I 

118TH CONGRESS 

1ST SESSION H. R. 5299 

To amend title XVIII of the Social Security Act to establish a demonstration 

program for international coverage under the Medicare program. 

IN THE HOUSE OF REPRESENTATIVES 

AUGUST 29, 2023 

Mr. ESPAILLAT introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy 

and Commerce, 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 title XVIII of the Social Security Act to establish 

a demonstration program for international coverage 

under the Medicare program. 

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

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Earned Benefits 

5 Equality and Family Reunification Act’’. 


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1 SEC. 2. ESTABLISHING A DEMONSTRATION PROGRAM FOR 

2 INTERNATIONAL COVERAGE UNDER THE 

3 MEDICARE PROGRAM. 

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

5 1395 et seq.) is amended by inserting after section 1866F 

6 the following new section: 

7 ‘‘SEC. 1866G. DEMONSTRATION PROGRAM FOR INTER8 NATIONAL COVERAGE. 

9 ‘‘(a) IMPLEMENTATION OF 10-YEAR DEMONSTRA10 TION PROGRAM.—Not later than 1 year after the date of 

11 the enactment of this section, the Secretary shall imple12 ment a 10-year demonstration program under this title (in 

13 this section referred to as the Program) to allow Applica14 ble Beneficiaries to apply Medicare benefits to coverage 

15 of items and services, premiums, and other cost-sharing 

16 under the health insurance systems of other countries. 

17 Through the Program, the Secretary shall make payments 

18 under subsection (e) to or on behalf of Applicable Bene19 ficiaries participating in the Program. 

20 ‘‘(b) PROGRAM DESIGN.— 

21 ‘‘(1) IN GENERAL.—The Secretary shall design 

22 the Program in such a manner to allow for the eval23 uation of the extent to which the Program accom24 plishes the following purposes: 


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1 ‘‘(A) Increases the quality of care for Ap2 plicable Beneficiaries participating in the Pro3 gram. 

4 ‘‘(B) Decreases the cost of care to the gov5 ernment for the Applicable Beneficiaries. 

6 ‘‘(C) Enables Applicable Beneficiaries to 

7 reunify with family members. 

8 ‘‘(D) Reduced strain on the medical infra9 structure of the United States. 

10 ‘‘(2) CONSULTATION.—In designing the Pro11 gram, the Secretary shall use open door forums and 

12 other mechanisms to seek input from a consortium 

13 of stakeholders that may include but are not limited 

14 to— 

15 ‘‘(A) the United States Department of 

16 State; 

17 ‘‘(B) clinical and analytical experts with 

18 relevant expertise; 

19 ‘‘(C) beneficiaries; and 

20 ‘‘(D) foreign health insurance system ex21 perts. 

22 ‘‘(3) PROGRAM CONSIDERATIONS.—In consulta23 tion with stakeholders as identified in subsection 

24 (b)(2), the Secretary shall issue guidance on— 


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1 ‘‘(A) the guidelines to ensure the usage of 

2 medications and equipment that are of accept3 able quality relative to American quality stand4 ards; 

5 ‘‘(B) ways to ensuring quality of care; and 

6 ‘‘(C) ways to target low-income Americans 

7 as participants in the program. 

8 ‘‘(c) SELECTED COUNTRIES INITIAL SELECTION.— 

9 In choosing Selected Countries for the Program, the Sec10 retary shall initially select at least 11 distinct nations or 

11 political subdivisions thereof, which shall include Canada, 

12 the Federal Republic of Germany, the Republic of India, 

13 the State of Israel, the Republic of Korea, the Republic 

14 of the Philippines, the Republic of Panama, the United 

15 Mexican States, Dominican Republic, and at least one na16 tion or political subdivision thereof in Africa. 

17 ‘‘(d) APPLICABLE BENEFICIARY.— 

18 ‘‘(1) VOLUNTARY BENEFICIARY PARTICIPA19 TION.—An Applicable Beneficiary may participate in 

20 the Program on a voluntary basis and may termi21 nate participation in the Program at any time. The 

22 election to participate in the Program or to termi23 nate participation shall constitute a Special Election 

24 Period under section 1852(e)(4) of this title. 


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1 ‘‘(2) SERVICES.—In order to participate in the 

2 Program, an Applicable Beneficiary shall agree to 

3 receive coverage of health care items and services in 

4 a Selected Country during such time as the Applica5 ble Beneficiary is a resident of that country. 

6 ‘‘(3) BENEFICIARY ACCESS TO SERVICES.— 

7 Nothing in this section shall be construed as limiting 

8 an Applicable Beneficiary’s access to items and serv9 ices covered under this title when furnished in the 

10 United States, and Applicable Beneficiaries shall not 

11 be required to relinquish access to such benefits as 

12 a condition of receiving services from a participant 

13 in the Program. 

14 ‘‘(4) NUMBER OF APPLICABLE BENE15 FICIARIES.—The Secretary may cap the number of 

16 Applicable Beneficiaries accepted into the Program, 

17 but at a number no smaller than 150,000. 

18 ‘‘(e) PHYSICIAN CERTIFICATION.—Participating phy19 sicians must be in good standing with accreditation insti20 tutions or licensing authorities in the Selected Countries. 

21 ‘‘(f) PAYMENTS.— 

22 ‘‘(1) IN GENERAL.—The Secretary shall make 

23 payments to or on behalf of Applicable Beneficiaries 

24 for the costs of health care items and services paid 

25 by Applicable Beneficiaries in Selected Countries. 


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1 Such payments may include payments for individual 

2 items or services paid by Applicable Beneficiaries, 

3 payments for cost sharing incurred by Applicable 

4 Beneficiaries, and premiums and equivalent charges 

5 for health insurance coverage paid by Applicable 

6 Beneficiaries. Payments shall not include reimburse7 ment for taxes levied on income for the purpose of 

8 funding health care. 

9 ‘‘(2) PAYMENT AMOUNTS.—The Secretary shall 

10 limit the amounts of payment to ensure such pay11 ments and funds expended to design, implement, 

12 and evaluate the Program do not exceed in the ag13 gregate the amount the Secretary would pay under 

14 this title for equivalent services delivered in the 

15 United States. 

16 ‘‘(3) NO DUPLICATE PAYMENT.—The Secretary 

17 shall make or permit payments under this paragraph 

18 only for a calendar month in which the Applicable 

19 Beneficiary resides in the Selected Country and does 

20 not incur any costs under this title other than the 

21 payment hereunder. 

22 ‘‘(g) ROLE OF MEDICARE ADVANTAGE.— 

23 ‘‘(1) In carrying out the Program, the Sec24 retary may administer the Program, either in part 


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1 or exclusively, through Medicare Advantage Organi2 zations. 

3 ‘‘(2) To the extent Medicare Advantage Organi4 zations carry out functions under the Program, pay5 ments made by such organizations under subsection 

6 (e) shall be considered as if they were benefits under 

7 the original Medicare fee-for-service program option 

8 for purposes of sections 1852 and 1854 of this title, 

9 and a component of standard prescription drug cov10 erage and not supplemental prescription drug cov11 erage, under section 1860D2(a) of this title. 

12 ‘‘(3) The Secretary may limit the number of 

13 Medicare Advantage Organizations participating in 

14 the Program, in accordance with criteria established 

15 by the Secretary. 

16 ‘‘(h) REPORTING.—The Secretary shall conduct an17 nual intermediate and a final evaluation of the Program. 

18 Each such evaluation shall determine the extent to which 

19 each of the purposes described in subsection (b) have been 

20 accomplished under the Program. The evaluation shall 

21 contain recommendations to Congress with regards to the 

22 expansion of the Program. 

23 ‘‘(i) ADDRESSING WASTE, FRAUD, AND ABUSE.— 

24 ‘‘(1) Participating physicians are required to go 

25 through Fraud, Waste, and Abuse training within 


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1 90 days of implementation of the demonstration 

2 project and at least annually thereafter. 

3 ‘‘(2) The Secretary must create a system to 

4 allow patients and physicians to report instances or 

5 concerns of waste, fraud, and abuse. 

6 ‘‘(j) DEFINITIONS.—In this section: 

7 ‘‘(1) APPLICABLE BENEFICIARY.—The term 

8 ‘Applicable Beneficiary’ means an individual who— 

9 ‘‘(A) is entitled to or enrolled for benefits 

10 under part A, and enrolled for benefits under 

11 part B; 

12 ‘‘(B) may be enrolled in a Medicare Advan13 tage plan under part C; 

14 ‘‘(C) is either— 

15 ‘‘(i) a resident of the United States at 

16 the time of application to the Program who 

17 intends to relocate to a Selected Country 

18 on or after the date of such application, or 

19 is a former resident of the United States 

20 who has relocated to a Selected Country 

21 within 180 days of application to the Pro22 gram; or 

23 ‘‘(ii) a resident of a Selected Country 

24 for whom the Medicare program is at the 


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1 time of application the primary payor of 

2 their health care costs; and 

3 ‘‘(D) meets such other criteria as the Sec4 retary determines appropriate. 

5 ‘‘(2) SELECTED COUNTRY.—The term Selected 

6 Country means a nation or political subdivision 

7 thereof identified by the Secretary as having a 

8 health care system that provides for— 

9 ‘‘(A) health care coverage in scope and 

10 quality of coverage appropriate for Medicare 

11 beneficiaries in accordance with criteria estab12 lished by the Secretary; and 

13 ‘‘(B) cost of coverage, coinsurance, and 

14 items and services that is equivalent to or less 

15 than expected costs for such coverage, coinsur16 ance, and items and services in the United 

17 States under this title. 

18 ‘‘(k) FUNDING.— 

19 ‘‘(1) ADMINISTRATIVE FUNDING.—The Sec20 retary shall allocate funds made available under sec21 tion 1115A(f)(1) to design, implement, and evaluate 

22 the Program. 

23 ‘‘(2) BENEFIT FUNDING.—Payments for items 

24 and services under the Program shall be made in ap25 propriate part from the Federal Hospital Insurance 


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1 Trust Fund established by section 1817 of this title 

2 and the Federal Supplementary Medical Insurance 

3 Trust Fund established by section 1841 of this title. 

4 ‘‘(l) WAIVERS.—The Secretary may waive any provi5 sion of this title as may be necessary to carry out the Pro6 gram under this section. 

7 ‘‘(m) LIMITATIONS ON REVIEW.—There shall be no 

8 administrative or judicial review under section 1869, sec9 tion 1878, or otherwise of— 

10 ‘‘(1) the selection of organizations, sites, or par11 ticipants to test the Program; and 

12 ‘‘(2) the elements, parameters, scope, and dura13 tion of the Program. The preceding sentence shall 

14 not prevent an Applicable Beneficiary, having been 

15 selected as a participant, from exercising a right to 

16 appeal under sections 1869, 1155, 1852(g), 1860D– 

17 4, or otherwise. 

18 ‘‘(n) ADMINISTRATION.— 

19 ‘‘(1) Chapter 35 of title 44, United States 

20 Code, shall not apply to the activities under this sec21 tion. 

22 ‘‘(2) The Secretary may enter into contracts for 

23 the administration of the Program without regard to 


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1 any requirement for the use of competitive proce2 dures.’’. 

Æ 


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