I 
116TH CONGRESS 
1ST SESSION H. R. 2000 
To establish a public health plan. 
IN THE HOUSE OF REPRESENTATIVES 
APRIL 1, 2019 
Mr. DELGADO (for himself, Mr. LARSON of Connecticut, and Mr. HIGGINS of 
New York) introduced the following bill; which was referred to the Com-
mittee on Energy and Commerce, and in addition to the Committee on 
Ways and Means, 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 establish a public health plan. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Medicare-X Choice Act 
of 2019’’. 
SEC. 2. ESTABLISHMENT AND ADMINISTRATION OF A PUB-
LIC HEALTH PLAN. 
The Social Security Act is amended by adding at the 
end the following new title: 
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‘‘TITLE XXII—MEDICARE 
EXCHANGE HEALTH PLAN 
‘‘SEC. 2201. ESTABLISHMENT. 
‘‘(a) ESTABLISHMENT OF PLAN.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish a coordinated and low-cost health plan, to be 
known as the ‘Medicare Exchange health plan’ (re-
ferred to in this section as the ‘health plan’) to pro-
vide access to quality health care for enrollees. 
‘‘(2) TIMEFRAME.— 
‘‘(A) 
INDIVIDUAL
MARKET
AVAIL-
ABILITY.— 
‘‘(i) IN
GENERAL.—In accordance 
with clause (ii), the Secretary shall make 
the health plan available in the individual 
market, in certain rating areas, for plan 
year 2021 and each subsequent plan year, 
and increase the availability such that the 
plan is available in the individual market 
to all residents of all rating areas in the 
United States for plan year 2024 and each 
subsequent plan year. 
‘‘(ii) PRIORITY
AREAS.—In deter-
mining in which rating areas the Secretary 
initially will make the health plan avail-
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able, the Secretary shall give priority to 
rating areas in which— 
‘‘(I) not more than 1 health in-
surance issuer offers plans on the ap-
plicable State or Federal American 
Health Benefit Exchange (referred to 
in this title as the ‘Exchange’); or 
‘‘(II) there is a shortage of 
health providers or lack of competition 
that results in a high cost of health 
care services, including health profes-
sional shortage areas and rural areas. 
‘‘(B) SMALL GROUP MARKET.—The Sec-
retary shall make the health plan available in 
the small group market in all rating areas for 
plan year 2025. 
‘‘(b) ESTABLISHMENT OF FUNDS.— 
‘‘(1) PLAN RESERVE FUND.— 
‘‘(A) IN GENERAL.—There is established in 
the Treasury of the United States a ‘Plan Re-
serve Fund’, to be administered by the Sec-
retary of Health and Human Services, for pur-
poses of establishing the Medicare Exchange 
health plan and administering such plan, con-
sisting of amounts appropriated to such fund. 
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‘‘(B) APPROPRIATION.—There is appro-
priated $1,000,000,000, out of monies in the 
Treasury not otherwise obligated, to the Plan 
Reserve Fund for fiscal year 2020. 
‘‘(2) DATA AND TECHNOLOGY FUND.—There is 
established in the Treasury of the United States a 
‘Data and Technology Fund’, to be administered by 
the Secretary of Health and Human Services, acting 
through the Chief Actuary of the Centers for Medi-
care & Medicaid Services, for purposes of updating 
technology and performing data collection under sec-
tion 2205 in order to establish appropriate pre-
miums for all geographic regions of the United 
States. There are authorized to be appropriated to 
the Data and Technology Fund such sums as may 
be necessary for fiscal year 2020. 
‘‘(c) RULEMAKING.—The Secretary may promulgate 
such regulations as may be necessary to carry out this 
title. 
‘‘SEC. 2202. AVAILABILITY OF PLAN. 
‘‘(a) ELIGIBILITY.—An individual shall be eligible to 
enroll in the health plan if such individual, for the entire 
period for which enrollment is sought— 
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‘‘(1) is a qualified individual within the mean-
ing of section 1312 of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18032); and 
‘‘(2) is not eligible for benefits under the Medi-
care program under title XVIII. 
‘‘(b) EXCHANGES.—In accordance with the time-
frame under section 2201(a)(2), the health plan shall be 
made available through the American Health Benefit Ex-
changes described in sections 1311 and 1321 of the Pa-
tient Protection and Affordable Care Act (42 U.S.C. 
18031, 18041), including the Small Business Health Op-
tions Program Exchange. 
‘‘SEC. 2203. PLAN REQUIREMENTS. 
‘‘(a) GENERAL REQUIREMENTS.—The health plan 
shall comply with all requirements, as applicable, of sub-
title D of title I of the Patient Protection and Affordable 
Care Act (42 U.S.C. 18021 et seq.) and title XXVII of 
the Public Health Service Act (42 U.S.C. 300gg et seq.) 
applicable to qualified health plans, and such health plan 
shall be a qualified health plan, including for purposes of 
the Internal Revenue Code of 1986. 
‘‘(b) LEVELS OF COVERAGE.—The Secretary— 
‘‘(1) shall make available a silver level and gold 
level version of the plan, in accordance with section 
1301(a)(1)(C)(ii); and 
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‘‘(2) may make available no more than 2 
versions of the plan for each of the 4 levels of cov-
erage described in subparagraphs (A) through (D) of 
section 1302(d)(1) of the Patient Protection and Af-
fordable Care Act (42 U.S.C. 18022(d)(1)). 
‘‘SEC. 2204. ADMINISTRATIVE CONTRACTING. 
‘‘(a) IN GENERAL.—The Secretary may enter into 
contracts for the purpose of performing administrative 
functions (including functions described in subsection 
(a)(4) of section 1874A) with respect to the health plan 
in the same manner as the Secretary may enter into con-
tracts under subsection (a)(1) of such section. The Sec-
retary shall have the same authority with respect to the 
public health insurance option as the Secretary has under 
such subsection (a)(1) and subsection (b) of section 1874A 
with respect to title XVIII. 
‘‘(b) TRANSFER OF INSURANCE RISK.—Any contract 
under subsection (a) shall not involve the transfer of in-
surance risk from the Secretary to the entity entering into 
such contract with the Secretary, except in the case of an 
alternative payment model under section 2209(h). 
‘‘SEC. 2205. DATA COLLECTION. 
‘‘Subject to all applicable privacy requirements, in-
cluding the requirements under the regulations promul-
gated pursuant to section 264(c) of the Health Insurance 
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Portability and Accountability Act of 1996 (42 U.S.C. 
1320d–2 note), the Secretary may collect data from State 
insurance commissioners and other relevant entities to es-
tablish rates for premiums and for other purposes includ-
ing to improve quality, and reduce racial, ethnic, and other 
disparities, with respect to the health plan. 
‘‘SEC. 2206. PREMIUMS; RISK POOL. 
‘‘(a) SETTING PREMIUMS.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish premiums for the health plan that cover the full 
actuarial cost of offering such plan, including the 
administrative costs of offering such plan. Such pre-
miums shall vary geographically and between the 
small group market and the individual market in ac-
cordance with differences in the cost of providing 
such coverage. If, for any plan year, the amount col-
lected in premiums exceeds the amount required for 
health care benefits and administrative costs in that 
plan year, such excess amounts shall remain avail-
able to the Secretary to administer the health plan 
and finance beneficiary costs in subsequent years. 
‘‘(2) INITIAL PLAN YEAR.—For plan year 2021, 
the Secretary shall set premiums for the health plan 
for each rating area in which the health plan is 
available for such plan year, taking into consider-
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ation the premium rates for plans offered in each 
such rating area for plan year 2020. 
‘‘(b) RISK POOL.—After plan year 2021, all enrollees 
in the health plan within a State shall be members of a 
single risk pool, except that the Secretary may establish 
separate risk pools for the individual market and small 
group market if the State has not exercised its authority 
under section 1312(c)(3) of the Patient Protection and Af-
fordable Care Act. 
‘‘SEC. 2207. REIMBURSEMENT RATES. 
‘‘(a) MEDICARE RATES.— 
‘‘(1) IN GENERAL.—Except as provided in para-
graph (2) and subsections (b) and (c) and subject to 
subsection (d), the Secretary shall reimburse health 
care providers furnishing items and services under 
the health plan at rates determined for equivalent 
items and services under the original Medicare fee- 
for-service program under parts A and B of title 
XVIII. 
‘‘(2) AUTHORITY
TO
INCREASE
PAYMENTS 
RATES IN RURAL AREAS.—If the Secretary deter-
mines appropriate, the Secretary may increase the 
reimbursements rates described in paragraph (1) by 
up to 25 percent for items and services furnished in 
rural areas (as defined in section 1886(d)(2)(D)). 
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‘‘(b) PRESCRIPTION DRUGS.—Subject to subsection 
(d), payment rates for prescription drugs shall be at a rate 
negotiated by the Secretary. Such negotiations may be in 
conjunction with negotiations for covered part D drugs 
under part D of title XVIII. 
‘‘(c) ADDITIONAL ITEMS AND SERVICES.—Subject to 
subsection (d), the Secretary shall establish reimburse-
ment rates for any items and services provided under the 
health plan that are not items and services provided under 
the original Medicare fee-for-service program under parts 
A and B of title XVIII. 
‘‘(d) INNOVATIVE PAYMENT METHODS.—The Sec-
retary may utilize innovative payment methods, including 
value-based payment arrangements, in making payments 
for items and services (including prescription drugs) fur-
nished under the health plan. 
‘‘SEC. 2208. PARTICIPATING PROVIDERS. 
‘‘(a) REQUIREMENT TO PARTICIPATE IN ORDER TO 
BE ENROLLED UNDER MEDICARE.—Subject to sub-
section (d), beginning January 1, 2021, a health care pro-
vider may not be enrolled under the Medicare program 
under section 1866(j) unless the provider is also a partici-
pating provider under the health plan. 
‘‘(b) REQUIREMENT TO PARTICIPATE IN ORDER TO 
PARTICIPATE IN MEDICAID.—Subject to subsection (d), 
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beginning January 1, 2021, a health care provider may 
not be a participating provider under a State Medicaid 
plan under title XIX unless the provider is also a partici-
pating provider under the health plan. 
‘‘(c) ADDITIONAL PROVIDERS.—The Secretary shall 
establish a process to allow health care providers not de-
scribed in subsection (a) or (b) to become a participating 
provider under the health plan. 
‘‘(d) OPT-OUT.—The Secretary shall establish a 
process by which a health care provider described in sub-
section (a) or (b) may opt out of being a participating 
provider under the health plan. 
‘‘SEC. 2209. DELIVERY SYSTEM REFORM FOR AN ENHANCED 
HEALTH PLAN. 
‘‘(a) IN GENERAL.—For plan years beginning with 
plan year 2021, the Secretary may utilize innovative pay-
ment mechanisms and policies to determine payments for 
items and services under the health plan. The payment 
mechanisms and policies under this section may include 
patient-centered medical home and other care manage-
ment payments, accountable care organizations, account-
able communities for health, value-based purchasing, bun-
dling of services, differential payment rates, performance 
or utilization based payments, telehealth, remote patient 
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monitoring, partial capitation, and direct contracting with 
providers. 
‘‘(b) REQUIREMENTS FOR INNOVATIVE PAYMENTS.— 
The Secretary shall design and implement the payment 
mechanisms and policies under this section in a manner 
that— 
‘‘(1) seeks to— 
‘‘(A) improve health outcomes; 
‘‘(B) reduce health disparities (including 
racial, ethnic, and other disparities); 
‘‘(C) provide efficient and affordable care; 
‘‘(D) address geographic variation in the 
provision of health services; or 
‘‘(E) prevent or manage chronic illness; 
and 
‘‘(2) promotes care that is integrated, patient- 
centered, quality, and efficient. 
‘‘(c) ENCOURAGING THE USE OF HIGH VALUE SERV-
ICES.—To the extent allowed by the benefit standards ap-
plied to all health benefits plans participating in the Ex-
changes (as described in section 2202(b)), the health plan 
may modify cost-sharing and payment rates to encourage 
the use of services that promote health and value. 
‘‘(d) PROMOTION OF DELIVERY SYSTEM REFORM.— 
The Secretary shall monitor and evaluate the progress of 
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payment and delivery system reforms under this section 
and shall seek to implement such reforms subject to the 
following: 
‘‘(1) To the extent that the Secretary finds a 
payment and delivery system reform successful in 
improving quality and reducing costs, the Secretary 
shall implement such reform on as large a geo-
graphic scale as practical and economical. 
‘‘(2) The Secretary may delay the implementa-
tion of such a reform in geographic areas in which 
such implementation would place the public health 
insurance option at a competitive disadvantage. 
‘‘(3) The Secretary may prioritize implementa-
tion of such a reform in high-cost geographic areas 
or otherwise in order to reduce total program costs 
or to promote high value care. 
‘‘(e) NON-UNIFORMITY
PERMITTED.—Nothing in 
this section shall prevent the Secretary from varying pay-
ments based on different payment structure models (such 
as accountable care organizations and medical homes) 
under the health plan for different geographic areas. 
‘‘(f) INTEGRATION WITH SOCIAL SERVICES.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish processes and, when appropriate, collaborate 
with other agencies to integrate medical care under 
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the health plan with food, housing, transportation, 
and income assistance if the Secretary determines 
that such integration is expected to— 
‘‘(A) reduce spending without reducing the 
quality of patient care; or 
‘‘(B) improve the quality of patient care 
without increasing spending. 
‘‘(2) AUTHORIZATION OF A GRANT PROGRAM.— 
‘‘(A) IN GENERAL.—The Secretary may es-
tablish a grant program to permit broader ex-
perimentation with accountable communities for 
health model. 
‘‘(B) ELIGIBLE
RECIPIENTS.—The Sec-
retary may award a grant under this section 
to— 
‘‘(i) an institution of higher learning 
(as defined in section 3452(f) of title 38, 
United States Code); 
‘‘(ii) a local educational agency (as de-
fined in section 8101 of the Elementary 
and Secondary Education Act of 1965) or 
health care agency; 
‘‘(iii) a nonprofit entity that the Sec-
retary determines has a demonstrated his-
tory of community engagement; or 
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‘‘(iv) any other entity, as the Sec-
retary determines appropriate. 
‘‘(C) USE
OF
FUNDS.—A recipient of a 
grant under this section may use the grant to— 
‘‘(i) support community needs assess-
ment; 
‘‘(ii) establish social service partner-
ships; or 
‘‘(iii) establish interactive data sys-
tems across health and social service pro-
viders. 
‘‘(D) 
AUTHORIZATION
OF
APPROPRIA-
TIONS.—There are authorized to be appro-
priated such sums as may be necessary to carry 
out this paragraph. 
‘‘(3) REGULATIONS.—If the Secretary estab-
lishes a grant program under this section, the Sec-
retary shall promulgate regulations on— 
‘‘(A) the evaluation of applications for 
grants under the program; and 
‘‘(B) administration of the program. 
‘‘(g) TELEHEALTH.—The Secretary shall ensure the 
integration of telehealth tools that increase patient access 
to medical care, particularly in remote or underserved 
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areas, if the Secretary determines that such integration 
is expected to— 
‘‘(1) reduce spending without reducing the qual-
ity of patient care; or 
‘‘(2) improve the quality of patient care without 
increasing spending. 
‘‘(h) ALTERNATIVE PAYMENT MODEL.— 
‘‘(1) IN GENERAL.—The Secretary shall evalu-
ate the possibility of providing incentives, and, if ap-
propriate, apply incentives, for enrollees in the 
health plan who receive services from providers who 
are participating in an alternative payment model 
(as defined in section 1833(z)(3)(C)). 
‘‘(2) AUTHORITY TO USE APMS IN USE UNDER 
TRADITIONAL MEDICARE.—Nothing in this section 
shall preclude the Secretary from using alternative 
payment models (as so defined) under this title that 
are in use under title XVIII. 
‘‘SEC. 2210. NO EFFECT ON MEDICARE BENEFITS OR MEDI-
CARE TRUST FUNDS. 
‘‘Nothing in this title shall— 
‘‘(1) affect the benefits available under title 
XVIII; or 
‘‘(2) impact the Federal Hospital Insurance 
Trust Fund under section 1817 or the Federal Sup-
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plementary Medical Insurance Trust Fund under 
section 1841 (including the Medicare Prescription 
Drug Account within such Trust Fund).’’. 
SEC. 3. REINSURANCE. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services shall establish a mechanism to pool, on 
a nationwide basis, the costs of the highest-cost patients 
enrolled in individual health insurance coverage (as de-
fined in section 2791 of the Public Health Service Act (42 
U.S.C. 300gg–91)) offered on or off the Exchanges, to the 
extent such costs are not already pooled pursuant to sec-
tion 1343 of the Patient Protection and Affordable Care 
Act (42 U.S.C. 18063), for the purpose of reducing pre-
miums for such individual health insurance coverage. 
(b) AUTHORIZATION OF APPROPRIATIONS.—For pur-
poses of carrying out paragraph (1), there is authorized 
to be appropriated $10,000,000,000 for each of fiscal 
years 2021, 2022, and 2023. 
SEC. 4. EXPANSION OF TAX CREDIT. 
(a) IN GENERAL.—Subparagraph (A) of section 
36B(c)(1) of the Internal Revenue Code of 1986 is amend-
ed by striking ‘‘but does not exceed 400 percent’’. 
(b) APPLICABLE PERCENTAGES.—Clause (i) of sec-
tion 36B(b)(3)(A) of the Internal Revenue Code of 1986 
is amended to read as follows: 
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‘‘(i) IN
GENERAL.—The applicable 
percentage for any taxable year shall be 
the percentage such that the applicable 
percentage for any taxpayer whose house-
hold income is within an income tier speci-
fied in the following table shall increase, on 
a sliding scale in a linear manner, from the 
initial premium percentage to the final pre-
mium percentage specified in such table 
for such income tier: 
‘‘In the case of household income (expressed as a 
percent of poverty line) within the following in-
come tier: 
The initial 
premium 
percentage 
is— 
The final 
premium 
percentage 
is— 
Up to 138 percent ..................................................
1.5 
1.5
138 percent up to 150 percent ...............................
2.5 
3.5
150 percent up to 200 percent ...............................
3.5 
5.8
200 percent up to 250 percent ...............................
5.8 
7.55
250 percent up to 300 percent ...............................
7.55 
9.0
300 percent up to 400 percent ...............................
9.0 
9.0
400 percent up to 600 percent ...............................
9.0 
13.0
600 percent and up ................................................
13.0 
13.0.’’. 
(c) LIMITATION ON RECAPTURE.—Clause (i) of sec-
tion 36B(f)(2)(B) of the Internal Revenue Code of 1986 
is amended— 
(1) by striking ‘‘In the case of a taxpayer’’ and 
all that follows through ‘‘the amount of the in-
crease’’ and inserting ‘‘The amount of the increase’’; 
(2) by striking the period at the end of the last 
row of the table; and 
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(3) by adding at the end of the table the fol-
lowing new row: 
‘‘400 percent and up .......................................................................
$5,000.’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
December 31, 2019. 
SEC. 5. AUTHORITY TO NEGOTIATE FAIR PRICES FOR MEDI-
CARE PRESCRIPTION DRUGS. 
(a) IN GENERAL.—Section 1860D–11 of the Social 
Security Act (42 U.S.C. 1395w–111) is amended by strik-
ing subsection (i). 
(b) EFFECTIVE DATE.—The amendment made by 
this section shall take effect on the date of the enactment 
of this Act. 
Æ 
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