I 
116TH CONGRESS 
1ST SESSION H. R. 1384 
To establish an improved Medicare for All national health insurance program. 
IN THE HOUSE OF REPRESENTATIVES 
FEBRUARY 27, 2019 
Ms. JAYAPAL (for herself, Mrs. DINGELL, Ms. ADAMS, Ms. BARRAGA´N, Ms. 
BASS, Mrs. BEATTY, Mr. BEYER, Mr. BLUMENAUER, Ms. BONAMICI, Mr. 
BRENDAN F. BOYLE of Pennsylvania, Mr. BROWN of Maryland, Mr. CAR-
SON of Indiana, Mr. CARTWRIGHT, Ms. JUDY CHU of California, Mr. 
CICILLINE, Ms. CLARK of Massachusetts, Ms. CLARKE of New York, Mr. 
CLAY, Mr. CLEAVER, Mr. COHEN, Mr. DANNY K. DAVIS of Illinois, Mr. 
DEFAZIO, Ms. DEGETTE, Mr. DESAULNIER, Mr. MICHAEL F. DOYLE of 
Pennsylvania, Mr. ENGEL, Ms. ESCOBAR, Mr. ESPAILLAT, Ms. FRANKEL, 
Ms. FUDGE, Ms. GABBARD, Mr. GALLEGO, Mr. GARCI´A of Illinois, Mr. 
GOLDEN, Mr. GOMEZ, Mr. GONZALEZ of Texas, Mr. GREEN of Texas, 
Mr. GRIJALVA, Ms. HAALAND, Mr. HARDER of California, Mr. HAS-
TINGS, Mrs. HAYES, Mr. HIGGINS of New York, Ms. HILL of California, 
Ms. NORTON, Mr. HUFFMAN, Ms. JACKSON LEE, Mr. JOHNSON of Geor-
gia, Mr. KEATING, Ms. KELLY of Illinois, Mr. KENNEDY, Mr. KHANNA, 
Mrs. KIRKPATRICK, Mr. LANGEVIN, Mrs. LAWRENCE, Ms. LEE of Cali-
fornia, Mr. LEVIN of California, Mr. LEVIN of Michigan, Mr. LEWIS, Mr. 
TED LIEU of California, Mr. LOWENTHAL, Mrs. LOWEY, Mrs. CAROLYN 
B. MALONEY of New York, Mr. MCGOVERN, Mr. MCNERNEY, Mr. 
MEEKS, Ms. MENG, Mr. NADLER, Mrs. NAPOLITANO, Mr. NEGUSE, Ms. 
OCASIO-CORTEZ, Ms. OMAR, Mr. PANETTA, Mr. PAYNE, Mr. PERL-
MUTTER, Ms. PINGREE, Mr. POCAN, Ms. PORTER, Ms. PRESSLEY, Mr. 
RASKIN, Ms. ROYBAL-ALLARD, Mr. RUSH, Mr. RYAN, Mr. SABLAN, Ms. 
SA´NCHEZ, Mr. SARBANES, Ms. SCHAKOWSKY, Mr. SCHIFF, Mr. SCOTT of 
Virginia, Mr. SERRANO, Mr. SMITH of Washington, Ms. SPEIER, Mr. 
SWALWELL of California, Mr. TAKANO, Mr. THOMPSON of California, Mr. 
THOMPSON of Mississippi, Ms. TITUS, Ms. TLAIB, Mr. TONKO, Mr. 
VEASEY, Ms. VELA´ZQUEZ, Mr. VISCLOSKY, Ms. WATERS, Mrs. WATSON 
COLEMAN, Mr. WELCH, Ms. WILD, and Ms. WILSON of Florida) intro-
duced the following bill; which was referred to the Committee on Energy 
and Commerce, and in addition to the Committees on Ways and Means, 
Education and Labor, Rules, Oversight and Reform, and Armed Services, 
for a period to be subsequently determined by the Speaker, in each case 
for consideration of such provisions as fall within the jurisdiction of the 
committee concerned 
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A BILL 
To establish an improved Medicare for All national health 
insurance program. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Medicare for All Act of 2019’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
TITLE I—ESTABLISHMENT OF THE MEDICARE FOR ALL 
PROGRAM; UNIVERSAL COVERAGE; ENROLLMENT 
Sec. 101. Establishment of the Medicare for All Program. 
Sec. 102. Universal coverage. 
Sec. 103. Freedom of choice. 
Sec. 104. Non-discrimination. 
Sec. 105. Enrollment. 
Sec. 106. Effective date of benefits. 
Sec. 107. Prohibition against duplicating coverage. 
TITLE II—COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE 
BENEFITS AND BENEFITS FOR LONG-TERM CARE 
Sec. 201. Comprehensive benefits. 
Sec. 202. No cost-sharing. 
Sec. 203. Exclusions and limitations. 
Sec. 204. Coverage of long-term care services. 
TITLE III—PROVIDER PARTICIPATION 
Sec. 301. Provider participation and standards; whistleblower protections. 
Sec. 302. Qualifications for providers. 
Sec. 303. Use of private contracts. 
TITLE IV—ADMINISTRATION 
Subtitle A—General Administration Provisions 
Sec. 401. Administration. 
Sec. 402. Consultation. 
Sec. 403. Regional administration. 
Sec. 404. Beneficiary ombudsman. 
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Sec. 405. Conduct of related health programs. 
Subtitle B—Control Over Fraud and Abuse 
Sec. 411. Application of Federal sanctions to all fraud and abuse under the 
Medicare for All Program. 
TITLE V—QUALITY ASSESSMENT 
Sec. 501. Quality standards. 
Sec. 502. Addressing health care disparities. 
TITLE VI—HEALTH BUDGET; PAYMENTS; COST CONTAINMENT 
MEASURES 
Subtitle A—Budgeting 
Sec. 601. National health budget. 
Subtitle B—Payments to Providers 
Sec. 611. Payments to institutional providers based on global budgets. 
Sec. 612. Payment to individual providers through fee-for-service. 
Sec. 613. Ensuring accurate valuation of services under the Medicare physician 
fee schedule. 
Sec. 614. Payment prohibitions; capital expenditures; special projects. 
Sec. 615. Office of primary health care. 
Sec. 616. Payments for prescription drugs and approved devices and equip-
ment. 
TITLE VII—UNIVERSAL MEDICARE TRUST FUND 
Sec. 701. Universal Medicare Trust Fund. 
TITLE VIII—CONFORMING AMENDMENTS TO THE EMPLOYEE 
RETIREMENT INCOME SECURITY ACT OF 1974 
Sec. 801. Prohibition of employee benefits duplicative of benefits under the 
Medicare for All Program; coordination in case of workers’ 
compensation. 
Sec. 802. Application of continuation coverage requirements under ERISA and 
certain other requirements relating to group health plans. 
Sec. 803. Effective date of title. 
TITLE IX—ADDITIONAL CONFORMING AMENDMENTS 
Sec. 901. Relationship to existing Federal health programs. 
Sec. 902. Sunset of provisions related to the State Exchanges. 
Sec. 903. Sunset of provisions related to pay for performance programs. 
TITLE X—TRANSITION 
Subtitle A—Medicare for All Transition Over 2 Years and Transitional Buy- 
In Option 
Sec. 1001. Medicare for all transition over two years. 
Sec. 1002. Establishment of the Medicare transition buy-in. 
Subtitle B—Transitional Medicare Reforms 
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Sec. 1011. Eliminating the 24-month waiting period for Medicare coverage for 
individuals with disabilities. 
Sec. 1012. Ensuring continuity of care. 
TITLE XI—MISCELLANEOUS 
Sec. 1101. Definitions. 
Sec. 1102. Rules of construction. 
TITLE 
I—ESTABLISHMENT 
OF 
THE MEDICARE FOR ALL PRO-
GRAM; 
UNIVERSAL 
COVER-
AGE; ENROLLMENT 
SEC. 101. ESTABLISHMENT OF THE MEDICARE FOR ALL 
PROGRAM. 
There is hereby established a national health insur-
ance program to provide comprehensive protection against 
the costs of health care and health-related services, in ac-
cordance with the standards specified in, or established 
under, this Act. 
SEC. 102. UNIVERSAL COVERAGE. 
(a) IN GENERAL.—Every individual who is a resident 
of the United States is entitled to benefits for health care 
services under this Act. The Secretary shall promulgate 
a rule that provides criteria for determining residency for 
eligibility purposes under this Act. 
(b) TREATMENT OF OTHER INDIVIDUALS.—The Sec-
retary may make eligible for benefits for health care serv-
ices under this Act other individuals not described in sub-
section (a), and regulate the eligibility of such individuals, 
to ensure that every person in the United States has ac-
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cess to health care. In regulating such eligibility, the Sec-
retary shall ensure that individuals are not allowed to 
travel to the United States for the sole purpose of obtain-
ing health care items and services provided under the pro-
gram established under this Act. 
SEC. 103. FREEDOM OF CHOICE. 
Any individual entitled to benefits under this Act may 
obtain health services from any institution, agency, or in-
dividual qualified to participate under this Act. 
SEC. 104. NON-DISCRIMINATION. 
(a) IN GENERAL.—No person shall, on the basis of 
race, color, national origin, age, disability, marital status, 
citizenship status, primary language use, genetic condi-
tions, previous or existing medical conditions, religion, or 
sex, including sex stereotyping, gender identity, sexual ori-
entation, and pregnancy and related medical conditions 
(including termination of pregnancy), be excluded from 
participation in or be denied the benefits of the program 
established under this Act (except as expressly authorized 
by this Act for purposes of enforcing eligibility standards 
described in section 102), or be subject to any reduction 
of benefits or other discrimination by any participating 
provider (as defined in section 301), or any entity con-
ducting, administering, or funding a health program or 
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activity, including contracts of insurance, pursuant to this 
Act. 
(b) CLAIMS OF DISCRIMINATION.— 
(1) IN GENERAL.—The Secretary shall establish 
a procedure for adjudication of administrative com-
plaints alleging a violation of subsection (a). 
(2) JURISDICTION.—Any person aggrieved by a 
violation of subsection (a) by a covered entity may 
file suit in any district court of the United States 
having jurisdiction of the parties. A person may 
bring an action under this paragraph concurrently 
as such administrative remedies as established in 
paragraph (1). 
(3) DAMAGES.—If the court finds a violation of 
subsection (a), the court may grant compensatory 
and punitive damages, declaratory relief, injunctive 
relief, attorneys’ fees and costs, or other relief as ap-
propriate. 
(c) CONTINUED APPLICATION OF LAWS.—Nothing in 
this title (or an amendment made by this title) shall be 
construed to invalidate or otherwise limit any of the rights, 
remedies, procedures, or legal standards available to indi-
viduals aggrieved under section 1557 of the Patient Pro-
tection and Affordable Care Act (42 U.S.C. 18116), title 
VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et 
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seq.), title VII of the Civil Rights Act of 1964 (42 U.S.C. 
2000e et seq.), title IX of the Education Amendments of 
1972 (20 U.S.C. 1681 et seq.), section 504 of the Reha-
bilitation Act of 1973 (29 U.S.C. 794), or the Age Dis-
crimination Act of 1975 (42 U.S.C. 611 et seq.). Nothing 
in this title (or an amendment to this title) shall be con-
strued to supersede State laws that provide additional pro-
tections against discrimination on any basis described in 
subsection (a). 
SEC. 105. ENROLLMENT. 
(a) IN GENERAL.—The Secretary shall provide a 
mechanism for the enrollment of individuals eligible for 
benefits under this Act. The mechanism shall— 
(1) include a process for the automatic enroll-
ment of individuals at the time of birth in the 
United States (or upon establishment of residency in 
the United States); 
(2) provide for the enrollment, as of the dates 
described in section 106, of all individuals who are 
eligible to be enrolled as of such dates, as applicable; 
and 
(3) include a process for the enrollment of indi-
viduals made eligible for health care services under 
section 102(b). 
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(b) ISSUANCE OF UNIVERSAL MEDICARE CARDS.— 
In conjunction with an individual’s enrollment for benefits 
under this Act, the Secretary shall provide for the issuance 
of a Universal Medicare card that shall be used for pur-
poses of identification and processing of claims for bene-
fits under this program. The card shall not include an in-
dividual’s Social Security number. 
SEC. 106. EFFECTIVE DATE OF BENEFITS. 
(a) IN GENERAL.—Except as provided in subsection 
(b), benefits shall first be available under this Act for 
items and services furnished 2 years after the date of the 
enactment of this Act. 
(b) COVERAGE FOR CERTAIN INDIVIDUALS.— 
(1) IN GENERAL.—For any eligible individual 
who— 
(A) has not yet attained the age of 19 as 
of the date that is 1 year after the date of the 
enactment of this Act; or 
(B) has attained the age of 55 as of the 
date that is 1 year after the date of the enact-
ment of this Act, 
benefits shall first be available under this Act for 
items and services furnished as of such date. 
(2) OPTION TO CONTINUE IN OTHER COVERAGE 
DURING TRANSITION PERIOD.—Any person who is 
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eligible to receive benefits as described in paragraph 
(1) may opt to maintain any coverage described in 
section 901, private health insurance coverage, or 
coverage offered pursuant to subtitle A of title X 
(including the amendments made by such subtitle) 
until the date described in subsection (a). 
SEC. 107. PROHIBITION AGAINST DUPLICATING COVERAGE. 
(a) IN GENERAL.—Beginning on the effective date 
described in section 106(a), it shall be unlawful for— 
(1) a private health insurer to sell health insur-
ance coverage that duplicates the benefits provided 
under this Act; or 
(2) an employer to provide benefits for an em-
ployee, former employee, or the dependents of an 
employee or former employee that duplicate the ben-
efits provided under this Act. 
(b) CONSTRUCTION.—Nothing in this Act shall be 
construed as prohibiting the sale of health insurance cov-
erage for any additional benefits not covered by this Act, 
including additional benefits that an employer may provide 
to employees or their dependents, or to former employees 
or their dependents. 
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TITLE II—COMPREHENSIVE BEN-
EFITS, INCLUDING PREVEN-
TIVE BENEFITS AND BENE-
FITS FOR LONG-TERM CARE 
SEC. 201. COMPREHENSIVE BENEFITS. 
(a) IN GENERAL.—Subject to the other provisions of 
this title and titles IV through IX, individuals enrolled for 
benefits under this Act are entitled to have payment made 
by the Secretary to an eligible provider for the following 
items and services if medically necessary or appropriate 
for the maintenance of health or for the diagnosis, treat-
ment, or rehabilitation of a health condition: 
(1) Hospital services, including inpatient and 
outpatient hospital care, including 24-hour-a-day 
emergency services and inpatient prescription drugs. 
(2) Ambulatory patient services. 
(3) Primary and preventive services, including 
chronic disease management. 
(4) Prescription drugs and medical devices, in-
cluding outpatient prescription drugs, medical de-
vices, and biological products. 
(5) Mental health and substance abuse treat-
ment services, including inpatient care. 
(6) Laboratory and diagnostic services. 
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(7) Comprehensive reproductive, maternity, and 
newborn care. 
(8) Pediatrics. 
(9) Oral health, audiology, and vision services. 
(10) Rehabilitative and habilitative services and 
devices. 
(11) Emergency services and transportation. 
(12) Early and periodic screening, diagnostic, 
and treatment services, as described in sections 
1902(a)(10)(A), 1902(a)(43), 1905(a)(4)(B), and 
1905(r) of the Social Security Act (42 U.S.C. 
1396a(a)(10)(A); 
1396a(a)(43); 
1396d(a)(4)(B); 
1396d(r)). 
(13) Necessary transportation to receive health 
care services for persons with disabilities or low-in-
come individuals (as determined by the Secretary). 
(14) Long-term care services and support (as 
described in section 204). 
(b) REVISION
AND ADJUSTMENT.—The Secretary 
shall, at least annually, and on a regular basis, evaluate 
whether the benefits package should be improved or ad-
justed to promote the health of beneficiaries, account for 
changes in medical practice or new information from med-
ical research, or respond to other relevant developments 
in health science, and shall make recommendations to 
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Congress regarding any such improvements or adjust-
ments. 
(c) HEARINGS.— 
(1) IN GENERAL.—The Committee on Energy 
and Commerce and the Committee on Ways and 
Means of the House of Representatives shall, not 
less frequently than annually, hold a hearing on the 
recommendations submitted by the Secretary under 
subsection (b). 
(2) EXERCISE OF RULEMAKING AUTHORITY.— 
Paragraph (1) is enacted— 
(A) as an exercise of rulemaking power of 
the House of Representatives, and, as such, 
shall be considered as part of the rules of the 
House, and such rules shall supersede any other 
rule of the House only to the extent that rule 
is inconsistent therewith; and 
(B) with full recognition of the constitu-
tional right of either House to change such 
rules (so far as relating to the procedure in 
such House) at any time, in the same manner, 
and to the same extent as in the case of any 
other rule of the House. 
(d) COMPLEMENTARY
AND
INTEGRATIVE
MEDI-
CINE.— 
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(1) IN GENERAL.—In carrying out subsection 
(b), the Secretary shall consult with the persons de-
scribed in paragraph (2) with respect to— 
(A) identifying specific complementary and 
integrative medicine practices that are appro-
priate to include in the benefits package; and 
(B) identifying barriers to the effective 
provision and integration of such practices into 
the delivery of health care, and identifying 
mechanisms for overcoming such barriers. 
(2) CONSULTATION.—In accordance with para-
graph (1), the Secretary shall consult with— 
(A) the Director of the National Center for 
Complementary and Integrative Health; 
(B) the Commissioner of Food and Drugs; 
(C) institutions of higher education, pri-
vate research institutes, and individual re-
searchers with extensive experience in com-
plementary and alternative medicine and the in-
tegration of such practices into the delivery of 
health care; 
(D) nationally recognized providers of com-
plementary and integrative medicine; and 
(E) such other officials, entities, and indi-
viduals with expertise on complementary and 
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integrative medicine as the Secretary deter-
mines appropriate. 
(e) STATES
MAY
PROVIDE
ADDITIONAL
BENE-
FITS.—Individual States may provide additional benefits 
for the residents of such States, as determined by such 
State, and may provide benefits to individuals not eligible 
for benefits under this Act, at the expense of the State, 
subject to the requirements specified in section 1102. 
SEC. 202. NO COST-SHARING. 
(a) IN GENERAL.—The Secretary shall ensure that 
no cost-sharing, including deductibles, coinsurance, copay-
ments, or similar charges, is imposed on an individual for 
any benefits provided under this Act. 
(b) NO BALANCE BILLING.—No provider may impose 
a charge to an enrolled individual for covered services for 
which benefits are provided under this Act. 
SEC. 203. EXCLUSIONS AND LIMITATIONS. 
(a) IN GENERAL.—Benefits for items and services 
are not available under this Act unless the items and serv-
ices meet the standards developed by the Secretary pursu-
ant to section 201(a). 
(b) TREATMENT
OF EXPERIMENTAL ITEMS
AND 
SERVICES AND DRUGS.— 
(1) IN GENERAL.—In applying subsection (a), 
the Secretary shall make national coverage deter-
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minations with respect to items and services that are 
experimental in nature. Such determinations shall be 
consistent with the national coverage determination 
process as defined in section 1869(f)(1)(B) of the 
Social Security Act (42 U.S.C. 1395ff(f)(1)(B)). 
(2) APPEALS
PROCESS.—The Secretary shall 
establish a process by which individuals can appeal 
coverage decisions. The process shall, as much as is 
feasible, follow the process for appeals under the 
Medicare program described in section 1869 of the 
Social Security Act (42 U.S.C. 1395ff). 
(c) APPLICATION OF PRACTICE GUIDELINES.— 
(1) IN GENERAL.—In the case of items and 
services for which the Department of Health and 
Human Services has recognized a national practice 
guideline, such items and services shall be deemed to 
meet the standards specified in section 201(a) if 
they have been provided in accordance with such 
guideline. For purposes of this subsection, an item 
or service not provided in accordance with a practice 
guideline shall be deemed to have been provided in 
accordance with the guideline if the health care pro-
vider providing the item or service— 
(A) 
exercised 
appropriate 
professional 
judgment in accordance with the laws and re-
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quirements of the State in which such item or 
service is furnished in deviating from the guide-
line; 
(B) acted in the best interest of the indi-
vidual receiving the item or service; and 
(C) acted in a manner consistent with the 
individual’s wishes. 
(2) OVERRIDE OF STANDARDS.— 
(A) IN GENERAL.—An individual’s treating 
physician or other health care professional au-
thorized to exercise independent professional 
judgment in implementing a patient’s medical 
or nursing care plan in accordance with the 
scope of practice, licensure, and other law of 
the State where items and services are to be 
furnished may override practice standards es-
tablished pursuant to section 201(a) or practice 
guidelines described in paragraph (1), including 
such standards and guidelines that are imple-
mented by a provider through the use of health 
information technology, such as electronic 
health record technology, clinical decision sup-
port technology, and computerized order entry 
programs. 
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(B) LIMITATION.—An override described 
in subparagraph (A) shall, in the professional 
judgment of such physician, nurse, or health 
care professional, be— 
(i) consistent with such physician’s, 
nurse’s, or health care professional’s deter-
mination of medical necessity and appro-
priateness or nursing assessment; 
(ii) in the best interests of the indi-
vidual; and 
(iii) consistent with the individual’s 
wishes. 
SEC. 204. COVERAGE OF LONG-TERM CARE SERVICES. 
(a) IN GENERAL.—Subject to the other provisions of 
this Act, individuals enrolled for benefits under this Act 
are entitled to the following long-term services and sup-
ports and to have payment made by the Secretary to an 
eligible provider for such services and supports if medically 
necessary and appropriate and in accordance with the 
standards established in this Act, for maintenance of 
health or for care, services, diagnosis, treatment, or reha-
bilitation that is related to a medically determinable condi-
tion, whether physical or mental, of health, injury, or age 
that— 
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(1) causes a functional limitation in performing 
one or more activities of daily living; or 
(2) requires a similar need of assistance in per-
forming instrumental activities of daily living due to 
cognitive or other impairments. 
(b) ELIGIBILITY.—The Secretary shall promulgate 
rules that provide for the following: 
(1) The determination of individual eligibility 
for long-term services and supports under this sec-
tion. 
(2) The assessment of the long-term services 
and supports needed for eligible individuals. 
(c) SERVICES AND SUPPORTS.—Long-term services 
and supports under this section shall be tailored to an in-
dividual’s needs, as determined through assessment, and 
shall be defined by the Secretary to— 
(1) include any long-term nursing services for 
the enrollee, whether provided in an institution or in 
a home and community-based setting; 
(2) provide coverage for a broad spectrum of 
long-term services and supports, including for home 
and community-based services and other care pro-
vided through non-institutional settings; 
(3) provide coverage that meets the physical, 
mental, and social needs of recipients while allowing 
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recipients their maximum possible autonomy and 
their maximum possible civic, social, and economic 
participation; 
(4) prioritize delivery of long-term services and 
supports through home and community-based serv-
ices over institutionalization; 
(5) unless an individual elects otherwise, ensure 
that recipients will receive home and community 
based long-term services and supports (as defined in 
subsection (f)(4)), regardless of the individuals’s 
type or level of disability, service need, or age; 
(6) be provided with the goal of enabling per-
sons with disabilities to receive services in the least 
restrictive and most integrated setting appropriate 
to the individual’s needs; 
(7) be provided in such a manner that allows 
persons with disabilities to maintain their independ-
ence, self-determination, and dignity; 
(8) provide long-term services and supports 
that are of equal quality and equally accessible 
across geographic regions; and 
(9) ensure that long-term services and supports 
provide recipient’s the option of self-direction of 
services from either the recipient or care coordina-
tors of the recipient’s choosing. 
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(d) PUBLIC CONSULTATION.—In developing regula-
tions to implement this section, the Secretary shall consult 
with an advisory commission on long-term services and 
supports that includes— 
(1) people with disabilities who use long-term 
services and supports and older adults who use long- 
term services and supports; 
(2) representatives of people with disabilities 
and representatives of older adults; 
(3) groups that represent the diversity of the 
population of people living with disabilities, including 
gender, racial, and economic diversity; 
(4) providers of long-term services and sup-
ports, including family attendants and family care-
givers, and members of organized labor; 
(5) disability rights organizations; and 
(6) relevant academic institutions and research-
ers. 
(e) BUDGETING
AND PAYMENTS.—Budgeting and 
payments for long-term services and supports provided 
under this section shall be made in accordance with the 
provisions under title VI. 
(f) DEFINITIONS.—In this section: 
(1) The term ‘‘long-term services and supports’’ 
means long-term care, treatment, maintenance, or 
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services needed to support the activities of daily liv-
ing and instrumental activities of daily living, includ-
ing all long-term services and supports available 
under section 1915 of the Social Security Act (42 
U.S.C. 1396n), home and community-based services, 
and any additional services and supports identified 
by the Secretary to support people with disabilities 
to live, work, and participate in their communities. 
(2) The term ‘‘activities of daily living’’ means 
basic personal everyday activities, including tasks 
such as eating, toileting, grooming, dressing, bath-
ing, and transferring. 
(3) The term ‘‘instrumental activities of daily 
living’’ means activities related to living independ-
ently in the community, including but not limited to, 
meal planning and preparation, managing finances, 
shopping for food, clothing, and other essential 
items, performing essential household chores, com-
municating by phone or other media, and traveling 
around and participating in the community. 
(4) The term ‘‘home and community-based 
services’’ means the home and community-based 
services that are coverable under subsections (c), 
(d), (i), and (k) of section 1915 of the Social Secu-
rity Act (42 U.S.C. 1396n), and as defined by the 
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Secretary, including as defined in the home and 
community-based services settings rule in sections 
441.530 and 441.710 of title 42, Code of Federal 
Regulations (or a successor regulation). 
TITLE III—PROVIDER 
PARTICIPATION 
SEC. 301. PROVIDER PARTICIPATION AND STANDARDS; 
WHISTLEBLOWER PROTECTIONS. 
(a) IN GENERAL.—An individual or other entity fur-
nishing any covered item or service under this Act is not 
a qualified provider unless the individual or entity— 
(1) is a qualified provider of the items or serv-
ices under section 302; 
(2) has filed with the Secretary a participation 
agreement described in subsection (b); and 
(3) meets, as applicable, such other qualifica-
tions and conditions with respect to a provider of 
services under title XVIII of the Social Security Act 
as described in section 1866 of the Social Security 
Act (42 U.S.C. 1395cc). 
(b) REQUIREMENTS
IN
PARTICIPATION
AGREE-
MENT.— 
(1) IN
GENERAL.—A participation agreement 
described in this subsection between the Secretary 
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and a provider shall provide at least for the fol-
lowing: 
(A) Items and services to eligible persons 
shall be furnished by the provider without dis-
crimination, in accordance with section 104(a). 
Nothing in this subparagraph shall be con-
strued as requiring the provision of a type or 
class of items or services that are outside the 
scope of the provider’s normal practice. 
(B) No charge will be made to any enrolled 
individual for any covered items or services 
other than for payment authorized by this Act. 
(C) The provider agrees to furnish such in-
formation as may be reasonably required by the 
Secretary, in accordance with uniform reporting 
standards established under section 401(b)(1), 
for— 
(i) quality review by designated enti-
ties; 
(ii) making payments under this Act, 
including the examination of records as 
may be necessary for the verification of in-
formation on which such payments are 
based; 
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(iii) statistical or other studies re-
quired for the implementation of this Act; 
and 
(iv) such other purposes as the Sec-
retary may specify. 
(D) In the case of a provider that is not 
an individual, the provider agrees not to employ 
or use for the provision of health services any 
individual or other provider that has had a par-
ticipation agreement under this subsection ter-
minated for cause. The Secretary may authorize 
such employment or use on a case-by-case 
basis. 
(E) In the case of a provider paid under 
a fee-for-service basis for items and services 
furnished under this Act, the provider agrees to 
submit bills and any required supporting docu-
mentation relating to the provision of covered 
items and services within 30 days after the date 
of providing such items and services. 
(F) In the case of an institutional provider 
paid pursuant to section 611, the provider 
agrees to submit information and any other re-
quired supporting documentation as may be 
reasonably required by the Secretary within 30 
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days after the date of providing such items and 
services and in accordance with the uniform re-
porting standards established under section 
401(b)(1), including information on a quarterly 
basis that— 
(i) relates to the provision of covered 
items and services; and 
(ii) describes items and services fur-
nished with respect to specific individuals. 
(G) In the case of a provider that receives 
payment for items and services furnished under 
this Act based on diagnosis-related coding, pro-
cedure coding, or other coding system or data, 
the provider agrees— 
(i) to disclose to the Secretary any 
system or index of coding or classifying pa-
tient symptoms, diagnoses, clinical inter-
ventions, episodes, or procedures that such 
provider utilizes for global budget negotia-
tions under title VI or for meeting any 
other payment, documentation, or data col-
lection requirements under this Act; and 
(ii) not to use any such system or 
index to establish financial incentives or 
disincentives for health care professionals, 
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or that is proprietary, interferes with the 
medical or nursing process, or is designed 
to increase the amount or number of pay-
ments. 
(H) The provider complies with the duty of 
provider ethics and reporting requirements de-
scribed in paragraph (2). 
(I) In the case of a provider that is not an 
individual, the provider agrees that no board 
member, executive, or administrator of such 
provider receives compensation from, owns 
stock or has other financial investments in, or 
serves as a board member of any entity that 
contracts with or provides items or services, in-
cluding pharmaceutical products and medical 
devices or equipment, to such provider. 
(2) PROVIDER DUTY OF ETHICS.—Each health 
care provider, including institutional providers, has a 
duty to advocate for and to act in the exclusive in-
terest of each individual under the care of such pro-
vider according to the applicable legal standard of 
care, such that no financial interest or relationship 
impairs any health care provider’s ability to furnish 
necessary and appropriate care to such individual. 
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To implement the duty established in this para-
graph, the Secretary shall— 
(A) promulgate reasonable reporting rules 
to evaluate participating provider compliance 
with this paragraph; 
(B) 
prohibit 
participating 
providers, 
spouses, and immediate family members of par-
ticipating providers, from accepting or entering 
into any arrangement for any bonus, incentive 
payment, profit-sharing, or compensation based 
on patient utilization or based on financial out-
comes of any other provider or entity; and 
(C) prohibit participating providers or any 
board member or representative of such pro-
vider from serving as board members for or re-
ceiving any compensation, stock, or other finan-
cial investment in an entity that contracts with 
or provides items or services (including pharma-
ceutical products and medical devices or equip-
ment) to such provider. 
(3) TERMINATION OF PARTICIPATION AGREE-
MENT.— 
(A) IN
GENERAL.—Participation agree-
ments may be terminated, with appropriate no-
tice— 
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(i) by the Secretary for failure to meet 
the requirements of this Act; 
(ii) in accordance with the provisions 
described in section 411; or 
(iii) by a provider. 
(B) TERMINATION
PROCESS.—Providers 
shall be provided notice and a reasonable oppor-
tunity to correct deficiencies before the Sec-
retary terminates an agreement unless a more 
immediate termination is required for public 
safety or similar reasons. 
(C) PROVIDER PROTECTIONS.— 
(i) PROHIBITION.—The Secretary may 
not terminate a participation agreement or 
in any other way discriminate against, or 
cause to be discriminated against, any cov-
ered provider or authorized representative 
of the provider, on account of such pro-
vider or representative— 
(I) providing, causing to be pro-
vided, or being about to provide or 
cause to be provided to the provider, 
the Federal Government, or the attor-
ney general of a State information re-
lating to any violation of, or any act 
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or omission the provider or represent-
ative reasonably believes to be a viola-
tion of, any provision of this title (or 
an amendment made by this title); 
(II) testifying or being about to 
testify in a proceeding concerning 
such violation; 
(III) assisting or participating, or 
being about to assist or participate, in 
such a proceeding; or 
(IV) objecting to, or refusing to 
participate in, any activity, policy, 
practice, or assigned task that the 
provider or representative reasonably 
believes to be in violation of any provi-
sion of this Act (including any amend-
ment made by this Act), or any order, 
rule, regulation, standard, or ban 
under this Act (including any amend-
ment made by this Act). 
(ii) COMPLAINT PROCEDURE.—A pro-
vider or representative who believes that he 
or she has been discriminated against in 
violation of this section may seek relief in 
accordance with the procedures, notifica-
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tions, burdens of proof, remedies, and stat-
utes of limitation set forth in section 
2087(b) of title 15, United States Code. 
(c) WHISTLEBLOWER PROTECTIONS.— 
(1) RETALIATION
PROHIBITED.—No person 
may discharge or otherwise discriminate against any 
employee because the employee or any person acting 
pursuant to a request of the employee— 
(A) notified the Secretary or the employ-
ee’s employer of any alleged violation of this 
title, including communications related to car-
rying out the employee’s job duties; 
(B) refused to engage in any practice made 
unlawful by this title, if the employee has iden-
tified the alleged illegality to the employer; 
(C) testified before or otherwise provided 
information relevant for Congress or for any 
Federal or State proceeding regarding any pro-
vision (or proposed provision) of this title; 
(D) commenced, caused to be commenced, 
or is about to commence or cause to be com-
menced a proceeding under this title; 
(E) testified or is about to testify in any 
such proceeding; or 
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(F) assisted or participated or is about to 
assist or participate in any manner in such a 
proceeding or in any other manner in such a 
proceeding or in any other action to carry out 
the purposes of this title. 
(2) ENFORCEMENT
ACTION.—Any employee 
covered by this section who alleges discrimination by 
an employer in violation of paragraph (1) may bring 
an action, subject to the statute of limitations in the 
anti-retaliation provisions of the False Claims Act 
and the rules and procedures, legal burdens of proof, 
and remedies applicable under the employee protec-
tions provisions of the Surface Transportation As-
sistance Act. 
(3) APPLICATION.— 
(A) Nothing in this subsection shall be 
construed to diminish the rights, privileges, or 
remedies of any employee under any Federal or 
State law or regulation, including the rights 
and remedies against retaliatory action under 
the False Claims Act (31 U.S.C. 3730(h)), or 
under any collective bargaining agreement. The 
rights and remedies in this section may not be 
waived by any agreement, policy, form, or con-
dition of employment. 
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(B) Nothing in this subsection shall be 
construed to preempt or diminish any other 
Federal or State law or regulation against dis-
crimination, demotion, discharge, suspension, 
threats, harassment, reprimand, retaliation, or 
any other manner of discrimination, including 
the rights and remedies against retaliatory ac-
tion under the False Claims Act (31 U.S.C. 
3730(h)). 
(4) DEFINITIONS.—In this subsection: 
(A) EMPLOYER.—The term ‘‘employer’’ 
means any person engaged in profit or non-
profit business or industry, including one or 
more individuals, partnerships, associations, 
corporations, trusts, professional membership 
organization including a certification, discipli-
nary, or other professional body, unincorporated 
organizations, nongovernmental organizations, 
or trustees, and subject to liability for violating 
the provisions of this Act. 
(B) EMPLOYEE.—The term ‘‘employee’’ 
means any individual performing activities 
under this Act on behalf of an employer. 
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SEC. 302. QUALIFICATIONS FOR PROVIDERS. 
(a) IN GENERAL.—A health care provider is consid-
ered to be qualified to furnish covered items and services 
under this Act if the provider is licensed or certified to 
furnish such items and services in the State in which such 
items or services are furnished and meets— 
(1) the requirements of such State’s law to fur-
nish such items and services; and 
(2) applicable requirements of Federal law to 
furnish such items and services. 
(b) LIMITATION.—An entity or provider shall not be 
qualified to furnish covered items and services under this 
Act if the entity or provider provides no items and services 
directly to individuals, including— 
(1) entities or providers that contract with 
other entities or providers to provide such items and 
services; and 
(2) entities that are currently approved to co-
ordinate care plans under the Medicare Advantage 
program established in part C of title XVIII of the 
Social Security Act (42 U.S.C. 1851 et seq.) but do 
not directly provide items and services of such care 
plans. 
(c) MINIMUM PROVIDER STANDARDS.— 
(1) IN GENERAL.—The Secretary shall estab-
lish, evaluate, and update national minimum stand-
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ards to ensure the quality of items and services pro-
vided under this Act and to monitor efforts by 
States to ensure the quality of such items and serv-
ices. A State may establish additional minimum 
standards which providers shall meet with respect to 
items and services provided in such State. 
(2) NATIONAL
MINIMUM
STANDARDS.—The 
Secretary shall establish national minimum stand-
ards under paragraph (1) for institutional providers 
of services and individual health care practitioners. 
Except as the Secretary may specify in order to 
carry out this Act, a hospital, skilled nursing facility, 
or other institutional provider of services shall meet 
standards applicable to such a provider under the 
Medicare program under title XVIII of the Social 
Security Act (42 U.S.C. 1395 et seq.). Such stand-
ards also may include, where appropriate, elements 
relating to— 
(A) adequacy and quality of facilities; 
(B) mandatory minimum safe registered 
nurse-to-patient staffing ratios and optimal 
staffing levels for physicians and other health 
care practitioners; 
(C) training and competence of personnel 
(including requirements related to the number 
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of or type of required continuing education 
hours); 
(D) comprehensiveness of service; 
(E) continuity of service; 
(F) patient waiting time, access to serv-
ices, and preferences; and 
(G) performance standards, including orga-
nization, facilities, structure of services, effi-
ciency of operation, and outcome in palliation, 
improvement of health, stabilization, cure, or 
rehabilitation. 
(3) TRANSITION IN APPLICATION.—If the Sec-
retary provides for additional requirements for pro-
viders under this subsection, any such additional re-
quirement shall be implemented in a manner that 
provides for a reasonable period during which a pre-
viously qualified provider is permitted to meet such 
an additional requirement. 
(4) ABILITY TO PROVIDE SERVICES.—With re-
spect to any entity or provider certified to provide 
items and services described in section 201(a)(7), 
the Secretary may not prohibit such entity or pro-
vider from participating for reasons other than such 
entity’s or provider’s ability to provide such items 
and services. 
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(d) FEDERAL PROVIDERS.—Any provider qualified to 
provide health care items and services through the Depart-
ment of Veterans Affairs or Indian Health Service is a 
qualifying provider under this section with respect to any 
individual who qualifies for such items and services under 
applicable Federal law. 
SEC. 303. USE OF PRIVATE CONTRACTS. 
(a) IN GENERAL.—This section shall apply beginning 
2 years after the date of the enactment of this Act. 
(b) PARTICIPATING PROVIDERS.— 
(1) PRIVATE CONTRACTS FOR COVERED ITEMS 
AND SERVICES FOR ELIGIBLE INDIVIDUALS.—An in-
stitutional or individual provider with an agreement 
in effect under section 301 may not bill or enter into 
any private contract with any individual eligible for 
benefits under the Act for any item or service that 
is a benefit under this Act. 
(2) PRIVATE
CONTRACTS
FOR
NONCOVERED 
ITEMS AND SERVICES FOR ELIGIBLE INDIVIDUALS.— 
An institutional or individual provider with an agree-
ment in effect under section 301 may bill or enter 
into a private contract with an individual eligible for 
benefits under the Act for any item or service that 
is not a benefit under this Act only if— 
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(A) the contract and provider meet the re-
quirements specified in paragraphs (3) and (4), 
respectively; 
(B) such item or service is not payable or 
available under this Act; and 
(C) the provider receives— 
(i) no reimbursement under this Act 
directly or indirectly for such item or serv-
ice, and 
(ii) receives no amount for such item 
or service from an organization which re-
ceives reimbursement for such items or 
service under this Act directly or indirectly. 
(3) CONTRACT REQUIREMENTS.—Any contract 
to provide items and services described in paragraph 
(2) shall— 
(A) be in writing and signed by the indi-
vidual (or authorized representative of the indi-
vidual) receiving the item or service before the 
item or service is furnished pursuant to the 
contract; 
(B) not be entered into at a time when the 
individual is facing an emergency health care 
situation; and 
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(C) clearly indicate to the individual receiv-
ing such items and services that by signing 
such a contract the individual— 
(i) agrees not to submit a claim (or to 
request that the provider submit a claim) 
under this Act for such items or services; 
(ii) agrees to be responsible for pay-
ment of such items or services and under-
stands that no reimbursement will be pro-
vided under this Act for such items or 
services; 
(iii) acknowledges that no limits under 
this Act apply to amounts that may be 
charged for such items or services; and 
(iv) acknowledges that the provider is 
providing services outside the scope of the 
program under this Act. 
(4) AFFIDAVIT.—A participating provider who 
enters into a contract described in paragraph (2) 
shall have in effect during the period any item or 
service is to be provided pursuant to the contract an 
affidavit that shall— 
(A) identify the provider who is to furnish 
such noncovered item or service, and be signed 
by such provider; 
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(B) state that the provider will not submit 
any claim under this Act for any noncovered 
item or service provided to any individual en-
rolled under this Act; and 
(C) be filed with the Secretary no later 
than 10 days after the first contract to which 
such affidavit applies is entered into. 
(5) ENFORCEMENT.—If a provider signing an 
affidavit described in paragraph (4) knowingly and 
willfully submits a claim under this title for any item 
or service provided or receives any reimbursement or 
amount for any such item or service provided pursu-
ant to a private contract described in paragraph (2) 
with respect to such affidavit— 
(A) any contract described in paragraph 
(2) shall be null and void; 
(B) no payment shall be made under this 
title for any item or service furnished by the 
provider during the 1-year period beginning on 
the date the affidavit was signed; and 
(C) any payment received under this title 
for any item or service furnished during such 
period shall be remitted. 
(6) PRIVATE CONTRACTS FOR INELIGIBLE INDI-
VIDUALS.—An institutional or individual provider 
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