGLE-USE UNIT.—The term 

14 ‘discrete single-use unit’ means any product con15 taining tobacco that— 

16 ‘‘(A) is not intended to be smoked; and 

17 ‘‘(B) is in the form of a lozenge, tablet, 

18 pill, pouch, dissolvable strip, or other discrete 

19 single-use or single-dose unit’’. 

20 SEC. 208. EXCISE TAX ON ALCOHOL. 

21 (a) DISTILLED SPIRITS.—Section 5001(a)(1) of the 

22 Internal Revenue Code of 1986 is amended by striking 

23 ‘‘$13.50’’ and inserting ‘‘$16.00’’. 


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1 (b) WINE.—(1) Section 5041(b)(1) of the Internal 

2 Revenue Code of 1986 is amended by striking ‘‘$1.07 per 

3 wine gallon’’ and inserting ‘‘$16.00 per proof gallon’’. 

4 (2) Section 5041(b)(2) of the Internal Revenue Code 

5 of 1986 is amended by striking ‘‘$1.57 per wine gallon’’ 

6 and inserting ‘‘$16.00 per proof gallon’’. 

7 (3) Section 5041(b)(3) of the Internal Revenue Code 

8 of 1986 is amended by striking ‘‘$3.15 per wine gallon’’ 

9 and inserting ‘‘$16.00 per proof gallon’’. 

10 (4) Section 5041(b)(4) of the Internal Revenue Code 

11 of 1986 is amended by striking ‘‘$3.40 per wine gallon’’ 

12 and inserting ‘‘$16.00 per proof gallon’’. 

13 (5) Section 5041(b)(5) of the Internal Revenue Code 

14 of 1986 is amended by striking ‘‘$3.30 per wine gallon’’ 

15 and inserting ‘‘$16.00 per proof gallon’’. 

16 (6) Section 5041(b)(3) of the Internal Revenue Code 

17 of 1986 is amended by striking ‘‘$22.6 cents per wine gal18 lon’’ and inserting ‘‘$16.00 per proof gallon’’. 

19 (c) BEER.—Section 5051(B) of the Internal Revenue 

20 Code of 1986 is amended by striking ‘‘$18 for per barrel’’ 

21 and inserting ‘‘$16 per proof gallon’’. 

22 SEC. 209. TAX ON SUGARED DRINKS. 

23 (a) IN GENERAL.—Subchapter D of chapter 32 of the 

24 Internal Revenue Code of 1986 is amended by inserting 

25 after part I the following new part: 


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1 ‘‘PART II—SUGAR-SWEETENED BEVERAGES 

‘‘Sec. 4171. Imposition of tax. 

‘‘Sec. 4172. Definitions. 

‘‘Sec. 4173. Special rules. 

2 ‘‘SEC. 4171. IMPOSITION OF TAX. 

3 ‘‘(a) IN GENERAL.—There is hereby imposed a tax 

4 on the sale or transfer of any specified sugar-sweetened 

5 beverage product by the manufacturer, producer, or im6 porter thereof. 

7 ‘‘(b) RATE OF TAX.—The rate of tax imposed under 

8 subsection (a) shall be equal to one cent per 4.2 grams 

9 of caloric sweetener contained in such specified sugar10 sweetened beverage product. 

11 ‘‘(c) PERSONS LIABLE FOR TAX.—The manufac12 turer, producer, or importer referred to in subsection (a) 

13 shall be liable for the tax imposed by such subsection. 

14 ‘‘SEC. 4172. DEFINITIONS. 

15 ‘‘(a) SPECIFIED SUGAR-SWEETENED BEVERAGE

16 PRODUCT.—For purposes of this part— 

17 ‘‘(1) IN GENERAL.—For purposes of this part, 

18 the term ‘specified sugar-sweetened beverage prod19 uct’ means— 

20 ‘‘(A) any liquid intended for human con21 sumption which contains a caloric sweetener, 

22 and 

23 ‘‘(B) any liquid, or solid mixture of ingre24 dients, which— 


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1 ‘‘(i) contains a caloric sweetener, and 

2 ‘‘(ii) is intended for use as an ingre3 dient in a liquid described in subparagraph 

4 (A). 

5 ‘‘(2) EXCEPTIONS.—The following shall not be 

6 treated as liquids described in paragraph (1)(A): 

7 ‘‘(A) Any liquid the primary ingredients of 

8 which are milk or soy, rice, or similar plant9 based milk substitute. 

10 ‘‘(B) Any liquid composed entirely of one 

11 or more of the following: 

12 ‘‘(i) The original liquid resulting from 

13 the pressing of fruit or vegetables. 

14 ‘‘(ii) The liquid resulting from the re15 constitution of fruit or vegetable juice con16 centrate. 

17 ‘‘(iii) The liquid resulting from the 

18 restoration of water to dehydrated fruit or 

19 vegetable juice. 

20 ‘‘(C) Infant formula. 

21 ‘‘(D) Any liquid products manufactured for 

22 use as— 

23 ‘‘(i) an oral nutritional therapy for 

24 persons who cannot absorb or metabolize 

25 dietary nutrients from food or beverages, 


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1 ‘‘(ii) a source of necessary nutrition 

2 used due to a medical condition, or 

3 ‘‘(iii) an oral electrolyte solution for 

4 infants and children formulated to prevent 

5 dehydration due to illness. 

6 ‘‘(E) Any liquid with respect to which tax 

7 is imposed under chapter 51 (relating to dis8 tilled spirits, wines, and beer) or under section 

9 7652 by reason of the tax imposed under chap10 ter 51 being imposed on like articles of domes11 tic manufacture. 

12 ‘‘(b) CALORIC SWEETENER.—For purposes of this 

13 part, the term ‘caloric sweetener’ means monosaccharides, 

14 disaccharides, and high-fructose corn syrup. 

15 ‘‘SEC. 4173. SPECIAL RULES. 

16 ‘‘(a) SWEETENER TAXED ONLY ONCE.—In the case 

17 of any specified sugar-sweetened beverage product which 

18 is manufactured or produced by including one or more 

19 other specified sugar-sweetened beverage products, no tax 

20 shall be imposed under this section on any caloric sweet21 ener contained in the resulting specified sugar-sweetened 

22 beverage product if tax was previously imposed under this 

23 section on such caloric sweetener when contained in the 

24 specified sugar-sweetened beverage product so included. 


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1 ‘‘(b) INFLATION ADJUSTMENT.—In the case of any 

2 sale after December 31, 2015, the one cent amount in sec3 tion 4171(b) shall be increased by an amount equal to— 

4 ‘‘(1) such amount, multiplied by 

5 ‘‘(2) the cost-of-living adjustment determined 

6 under section 1(f)(3) for the calendar year in which 

7 such sale occurs, determined by substituting ‘cal8 endar year 2014’ for ‘calendar year 1992’ in sub9 paragraph (B) thereof. 

10 Any increase determined under this subsection shall be 

11 rounded to the nearest multiple of one-tenth of a cent.’’. 

12 (b) CONFORMING AMENDMENTS.— 

13 (1) Section 4221(a) is amended by adding at 

14 the end the following: ‘‘Paragraphs (1), (4), (5), and 

15 (6) shall not apply to the tax imposed under section 

16 4171.’’. 

17 (2) The table of parts for subchapter D of 

18 chapter 32 of such Code is amended by inserting 

19 after the item relating to part I the following new 

20 item: 

‘‘PART II—SUGAR-SWEETENED BEVERAGES’’. 

21 (c) EFFECTIVE DATE.— 

22 (1) IN GENERAL.—Except as provided in para23 graph (2), the amendments made by this section 

24 shall take effect on the date of the enactment of this 

25 Act. 


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1 (2) EXCISE TAX.—The amendments made by 

2 subsections (a) and (b) shall apply to sales after the 

3 date of the enactment of this Act. 

4 SEC. 210. REPEAL OF EXCISE TAX ON HIGH-COST EM5 PLOYER-SPONSORED HEALTH COVERAGE. 

6 (a) IN GENERAL.—Chapter 43 of the Internal Rev7 enue Code of 1986 is amended by striking section 4980I. 

8 (b) CONFORMING AMENDMENT.—Section 6051 of 

9 such Code is amended— 

10 (1) in paragraph (14) of subsection (a), by 

11 striking ‘‘section 4980I(d)(1)’’ and inserting ‘‘sub12 section (g)’’, and 

13 (2) by adding at the end the following: 

14 ‘‘(g) APPLICABLE EMPLOYER-SPONSORED COV15 ERAGE.—For purposes of subsection (a)(14)— 

16 ‘‘(1) IN GENERAL.—The term ‘applicable em17 ployer-sponsored coverage’ means, with respect to 

18 any employee, coverage under any group health plan 

19 made available to the employee by an employer 

20 which is excludable from the employee’s gross in21 come under section 106, or would be so excludable 

22 if it were employer-provided coverage (within the 

23 meaning of such section 106). 

24 ‘‘(2) EXCEPTIONS.—The term ‘applicable em25 ployer-sponsored coverage’ shall not include— 


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1 ‘‘(A) any coverage (whether through insur2 ance or otherwise) described in section 

3 9832(c)(1) (other than subparagraph (G) there4 of) or for long-term care; 

5 ‘‘(B) any coverage under a separate policy, 

6 certificate, or contract of insurance which pro7 vides benefits substantially all of which are for 

8 treatment of the mouth (including any organ or 

9 structure within the mouth) or for treatment of 

10 the eye; or 

11 ‘‘(C) any coverage described in section 

12 9832(c)(3) the payment for which is not exclud13 able from gross income and for which a deduc14 tion under section 162(l) is not allowable. 

15 ‘‘(3) COVERAGE INCLUDES EMPLOYEE PAID

16 PORTION.—Coverage shall be treated as applicable 

17 employer-sponsored coverage without regard to 

18 whether the employer or employee pays for the cov19 erage. 

20 ‘‘(4) GOVERNMENTAL PLANS INCLUDED.—Ap21 plicable employer-sponsored coverage shall include 

22 coverage under any group health plan established 

23 and maintained primarily for its civilian employees 

24 by the Government of the United States, by the gov25 ernment of any State or political subdivision thereof, 


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1 or by any agency or instrumentality of any such gov2 ernment. 

3 ‘‘(5) COST OF COVERAGE.— 

4 ‘‘(A) HEALTH FSAS.—In the case of appli5 cable employer-sponsored coverage consisting of 

6 coverage under a flexible spending arrangement 

7 (as defined in section 2205(g)), the cost of the 

8 coverage shall be equal to the amount deter9 mined under rules similar to the rules of section 

10 4980B(f)(4) with respect to any reimbursement 

11 under the arrangement reduced by the contribu12 tions described in subsection (a)(14)(B). 

13 ‘‘(B) ARCHER MSAS AND HSAS.—In the 

14 case of applicable employer-sponsored coverage 

15 consisting of coverage under an arrangement 

16 under which the employer makes contributions 

17 described in subsection (b) or (d) of section 

18 106, the cost of the coverage shall be equal to 

19 the amount of employer contributions under the 

20 arrangement until the termination of HSAs as 

21 described under section 206 of such Act. 

22 ‘‘(C) ALLOCATION ON A MONTHLY

23 BASIS.—If cost is determined on other than a 

24 monthly basis, the cost shall be allocated to 


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1 months in a taxable period on such basis as the 

2 Secretary may prescribe.’’. 

3 (c) CLERICAL AMENDMENT.—The table of sections 

4 for chapter 43 of such Code is amended by striking the 

5 item relating to section 4980I. 

6 (d) EFFECTIVE DATE.—The amendments made by 

7 this section shall apply to taxable years beginning after 

8 December 31, 2019. 

9 TITLE III—DRUG-RELATED 

10 PROVISIONS 

11 SEC. 301. ESTABLISHMENT OF THE PRESCRIPTION DRUG 

12 AND MEDICAL DEVICE REVIEW BOARD. 

13 There is established in the Department of Health and 

14 Human Services a board to be known as the Prescription 

15 Drug and Medical Device Price Review Board (in this Act 

16 referred to as the ‘‘Board’’). 

17 SEC. 302. MEMBERSHIP; STAFF. 

18 (a) MEMBERS.—The Board shall be composed of the 

19 members as follows: 

20 (1) The Assistant Secretary for Planning and 

21 Evaluation of the Department of Health and Human 

22 Services (or the Assistant Secretary’s designee). 

23 (2) The Administrator of the Centers for Medi24 care & Medicaid Services or, beginning with 2022, 


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1 the Administrator of the Center for Health Care (or 

2 the Administrator’s designee). 

3 (3) The Assistant Director for the Health Serv4 ices Division of the Federal Bureau of Prisons (or 

5 the Assistant Director’s designee). 

6 (4) The Secretary of Defense (or the Sec7 retary’s designee). 

8 (5) The Secretary of Veterans Affairs (or the 

9 Secretary’s designee). 

10 (6) The Commissioner of Food and Drugs (or 

11 the Commissioner’s designee). 

12 (7) The Director of the National Institutes of 

13 Health (or the Director’s designee). 

14 (b) CHAIRPERSON.—The Board shall designate 1 

15 member of the Board to serve as the chairperson. 

16 (c) DIRECTOR AND STAFF.— 

17 (1) DIRECTOR.—The Board shall have a direc18 tor who shall be appointed by the chairperson of the 

19 Board, subject to rules prescribed by the Board. 

20 (2) STAFF.—The director may appoint and fix 

21 the pay of such additional personnel as the chair22 person considers appropriate, subject to rules pre23 scribed by the Board. 

24 (3) APPLICABILITY OF CERTAIN CIVIL SERVICE

25 LAWS.—The director and staff of the Board shall be 


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1 appointed subject to the provisions of title 5, United 

2 States Code, governing appointments in the competi3 tive service, and shall be paid in accordance with the 

4 requirements of chapter 51 and subchapter III of 

5 chapter 53 of such title relating to classification and 

6 General Schedule pay rates; except that an indi7 vidual so appointed may not receive pay in excess of 

8 the maximum annual rate of basic pay payable for 

9 grade GS–15 of the General Schedule. 

10 (d) ASSISTANCE FOR THE BOARD.—Subject to sec11 tion 306(g), in carrying out this title, the Board— 

12 (1) may seek assistance from outside experts in 

13 the fields of consumer advocacy, medicine, pharma14 cology, pharmacy, and prescription drug reimburse15 ment; and 

16 (2) shall establish and maintain an advisory 

17 group and a stakeholder group for purposes of seek18 ing such assistance. 

19 (e) INITIAL MEETING.—The Board shall hold its ini20 tial meeting not later than 90 days after the date of the 

21 enactment of this Act. 

22 (f) BANNED INDIVIDUALS.— 

23 (1) DRUG COMPANY LOBBYISTS.—No former 

24 registered drug manufacturer lobbyist— 


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1 (A) may be appointed to the position of 

2 Director of the Office; or 

3 (B) may be employed by the Office during 

4 the 6-year period beginning on the date on 

5 which the registered lobbyist terminates its reg6 istration in accordance with section 4(d) of the 

7 Lobbying Disclosure Act of 1995 (2 U.S.C. 

8 1603(d)) or the agent terminates its status, as 

9 applicable. 

10 (2) SENIOR EXECUTIVES OF LAW-BREAKING

11 COMPANIES.—No former senior executive of a cov12 ered entity— 

13 (A) may be appointed to the position of 

14 Director of the Office; or 

15 (B) may be employed by the Office during 

16 the 6-year period beginning on the later of— 

17 (i) the date of the settlement; and 

18 (ii) the date on which the enforcement 

19 action has concluded. 

20 (3) COVERED ENTITY.—The term ‘‘covered en21 tity’’ means any entity that is— 

22 (A) a drug manufacturer; and 

23 (B)(i) operating under Federal settlement, 

24 including a Federal consent decree; or 


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1 (ii) the subject of an enforcement action in 

2 a court of the United States or by an agency. 

3 SEC. 303. PROHIBITION AGAINST EXCESSIVE PRICE. 

4 (a) PROHIBITION.—Beginning on the effective date 

5 of the regulation required by subsection (b), the manufac6 turer of a prescription drug or medical device shall not 

7 charge an excessive price, as determined pursuant to such 

8 regulation, for such drug or device. 

9 (b) FORMULA.—The Board shall by regulation pre10 scribe a formula for determining whether the average 

11 manufacturer price of such drug or device over an annual 

12 quarter is an excessive price. 

13 (c) DETERMINATION OF EXCESSIVE PRICE.—If the 

14 Board determines, on its own initiative or in response to 

15 a petition submitted under subsection (d), that the manu16 facturer of a prescription drug or medical device charges 

17 an excessive price for such drug or device in violation of 

18 subsection (a)— 

19 (1) the Board shall give the manufacturer— 

20 (A) notice of such violation; and 

21 (B) subject to subsection (d), a period to 

22 correct such violation; and 

23 (2) if the manufacturer fails to correct the vio24 lation by the end of such period, the manufacturer 

25 shall be subject to section 304, section 


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1 1927(c)(2)(E) of the Social Security Act (as added 

2 by subsection (c) of section 304), and section 4192 

3 of the Internal Revenue Code of 1986, as added by 

4 subsection (d) of section 304. 

5 (d) PETITIONS.—Any person may petition the Board 

6 to make a determination under subsection (c) regarding 

7 the pricing of a prescription drug or medical device. Not 

8 later than 90 days after the date of receipt of such a peti9 tion, the Board shall— 

10 (1) make a determination under subsection (c) 

11 regarding such pricing; or 

12 (2) decline to make such a determination. 

13 (e) CONTINUING VIOLATION.—The Board shall not 

14 be required to give a manufacturer an opportunity to cor15 rect a violation, as described in subsection (c)(1)(B), be16 fore the manufacturer becomes subject to the provisions 

17 described in subsection (c)(2) for such violation, if— 

18 (1) the Board has already provided such an op19 portunity to correct to the manufacturer; and 

20 (2) the Board finds that the violation of sub21 section (a) is a continuation of an earlier violation 

22 with respect to which such an opportunity was pro23 vided. 

24 (f) CONSIDERATIONS.—The formula required by sub25 section (a) shall at a minimum take into consideration— 


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1 (1) the average manufacturer price of the pre2 scription drug or medical device over the respective 

3 annual quarter or quarters; 

4 (2) the average manufacturer price of other 

5 prescription drugs or medical devices in the same 

6 therapeutic class over the same quarter or quarters; 

7 (3) the average price at which the prescription 

8 drug or medical device and other prescription drugs 

9 and medical devices in the same therapeutic class 

10 have been sold by manufacturers in countries other 

11 than the United States; 

12 (4) the costs associated with producing and 

13 marketing the prescription drug or medical device, 

14 the value of the drug or device to patients where suf15 ficient data is available to determine such value, the 

16 total Federal investment in the development of the 

17 drug or device, the size of the patient population re18 ceiving the drug or device, and other factors deter19 minative as to the true cost of production; and 

20 (5) whether the price of the prescription drug 

21 or medical device increased during any annual quar22 ter by a percentage that is more than 2 percent 

23 greater than the CPI increase percentage (as defined 

24 in section 215(i) of the Social Security Act (42 

25 U.S.C. 415)) for the respective annual quarter. 


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1 (g) VALUE OR COST-EFFECTIVENESS ASSESS2 MENTS.—The use of Quality-Adjusted Life Years, Dis3 ability-Adjusted Life Years, or other similar mechanisms 

4 is prohibited for use in value or cost-effectiveness assess5 ments for purposes of this section. 

6 SEC. 304. ENFORCEMENT PROVISIONS. 

7 (a) REDUCED PATENT TERM.—If the Board finds 

8 that the manufacturer of a prescription drug or medical 

9 device, who is also an owner of a patent for such drug 

10 or device, charged an excessive price for such drug or de11 vice in violation of section 303(a), the Board may— 

12 (1) reduce the term, by not more than 5 years, 

13 of any patent issued under title 35, United States 

14 Code, relating to such drug or device; or 

15 (2) if the term of each patent for such drug or 

16 device has expired, reduce the term, by not more 

17 than 5 years, of another patent owned by the patent 

18 owner relating to a prescription drug or medical de19 vice. 

20 (b) CIVIL PENALTIES.—If the Board determines 

21 under section 303(c) that a manufacturer of a prescription 

22 drug or medical device charged an excessive price for a 

23 prescription drug or medical device in violation of section 

24 303(a), the Board may impose a civil penalty on the man25 ufacturer of not more than 10 percent of the manufacturVerDate Sep 11 2014 20:58 May 08, 2019 Jkt 089200 PO 00000 Frm 00158 Fmt 6652 Sfmt 6201 E:\BILLS\H2452.IH H2452

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1 er’s gross sales of the drug or device during the period 

2 beginning on the date on which an excessive price is first 

3 charged and ending on the date on which the manufac4 turer ceases to charge an excessive price. 

5 (c) TAX ON EXCESS PRESCRIPTION DRUG AND MED6 ICAL DEVICE PROFITS.— 

7 (1) DETERMINATION OF AMOUNT.—If the 

8 Board determines under section 303(a) that a man9 ufacturer, producer, or importer of a prescription 

10 drug or medical device charged an excessive price for 

11 such prescription drug or medical device during a 

12 taxable year, the Board may determine under this 

13 paragraph a reasonable price for such drug or device 

14 for such taxable year. 

15 (2) IMPOSITION OF TAX.— 

16 (A) IN GENERAL.—The Internal Revenue 

17 Code of 1986 is amended by inserting after sec18 tion 4191 the following new section: 

19 ‘‘SEC. 4192. EXCESSIVE PRESCRIPTION DRUG AND MEDICAL 

20 DEVICE PRICE. 

21 ‘‘(a) IN GENERAL.—There is hereby imposed on the 

22 sale of any prescription drug or medical device by the 

23 manufacturer, producer, or importer a tax equal to the 

24 difference between the price at which such drug or device 

25 is so sold and the reasonable price determined by the PreVerDate Sep 11 2014 20:58 May 08, 2019 Jkt 089200 PO 00000 Frm 00159 Fmt 6652 Sfmt 6201 E:\BILLS\H2452.IH H2452

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1 scription Drug and Medical Device Price Review Board 

2 under section 303(c)(1) of the Medicare for America Act 

3 for such drug or device for the taxable year for sales after 

4 the determination. 

5 ‘‘(b) PRESCRIPTION DRUG OR MEDICAL DEVICE.— 

6 For purposes of this section, the term ‘prescription drug 

7 or medical device’ means any prescription drug (as defined 

8 in section 9008 of the Patient Protection and Affordable 

9 Care Act) or device (as defined in section 201(h) of the 

10 Federal Food, Drug, and Cosmetic Act) intended for hu11 mans.’’. 

12 (B) CLERICAL AMENDMENT.—The table of 

13 parts for chapter 32 of such Code is amended— 

14 (i) in the item relating to subchapter 

15 E, by striking ‘‘Medical’’ and inserting 

16 ‘‘Drugs and medical’’; and 

17 (ii) by inserting after the item relating 

18 to section 4191 the following new item: 

‘‘Sec. 4192. Excessive prescription drug and medical device price.’’. 

19 (3) EFFECTIVE DATE.—This subsection and the 

20 amendments made by this subsection shall apply 

21 with respect to sales after December 31, 2019. 

22 SEC. 305. AUTHORITY. 

23 (a) OBTAINING OFFICIAL DATA.—The chairperson of 

24 the Board may secure directly from any Federal agency 

25 information necessary to enable the Board to carry out 


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1 its duties. Upon request of the chairperson, the head of 

2 the agency shall furnish such information to the Board 

3 to the extent such information is not prohibited from dis4 closure by law. 

5 (b) MAILS.—The Board may use the United States 

6 mails in the same manner and under the same conditions 

7 as other Federal agencies. 

8 (c) ADMINISTRATIVE SUPPORT SERVICES.—Upon the 

9 request of the chairperson of the Board, the Administrator 

10 of General Services shall provide to the Board, on a reim11 bursable basis, the administrative support services nec12 essary for the Board to carry out its duties. 

13 (d) CONTRACT AUTHORITY.—The Board may con14 tract with and compensate government and private agen15 cies or persons for the purpose of conducting research, 

16 surveys, and other services necessary to enable the Board 

17 to carry out its duties. 

18 (e) INVESTIGATIONS.—The Board may make such in19 vestigations as it considers necessary to determine whether 

20 there is or may be a violation of any regulation promul21 gated under this Act and may require or permit any per22 son to file with it a statement in writing, under oath or 

23 otherwise as the Board shall determine, as to all the facts 

24 and circumstances concerning the matter to be inves25 tigated. 


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1 (f) SUBPOENA POWER.— 

2 (1) IN GENERAL.—The Board may issue sub3 poenas requiring the attendance and testimony of 

4 witnesses and the production of any evidence relat5 ing to any matter under investigation by the Board. 

6 The attendance of witnesses and the production of 

7 evidence may be required from any place within the 

8 United States at any designated place of hearing 

9 within the United States. 

10 (2) FAILURE TO OBEY A SUBPOENA.—If a per11 son refuses to obey a subpoena issued under para12 graph (1), the Board may apply to a United States 

13 district court for an order requiring that person to 

14 appear before the Board to give testimony, produce 

15 evidence, or both, relating to the matter under inves16 tigation. The application may be made within the ju17 dicial district where the hearing is conducted or 

18 where that person is found, resides, or transacts 

19 business. Any failure to obey the order of the court 

20 may be punished by the court as civil contempt. 

21 (3) SERVICE OF SUBPOENAS.—The subpoenas 

22 of the Board shall be served in the manner provided 

23 for subpoenas issued by a United States district 

24 court under the Federal Rules of Civil Procedure for 

25 the United States district courts. 


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1 (4) SERVICE OF PROCESS.—All process of any 

2 court to which application is made under paragraph 

3 (2) may be served in the judicial district in which 

4 the person required to be served resides or may be 

5 found. 

6 (5) NOTICE.—Upon issuing any subpoena 

7 under this subsection, the Board shall give notice of 

8 such issuance to the appropriate committees of Con9 gress, including the Committee on Appropriations of 

10 the House of Representatives and the Committee on 

11 Appropriations of the Senate. 

12 (g) CONFIDENTIALITY.—Under this title, the Sec13 retary shall enforce applicable law concerning a trade se14 cret or confidential information subject to section 

15 552(b)(4) of title 5, United States Code, or section 1905 

16 of title 18. 

17 SEC. 306. REGULATIONS. 

18 (a) IN GENERAL.—Not later than 1 year after the 

19 date of the initial meeting held under section 302(e), the 

20 Board shall issue final regulations to carry out this Act. 

21 (b) NOTICE AND COMMENT REQUIREMENT.—The 

22 regulations developed under subsection (a) shall be issued 

23 in accordance with the notice and comment procedures es24 tablished under section 553 of title 5, United States Code. 


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1 SEC. 307. REPORT TO FEDERAL AGENCIES. 

2 Not later than 1 year after the effective date of the 

3 regulations under section 306 and annually thereafter, the 

4 Board shall submit to each Federal agency that dispenses 

5 or makes payments for the dispensing of prescription 

6 drugs or medical devices a report containing a list of each 

7 prescription drug and medical device for which an exces8 sive price was charged during the preceding calendar year, 

9 as determined by the Board under section 303. The Sec10 retary shall make this report publicly available. 

11 SEC. 308. DEFINITIONS. 

12 In this title: 

13 (1) AFFILIATE.—The term ‘‘affiliate’’ means, 

14 with respect to a manufacturer, any entity that con15 trols, is controlled by, or is under common control 

16 with such manufacturer. 

17 (2) AVERAGE MANUFACTURER PRICE.—The 

18 term ‘‘average manufacturer price’’ means the aver19 age price charged by the manufacturer of a prescrip20 tion drug or medical device, as applicable, for sales 

21 of the drug or device by the manufacturer in the 

22 United States over the respective annual quarter. 

23 (3) MEDICAL DEVICE.—The term ‘‘medical de24 vice’’ means a device (as defined in section 201 of 

25 the Federal Food, Drug, and Cosmetic Act (21 

26 U.S.C. 321)). 


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1 (4) PRESCRIPTION DRUG.—The term ‘‘prescrip2 tion drug’’ means a drug (as defined in section 201 

3 of the Federal Food, Drug, and Cosmetic Act (21 

4 U.S.C. 321)) that is subject to section 503(b)(1) of 

5 such Act (21 U.S.C. 353(b)(1)). 

6 (5) MANUFACTURER.—The term ‘‘manufac7 turer’’ means the person— 

8 (A) that holds the application for a drug 

9 approved under section 505 of the Federal 

10 Food, Drug, and Cosmetic Act or the license 

11 issued under section 351 of the Public Health 

12 Service Act; or 

13 (B) who is responsible for setting the price 

14 for the drug. 

15 (6) WHOLESALE ACQUISITION COST.—The term 

16 ‘‘wholesale acquisition cost’’ has the meaning given 

17 that term in section 1847A(c)(6)(B) of the Social 

18 Security Act (42 U.S.C. 1395w–3a(c)(6)(B)). 

19 SEC. 309. MORATORIUM ON DIRECT-TO-CONSUMER DRUG 

20 ADVERTISING. 

21 The Federal Food, Drug, and Cosmetic Act (21 

22 U.S.C. 301 et seq.) is amended— 

23 (1) in section 301 (21 U.S.C. 331), by adding 

24 at the end the following: 


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1 ‘‘(eee) The conduct of direct-to-consumer advertising 

2 of a drug in violation of section 506J.’’; and 

3 (2) in chapter V, by inserting after section 506I 

4 (21 U.S.C. 356f) the following: 

5 ‘‘SEC. 506J. DIRECT-TO-CONSUMER DRUG ADVERTISING. 

6 ‘‘(a) PROHIBITIONS.— 

7 ‘‘(1) FIRST THREE YEARS.— 

8 ‘‘(A) IN GENERAL.—Subject to subpara9 graph (B), no person shall conduct direct-to10 consumer advertising of a drug for which an 

11 application is submitted under section 505(b) 

12 before the end of the 3-year period beginning 

13 on the date of the approval of such application. 

14 ‘‘(B) WAIVER.—The Secretary may waive 

15 the application of subparagraph (A) to a drug 

16 during the third year of the 3-year period de17 scribed in such subparagraph if— 

18 ‘‘(i) the sponsor of the drug submits 

19 an application to the Secretary pursuant to 

20 subparagraph (C); and 

21 ‘‘(ii) the Secretary, after considering 

22 the application and any accompanying ma23 terials, determines that direct-to-consumer 

24 advertising of the drug would have an af25 firmative value to public health. 


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1 ‘‘(C) APPLICATION FOR WAIVER.—To seek 

2 a waiver under subparagraph (B), the sponsor 

3 of a drug shall submit an application to the 

4 Secretary at such time, in such manner, and 

5 containing such information as the Secretary 

6 may require. 

7 ‘‘(2) SUBSEQUENT YEARS.—The Secretary may 

8 prohibit direct-to-consumer advertising of a drug 

9 during the period beginning at the end of the 3-year 

10 period described in paragraph (1)(A) if the Sec11 retary determines that the drug has significant ad12 verse health effects based on post-approval studies, 

13 risk-benefit analyses, adverse event reports, the sci14 entific literature, any clinical or observational stud15 ies, or any other appropriate resource. 

16 ‘‘(b) REGULATIONS.—Not later than 1 year after the 

17 date of the enactment of this section, the Secretary shall 

18 revise the regulations promulgated under this Act gov19 erning drug advertisements to the extent necessary to im20 plement this section. 

21 ‘‘(c) RULE OF CONSTRUCTION.—This section shall 

22 not be construed to diminish the authority of the Secretary 

23 to prohibit or regulate direct-to-consumer advertising of 

24 drugs under other provisions of law.’’. 


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1 SEC. 310. REPORTING ON JUSTIFICATION FOR DRUG PRICE 

2 INCREASES. 

3 Title III of the Public Health Service Act (42 U.S.C. 

4 241 et seq.) is amended by adding at the end the fol5 lowing: 

6 ‘‘PART W—DRUG PRICE REPORTING; DRUG 

7 VALUE FUND 

8 ‘‘SEC. 399OO. REPORTING ON JUSTIFICATION FOR DRUG 

9 PRICE INCREASES. 

10 ‘‘(a) DEFINITIONS.—In this section: 

11 ‘‘(1) MANUFACTURER.—The term ‘manufac12 turer’ means the person— 

13 ‘‘(A) that holds the application for a drug 

14 approved under section 505 of the Federal 

15 Food, Drug, and Cosmetic Act or the license 

16 issued under section 351 of the Public Health 

17 Service Act; or 

18 ‘‘(B) who is responsible for setting the 

19 price for the drug. 

20 ‘‘(2) QUALIFYING DRUG.—The term ‘qualifying 

21 drug’ means any drug that is approved under sub22 section (c) or (j) of section 505 of the Federal Food, 

23 Drug, and Cosmetic Act or licensed under subsection 

24 (a) or (k) of section 351 of this Act— 

25 ‘‘(A) that has a wholesale acquisition cost 

26 of $100 or more per month supply or per a 


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1 course of treatment that lasts less than a 

2 month and is— 

3 ‘‘(i)(I) subject to section 503(b)(1) of 

4 the Federal Food, Drug, and Cosmetic 

5 Act; or 

6 ‘‘(II) commonly administered by hos7 pitals (as determined by the Secretary); 

8 ‘‘(ii) not designated as a drug for a 

9 rare disease or condition under section 526 

10 of the Federal Food, Drug, and Cosmetic 

11 Act; and 

12 ‘‘(iii) not designated by the Secretary 

13 as a vaccine; and 

14 ‘‘(B) for which, during the previous cal15 endar year, at least 1 dollar of the total amount 

16 of sales were for individuals enrolled under the 

17 Medicare program under title XVIII of the So18 cial Security Act (42 U.S.C. 1395 et seq.) or 

19 under a State Medicaid plan under title XIX of 

20 such Act (42 U.S.C. 1396 et seq.) or under a 

21 waiver of such plan. 

22 ‘‘(3) WHOLESALE ACQUISITION COST.—The 

23 term ‘wholesale acquisition cost’ has the meaning 

24 given that term in section 1847A(c)(6)(B) of the So25 cial Security Act (42 U.S.C. 1395w–3a(c)(6)(B)). 


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1 ‘‘(b) REPORT.— 

2 ‘‘(1) REPORT REQUIRED.—The manufacturer of 

3 a qualifying drug shall submit a report to the Sec4 retary for each price increase of a qualifying drug 

5 that will result in an increase in the wholesale acqui6 sition cost of that drug that is equal to— 

7 ‘‘(A) 10 percent or more over a 12-month 

8 period; or 

9 ‘‘(B) 25 percent or more over a 36-month 

10 period. 

11 ‘‘(2) REPORT DEADLINE.—Each report de12 scribed in paragraph (1) shall be submitted to the 

13 Secretary not later than 30 days prior to the 

14 planned effective date of such price increase. 

15 ‘‘(c) CONTENTS.—A report under subsection (b) 

16 shall, at a minimum, include— 

17 ‘‘(1) with respect to the qualifying drug— 

18 ‘‘(A) the percentage by which the manufac19 turer will raise the wholesale acquisition cost of 

20 the drug on the planned effective date of such 

21 price increase; 

22 ‘‘(B) a justification for, and description of, 

23 each manufacturer’s price increase that will 

24 occur during the 12-month period described in 


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1 subsection (b)(1)(A) or the 36-month period de2 scribed in subsection (b)(1)(B), as applicable; 

3 ‘‘(C) the identity of the initial developer of 

4 the drug; 

5 ‘‘(D) a description of the history of the 

6 manufacturer’s price increases for the drug 

7 since the approval of the application for the 

8 drug under section 505 of the Federal Food, 

9 Drug, and Cosmetic Act or the issuance of the 

10 license for the drug under section 351, or since 

11 the manufacturer acquired such approved appli12 cation or license; 

13 ‘‘(E) the current list price of the drug; 

14 ‘‘(F) the total expenditures of the manu15 facturer on— 

16 ‘‘(i) materials and manufacturing for 

17 such drug; and 

18 ‘‘(ii) acquiring patents and licensing 

19 for such drug; 

20 ‘‘(G) the percentage of total expenditures 

21 of the manufacturer on research and develop22 ment for such drug that was derived from Fed23 eral funds; 


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1 ‘‘(H) the total expenditures of the manu2 facturer on research and development for such 

3 drug that is used for— 

4 ‘‘(i) basic and preclinical research; 

5 ‘‘(ii) clinical research; 

6 ‘‘(iii) new drug development; 

7 ‘‘(iv) pursuing new or expanded indi8 cations for such drug through supple9 mental applications under section 505 of 

10 the Federal Food, Drug, and Cosmetic Act 

11 or section 351 of the Public Health Service 

12 Act; and 

13 ‘‘(v) carrying out postmarket require14 ments related to such drug, including those 

15 under section 505(o)(3) of the Federal 

16 Food, Drug, and Cosmetic Act; 

17 ‘‘(I) the total revenue and the net profit 

18 generated from the qualifying drug for each cal19 endar year since the approval of the application 

20 for the drug under section 505 of the Federal 

21 Food, Drug, and Cosmetic Act or the issuance 

22 of the license for the drug under section 351, 

23 or since the manufacturer acquired such ap24 proved application or license; and 


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1 ‘‘(J) the total costs associated with mar2 keting and advertising for the qualifying drug; 

3 ‘‘(2) with respect to the manufacturer— 

4 ‘‘(A) the total revenue and the net profit 

5 of the manufacturer for each of the 12- and 36- 

6 month periods preceding the submission of the 

7 report; 

8 ‘‘(B) all stock-based performance metrics 

9 used by the manufacturer to determine execu10 tive compensation for each of the 12- and 36- 

11 month periods preceding the submission of the 

12 report; and 

13 ‘‘(C) any additional information the manu14 facturer chooses to provide related to drug pric15 ing decisions, such as total expenditures on— 

16 ‘‘(i) drug research and development; 

17 or 

18 ‘‘(ii) clinical trials on drugs that failed 

19 to receive approval by the Food and Drug 

20 Administration; and 

21 ‘‘(3) such other related information as the Sec22 retary considers appropriate. 

23 ‘‘(d) CIVIL PENALTY.—Any manufacturer of a quali24 fying drug that fails to submit a report for the drug as 


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1 required by this section shall be subject to a civil penalty 

2 of $100,000 for each day on which the violation continues. 

3 ‘‘(e) PUBLIC POSTING.— 

4 ‘‘(1) IN GENERAL.—Subject to paragraph (3), 

5 not later than 30 days after the submission of a re6 port under subsection (b), the Secretary shall post 

7 the report on the public website of the Department 

8 of Health and Human Services. 

9 ‘‘(2) FORMAT.—In developing the format of 

10 such report for public posting, the Secretary shall 

11 consult stakeholders, including beneficiary groups, 

12 and shall seek feedback on the content and format 

13 from consumer advocates and readability experts to 

14 ensure such public reports are user-friendly to the 

15 public and are written in plain language that con16 sumers can readily understand. 

17 ‘‘(3) TRADE SECRETS AND CONFIDENTIAL IN18 FORMATION.—In carrying out this section, the Sec19 retary shall enforce applicable law concerning the 

20 protection of confidential commercial information 

21 and trade secrets. 

22 ‘‘SEC. 399OO–1. USE OF CIVIL PENALTY AMOUNTS. 

23 ‘‘The Secretary shall, without further appropriation, 

24 collect civil penalties under section 399OO and use the 

25 funds derived from such civil penalties, in addition to any 


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1 other amounts available to the Secretary, to carry out ac2 tivities described in this part and to improve consumer and 

3 provider information about drug value and drug price 

4 transparency. 

5 ‘‘SEC. 399OO–2. ANNUAL REPORT TO CONGRESS. 

6 ‘‘(a) IN GENERAL.—Subject to subsection (b), the 

7 Secretary shall submit to Congress, and post on the public 

8 website of the Department of Health and Human Services 

9 in a way that is easy to use and understand, an annual 

10 report— 

11 ‘‘(1) summarizing the information reported pur12 suant to section 399OO; and 

13 ‘‘(2) including copies of the reports and sup14 porting detailed economic analyses submitted pursu15 ant to such section. 

16 ‘‘(b) TRADE SECRETS AND CONFIDENTIAL INFORMA17 TION.—In carrying out this section, the Secretary shall 

18 enforce applicable law concerning the protection of con19 fidential commercial information and trade secrets.’’. 

20 TITLE IV—OUTCOMES AND 

21 REPORTING 

22 SEC. 401. SENSE OF CONGRESS. 

23 It is the sense of Congress that Medicare for America 

24 will have a significant impact on the health and well-being 

25 of the United States population and the social deterVerDate Sep 11 2014 20:58 May 08, 2019 Jkt 089200 PO 00000 Frm 00175 Fmt 6652 Sfmt 6201 E:\BILLS\H2452.IH H2452

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1 minants of the health of beneficiaries of Medicare for 

2 America. 

3 SEC. 402. EVALUATION OF BILL’S OUTCOME. 

4 (a) IN GENERAL.—To assess the impact of this Act 

5 on the health of the population, not later than 2 years 

6 after the date of the enactment of this Act, the Secretary 

7 of Health and Human Services shall allow for analysis of 

8 administrative records that have removed all personally 

9 identifiable information from the Center for Health Care 

10 to existing population surveys conducted by the Federal 

11 Government and federally supported surveys. 

12 (b) CDC AND NIH.—The Directors of the Centers 

13 for Disease Control and Prevention and the National In14 stitutes of Health shall solicit a comprehensive, longitu15 dinal study to evaluate any differential individual impact 

16 on coverage expansion based on— 

17 (1) race and ethnicity; 

18 (2) socioeconomic status; or 

19 (3) health status. 

20 (c) REPORT.—Ten years after the date of the enact21 ment of this Act and every ten years thereafter, the Sec22 retary shall submit a report to the House Committee on 

23 Energy and Commerce and the Senate Committee on 

24 Health, Education, Labor, and Pensions regarding impact 

25 of this Act on the health of the United States population 


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1 based on the results of subsection (b) contributions from 

2 all other relevant agencies. 

Æ 


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