495 
(2) in subsection (e), by inserting ‘‘(other than 
such a project that is described in paragraph 
(4)(B))’’ before the period at the end. 
SEC. 406. DEDUCTION FOR QUALIFIED CHARITY CARE. 
(a) IN GENERAL.—Part VI of subchapter B of chap-
ter 1 of the Internal Revenue Code of 1986 is amended 
by adding at the end the following new section: 
‘‘SEC. 199B. QUALIFIED CHARITY CARE. 
‘‘(a) IN GENERAL.—There shall be allowed as a de-
duction for the taxable year an amount equal to— 
‘‘(1) in the case of a direct primary care physi-
cian, an amount equal to the sum of— 
‘‘(A) the fee (as published on a publicly 
available website of such physician) for physi-
cians’ services that are qualified charity care 
furnished by such taxpayer during such year, 
and 
‘‘(B) for each visit by a patient to such 
physician during which qualified charity care is 
furnished, half of so much of the lowest sub-
scription fee of such physician that is attrib-
utable to a month, and 
‘‘(2) in the case of any other individual, the un-
reimbursed Medicare-based value of qualified charity 
care furnished by such taxpayer during such year. 
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‘‘(b) DEFINITIONS.—For purposes of this section: 
‘‘(1) 
UNREIMBURSED
MEDICARE-BASED 
VALUE.—The term ‘unreimbursed Medicare-based 
value’ means, with respect to physicians’ services, 
the amount payable for such services under the phy-
sician fee schedule established under section 1848 of 
the Social Security Act. 
‘‘(2) QUALIFIED
CHARITY
CARE.—The term 
‘qualified charity care’ means physicians’ services 
that are furnished— 
‘‘(A) without expectation of reimburse-
ment, and 
‘‘(B) to an individual enrolled— 
‘‘(i) under a State plan under title 
XIX of the Social Security Act (or a waiv-
er of such plan), or 
‘‘(ii) under a State child health plan 
under title XXI of the Social Security Act 
(or a waiver of such plan). 
‘‘(3) DIRECT PRIMARY CARE PHYSICIAN.—The 
term ‘direct primary care physician’ means a physi-
cian (as defined in section 1861(r) of the Social Se-
curity Act) who provides primary care— 
‘‘(A) to individuals who have paid a peri-
odic subscription fee, and 
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‘‘(B) in exchange for a fee that is pub-
lished on a publicly available website of such 
physician. 
‘‘(4) PHYSICIANS’ SERVICES.—The term ‘physi-
cians’ services’ has the meaning given such term by 
section 1861(q) of the Social Security Act. 
‘‘(c) LIMITATION.—The amount allowed as a deduc-
tion under subsection (a) for a taxable year shall not ex-
ceed the gross receipts attributable to physicians’ services 
furnished by the taxpayer during the taxable year.’’. 
(b) CLERICAL AMENDMENT.—The table of sections 
for part VI of subchapter B of chapter 1 of the Internal 
Revenue Code of 1986 is amended by adding at the end 
the following new item: 
‘‘Sec. 199B. Qualified charity care.’’. 
Subtitle B—Medicare Reforms 
SEC. 411. OFF-CAMPUS PROVIDER-BASED DEPARTMENT 
MEDICARE SITE NEUTRAL PAYMENT. 
(a) IN GENERAL.—Section 1834 of the Social Secu-
rity Act (42 U.S.C. 1395m) is amended by adding at the 
end the following new subsection: 
‘‘(x) OFF-CAMPUS PROVIDER-BASED DEPARTMENT 
MEDICARE SITE NEUTRAL PAYMENT.— 
‘‘(1) IN GENERAL.—With respect to items and 
services furnished in an off-campus provider-based 
department, payment under this section for such 
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498 
items and services shall be the amount determined 
under the fee schedule under section 1848 for such 
items and services furnished if furnished in a physi-
cian office setting. 
‘‘(2) OFF-CAMPUS
PROVIDER-BASED
DEPART-
MENT.—For purposes of this subsection, the term 
‘off-campus provider-based department’ has such 
meaning as specified by the Secretary.’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall apply with respect to items and serv-
ices furnished on or after January 1, 2021. 
SEC. 412. ELIMINATING FEHBP ELIGIBILITY FOR ANNU-
ITANTS. 
Section 8905(b) of title 5, United States Code, is 
amended— 
(1) in the matter preceding paragraph (1), by 
striking ‘‘An’’ and inserting ‘‘Consistent with the 
last sentence of this subsection, an’’; and 
(2) by adding at the end the following: ‘‘. An 
individual who is entitled to benefits under part A 
of title XVIII of the Social Security Act (42 U.S.C. 
1395c et seq.) by reason of section 226 or 226A of 
such Act (42 U.S.C. 426, 426–1), or otherwise eligi-
ble to enroll under such part pursuant to section 
1818 or 1818A of such Act (42 U.S.C. 1395i–2, 
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1395i–2a), and who first becomes an annuitant after 
the date of enactment of this sentence may not con-
tinue enrollment in any health benefits plan under 
this chapter.’’. 
SEC. 413. ELIMINATION OF MEDICARE ELIGIBILITY FOR 
CERTAIN INDIVIDUALS. 
(a) ENROLLMENT PROHIBITION.— 
(1) PART B.—Section 1836 of the Social Secu-
rity Act (42 U.S.C. 1395o) is amended by striking 
the period at the end and inserting ‘‘, except that an 
individual who attains age 65 on or after January 
1, 2030, and is an individual who, upon attaining 
such age, has earned $10,000,000 or more in life-
time wages, shall not be eligible to so enroll.’’. 
(2) PART
D.—Section 1860D–1(a)(3)(A) of 
such Act (42 U.S.C. 1395w–101(a)(3)(A)) is amend-
ed by striking the period at the end and inserting 
‘‘, excluding an individual who, upon attaining age 
65, has earned $10,000,000 or more in lifetime 
wages.’’. 
(b) MEDIGAP.—Section 1882 of the Social Security 
Act (42 U.S.C. 1395ss) is amended by adding at the end 
the following new subsection: 
‘‘(aa) ADDITIONAL LIMITATION ON NEWLY ELIGI-
BLE BENEFICIARIES.— 
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‘‘(1) IN GENERAL.—Notwithstanding any other 
provision of this section, on or after January 1, 
2030, a medicare supplemental policy may not be 
sold or issued to a targeted newly eligible Medicare 
beneficiary. 
‘‘(2) TARGETED
NEWLY
ELIGIBLE
MEDICARE 
BENEFICIARY.—For purposes of this subsection, the 
term ‘targeted newly eligible Medicare beneficiary’ 
means an individual who, upon attaining the age of 
65, has earned $10,000,000 or more in lifetime 
wages.’’. 
SEC. 414. MEDICARE PART D TAX DEDUCTION. 
(a) IN GENERAL.—Section 139A of the Internal Rev-
enue Code of 1986 is amended by adding at the end the 
following: ‘‘This section shall not be taken into account 
for purposes of determining whether any deduction is al-
lowable with respect to any cost taken into account in de-
termining such payment.’’. 
(b) EFFECTIVE DATE.—The amendment made by 
this section shall apply to taxable years beginning after 
December 31, 2018. 
SEC. 415. REPEAL OF NET INVESTMENT INCOME TAX. 
(a) IN GENERAL.—Subtitle A of the Internal Rev-
enue Code of 1986 is amended by striking chapter 2A. 
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(b) EFFECTIVE DATE.—The amendment made by 
this section shall apply to taxable years beginning after 
December 31, 2019. 
SEC. 416. MEDICARE COVERAGE OF BAD DEBT. 
Section 1861(v)(1) of the Social Security Act (42 
U.S.C. 1395(v)(1)) is amended— 
(1) in subparagraph (T)— 
(A) in clause (iv), by striking ‘‘and’’ at the 
end; 
(B) in clause (v)— 
(i) by striking ‘‘during fiscal year’’ 
and inserting ‘‘during fiscal years’’; 
(ii) by striking ‘‘or a subsequent fiscal 
year’’ and inserting ‘‘through 2021’’; and 
(iii) by striking the period at the end 
and inserting ‘‘, and’’; and 
(C) by adding at the end the following new 
clause: 
‘‘(vi) for cost reporting periods beginning dur-
ing fiscal year 2021 or a subsequent fiscal year, by 
the percent applicable for cost reporting periods be-
ginning during the previous fiscal year, increased 
(through fiscal year 2024) by 10 percentage 
points.’’; 
(2) in subparagraph (V)— 
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(A) in clause (i)— 
(i) in subclause (III), by striking 
‘‘and’’ at the end; 
(ii) in subclause (IV)— 
(I) by striking ‘‘during fiscal 
year’’ and inserting ‘‘during fiscal 
years 2015 through 2021’’; and 
(II) by striking the period at the 
end and inserting ‘‘; and’’; and 
(iii) by adding at the end the fol-
lowing new subclause: 
‘‘(V) for cost reporting periods beginning 
during fiscal year 2021 or a subsequent fiscal 
year, the percent applicable for cost reporting 
periods beginning during the previous fiscal 
year, increased (through fiscal year 2024) by 
10 percentage points.’’; and 
(B) in clause (ii)— 
(i) in subclause (III), by striking 
‘‘and’’ at the end; and 
(ii) in subclause (IV)— 
(I) by striking ‘‘a subsequent fis-
cal year’’ and inserting ‘‘fiscal years 
2015 through 2021’’; 
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(II) by striking the period at the 
end and inserting ‘‘; and’’; and 
(III) by adding at the end the 
following new subclause: 
‘‘(V) for cost reporting periods beginning 
during fiscal year 2021 or a subsequent fiscal 
year, shall be reduced by the percent applicable 
for cost reporting periods beginning during the 
previous fiscal year, increased (through fiscal 
year 2024) by 10 percentage points.’’; and 
(3) in subparagraph (W)(i)— 
(A) in subclause (II), by striking ‘‘and’’ at 
the end; 
(B) in subclause (III)— 
(i) by striking ‘‘during a subsequent 
fiscal year’’ and inserting ‘‘during fiscal 
years 2015 through 2021’’; and 
(ii) by striking the period at the end 
and inserting ‘‘; and’’; and 
(C) by adding at the end the following new 
subclause: 
‘‘(IV) for cost reporting periods beginning dur-
ing fiscal year 2021 or a subsequent fiscal year, by 
the percent applicable for cost reporting periods be-
ginning during the previous fiscal year, increased 
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(through fiscal year 2024) by 10 percentage 
points.’’. 
Subtitle C—Medicare Choice and 
Competition 
SEC. 421. COMPETITIVE BIDDING AND PREMIUMS UNDER 
UNIFIED MEDICARE. 
(a) IN GENERAL.—Part E of title XVIII of the Social 
Security Act, as added by section 101 and amended by 
section 103, is further amended by adding at the end the 
following: 
‘‘Subpart 3—Competitive Bidding and Premiums 
‘‘SEC. 1860E–31. APPLICATION OF COMPETITIVE BIDDING IN 
ENROLLMENT. 
‘‘(a) IN GENERAL.—Notwithstanding any other pro-
vision of this title, the Secretary shall, beginning with plan 
year 2021, establish a method whereby individuals enroll-
ing under this title so enroll through an online process 
designed to highlight enrollment options for such individ-
uals and allow such individuals to compare costs of enroll-
ment in such options. 
‘‘(b) ENROLLMENT OPTIONS.—For purposes of sub-
section (a), the Secretary shall make the following options 
available to individuals for enrollment under this title: 
‘‘(1) Traditional fee-for-service coverage. 
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ice coverage, such drug coverage shall be provided through 
a prescription drug plan. 
‘‘(f) SUPPLEMENTAL BENEFITS.— 
‘‘(1) MA PLANS.—An MA plan is allowed to 
offer two different packages of supplemental benefits 
(these packages are available only to individuals who 
select such plans). 
‘‘(2) ACOS.—ACOs may limit supplemental op-
tions for their enrollees to Medigap plans with con-
tractual ties. 
‘‘(3) FEE-FOR-SERVICE.—Fee-for-service indi-
viduals may select supplemental coverage from 
Medigap policies. 
‘‘SEC. 1860E–32. COMPETITION. 
‘‘(a) BID AREAS.—Market areas used for bid submis-
sions for Medicare Advantage plans, ACOs, and for cal-
culation per person fee-for-services costs shall be metro-
politan statistical regions plus associated regions. 
‘‘(b) PREMIUMS.—Medicare payment benchmark by 
market area shall be calculated based on weighted average 
(by enrollment in previous year) of the premium bids from 
MA plans, ACOs, and the per person costs of fee-for-serv-
ice, less the statutory part B premium. 
‘‘(c) BENEFICIARY RESPONSIBILITY.—Beneficiaries 
shall pay the difference between Medicare payment and 
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required premium of the plan they choose, and get 100 
percent of the savings by choosing a plan with a premium 
below the benchmark. 
‘‘(d) TRANSITION.—For beneficiaries who are in fee- 
for-service at the time of the enactment of this section, 
there shall be a limit on the amount of a premium increase 
allowable by year of no more than $20 per month com-
pared to what such premium would have otherwise been 
if this subpart had not been enacted for each year through 
the fifth year. 
‘‘(e) MULTIYEAR CONTRACTS.—A Medicare Advan-
tage plan may offer to beneficiaries multiyear contracts 
with guaranteed premiums over such years, bearing the 
risk of any change in payments from the Secretary in sub-
sequent years. A beneficiary enrolling under such a con-
tract shall be exempt from the method described in sub-
section (a).’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Section 1853(a)(1)(A) of the Social Security 
Act is amended by striking ‘‘and section 1859(e)(4)’’ 
and inserting ‘‘, section 1859(e)(4), and subpart 3 
of part E’’. 
(2) Section 1853(j) of such Act is amended by 
inserting ‘‘and subpart 3 of part E’’ after ‘‘sub-
section (o)’’. 
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508 
(3) Section 1854 of such Act is amended— 
(A) in subsection (a), after the heading, by 
inserting ‘‘Subject to subpart 3 of part E:’’; 
(B) in subsection (b), after the heading, by 
inserting ‘‘Subject to subpart 3 of part E:’’; 
(C) in subsection (d), after the heading, by 
inserting ‘‘Subject to subpart 3 of part E:’’; 
and 
(D) in subsection (e), after the heading, by 
inserting ‘‘Subject to subpart 3 of part E:’’. 
SEC. 422. NEW UNIFIED ELIGIBILITY AND ENROLLMENT 
RULES. 
(a) IN GENERAL.—Title XVIII of the Social Security 
Act is amended— 
(1) by redesignating part E as part F; and 
(2) by inserting after part D the following new 
part: 
‘‘PART E—MEDICARE WITH CHOICE AND 
COMPETITION 
‘‘Subpart 1—Opt-Out and Auto-Enrollment 
‘‘SEC. 1860E–11. PART A OPT-OUT AND MA AUTO-ENROLL-
MENT. 
‘‘(a) PERMITTING INDIVIDUALS TO OPT OUT
OF 
PART A COVERAGE WITHOUT LOSING SOCIAL SECURITY 
BENEFITS.— 
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509 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish— 
‘‘(A) a process by which an individual oth-
erwise entitled to benefits under part A may 
elect (at a time and in a manner specified 
under the process) to waive such entitlement; 
and 
‘‘(B) a process by which an individual who 
elects to waive such entitlement may revoke (at 
a time and in a manner specified under the 
process) such waiver. 
The process under subparagraph (B) shall be coordi-
nated with the enrollment process under section 
1837 for part B. 
‘‘(2) APPLICATION OF LATE ENROLLMENT PEN-
ALTY.—An individual who revokes a waiver under 
paragraph (1)(B) shall be subject to a late enroll-
ment penalty as applied under section 1860E– 
32(c)(2)(C). 
‘‘(3) NO IMPACT ON TITLE II BENEFITS.—Not-
withstanding any other provision of law, an election 
of an individual to waive entitlement to benefits 
under part A under paragraph (1)(A) shall not re-
sult in any loss of benefits under title II. 
‘‘(4) DEEMED OPT-OUT.— 
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‘‘(A) An election of an individual to waive 
entitlement to benefits under part A under 
paragraph (1)(A) is also deemed the filing of a 
notice of termination of benefits under part B 
pursuant to section 1838(b)(1). 
‘‘(B) The termination of benefits under 
part B pursuant to section 1838(b) is also 
deemed to be a waiver of any entitlement to 
benefits under part A. 
‘‘(b) SPECIAL OPEN ENROLLMENT PERIOD WITH-
OUT LATE ENROLLMENT PENALTY FOR CURRENT PART 
A ONLY
OR PART B ONLY ENROLLEES.—Notwith-
standing any other provision of law, in the case of an indi-
vidual who as of the general effective date, is entitled to 
benefits under part A but not enrolled under part B, or 
who is enrolled under part B but not entitled to benefits 
(or enrolled) under part A, beginning as of such date, such 
individual shall be deemed to be enrolled under part B 
or part A, respectively, unless such individual elects to be 
enrolled (or entitled to benefits) under neither of such 
parts during a special open enrollment period specified by 
the Secretary. No increase in the monthly premium of an 
individual pursuant to section 1839(b) or section 1818(c) 
shall be effected in the case of any such individual who 
is deemed enrolled under part B or part A pursuant to 
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511 
the previous sentence with respect to any period prior to 
the date of such enrollment. 
‘‘(c) AUTO ENROLLMENT OF DUAL ELIGIBLE INDI-
VIDUALS UNDER MEDICARE ADVANTAGE PLANS.— 
‘‘(1) IN GENERAL.—Except in the case of a 
State that has elected the maintenance of effort op-
tion described in section 1944(b)(2), in the case of 
an individual described in subparagraph (A)(ii) of 
section 1935(c)(6) (taking into account the applica-
tion of subparagraph (B) of such section), the Sec-
retary shall establish a process for the enrollment in 
an MA–PD plan that is a managed care plan under 
part C that has a monthly beneficiary premium that 
does not exceed the premium assistance available 
under section 1860E–41(b)(1)(A). If there is more 
than one such plan available, the Secretary shall en-
roll such an individual on a random basis among all 
such plans in the PDP region. 
‘‘(2) RIGHT TO DISENROLL.—Nothing in para-
graph (1) shall prevent such an individual from de-
clining enrollment in any such plan (and thereby ob-
taining coverage under Medicare fee-for-service) or 
from changing enrollment in such a plan to another 
MA–PD plan. 
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512 
‘‘SEC. 1860E–12. COORDINATION WITH PART D. 
‘‘(a) DEEMED ENROLLMENT UNDER PART D.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish a process that, beginning as of the general effec-
tive date, provides for the enrollment in a prescrip-
tion drug plan that has a monthly base beneficiary 
premium that does not exceed the weighted average 
of premiums for such plans that provide standard 
prescription drug coverage (as defined in section 
1860D–2(b)) with respect to the area involved (on 
a random basis among all such plans in the applica-
ble PDP region) of each Medicare enrollee (as de-
fined in section 1860E–51) who— 
‘‘(A) failed to enroll in such a prescription 
drug plan during the applicable enrollment or 
coverage election period under section 1860D– 
1(b); and 
‘‘(B) failed to elect not to enroll in such a 
prescription drug plan during an applicable opt- 
out period described in paragraph (2). 
Nothing in the previous sentence shall prevent such 
an individual from declining or changing such enroll-
ment. Such process shall be carried out in the same 
manner as the process described in section 1860D– 
1(b)(1)(C). 
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513 
‘‘(2) OPT-OUT
PERIODS.—The process under 
paragraph (1) shall provide for the opportunity to 
make an election described in subparagraph (B) of 
such paragraph during an opt-out period that is co-
ordinated with the relevant enrollment or coverage 
election period under section 1860D–1. 
‘‘(3) LATE ENROLLMENT PENALTIES.—In the 
case of an individual who makes an election de-
scribed in paragraph (1)(B) and then enrolls in a 
prescription drug plan, the late enrollment penalty 
under section 1860D–13(b) shall apply to the 
monthly beneficiary premium of such individual, ex-
cept that in applying such section, any reference to 
the initial enrollment period of such individual shall 
be deemed to be a reference to the opt-out period 
under paragraph (2) during which the individual 
elected not to enroll in a prescription drug plan. 
‘‘(4) NO
LATE
ENROLLMENT
PENALTY
FOR 
CURRENT
FEE-FOR-SERVICE
BENEFICIARIES
WITH-
OUT DRUG COVERAGE.—In the case of an individual 
who is a Medicare enrollee before the date of enact-
ment of this section and who was not enrolled under 
a prescription drug plan before being enrolled under 
such a plan pursuant to paragraph (1), there shall 
be no increase in the base beneficiary premium of an 
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individual under section 1860D–13 by a late enroll-
ment penalty under subsection (b) of such section 
with respect to any period prior to the date of such 
enrollment. 
‘‘(b) REFERENCE
TO
REQUIRED
PRESCRIPTION 
DRUG COVERAGE UNDER PART C.—For provision requir-
ing coverage under MA plans to include prescription drug 
coverage, see section 1860E–26.’’. 
(b) LIMITATION ON MEDICAID BENEFITS FOR FULL- 
BENEFIT DUAL ELIGIBLE INDIVIDUALS.—Section 1902 
of the Social Security Act (42 U.S.C. 1396a) is amended 
by adding at the end the following new subsection: 
‘‘(ll) LIMITATION ON BENEFITS FOR FULL-BENEFIT 
DUAL ELIGIBLE INDIVIDUALS.—Effective as of the gen-
eral effective date (as specified in section 1860E–62), ex-
cept in the case of a State which has elected the option 
described in section 1944(b)(2), in the case of an indi-
vidual described in subparagraph (A)(ii) of section 
1935(c)(6) (taking into account the application of sub-
paragraph (B) of such section), notwithstanding any other 
provision of law, medical assistance shall not be available 
under this title for any items and services for which pay-
ment may be made under title XVIII.’’. 
(c) MEDICAID MAINTENANCE OF EFFORT AND AL-
TERNATIVES.—Title XIX of the Social Security Act is 
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amended by inserting after section 1943 the following new 
section: 
‘‘MAINTENANCE OF EFFORT OPTIONS FOR FULL-BENEFIT 
DUAL ELIGIBLE INDIVIDUALS 
‘‘SEC. 1944. (a) IN GENERAL.—Effective as of the 
general effective date (as specified in section 1860E–62), 
a State shall elect, in a form and manner specified by the 
Secretary, a maintenance of effort option described in sub-
section (b). In the case of a State that fails to make such 
an election, the State shall be deemed to have elected the 
option described in subsection (b)(3). 
‘‘(b) MAINTENANCE
OF
EFFORT
OPTIONS
DE-
SCRIBED.—The following are maintenance of effort op-
tions described in this subsection for a State, which shall 
apply to all individuals described in subparagraph (A)(ii) 
of section 1935(c)(6) (taking into account the application 
of subparagraph (B) of such section) for such State: 
‘‘(1) ENROLLMENT
OF
DUAL
ELIGIBLES
IN 
COMPREHENSIVE MEDICAID MANAGED CARE PLAN.— 
‘‘(A) IN GENERAL.—The State enrolls all 
such individuals in a comprehensive Medicaid 
managed care plan offered by a managed care 
entity under section 1932. 
‘‘(B) PAYMENT OF SUBSIDY AMOUNT TO 
STATE.—In the case of a State that elects the 
option under this paragraph with respect to an 
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516 
individual, the Secretary established under sec-
tion 1860E–51 shall pay to the State the same 
amount that the individual would be entitled to 
have paid as an income-related premium sub-
sidy under section 1860E–41(b)(1)(A) plus the 
amount that the Secretary estimates would 
have been paid with respect to the individual 
under part D (including the actuarial value of 
subsidy payments under sections 1860D–13 
and 1860D–14). Such payment shall be made 
in appropriate part from the Federal Hospital 
Insurance Trust Fund under section 1817 and 
the Federal Supplementary Medical Insurance 
Trust Fund under section 1841. 
‘‘(C) RELATION
TO
PART
D
RULES.—In 
the case of a State that has elected the option 
under this paragraph, notwithstanding any 
other provision of law— 
‘‘(i) the coverage provided under this 
option shall be in lieu of any coverage that 
may otherwise be provided under part D; 
and 
‘‘(ii) the payment to the State under 
subparagraph (B) shall be in lieu of any 
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