I 
115TH CONGRESS 
2D SESSION 
H. R. 7339 
To amend the Social Security Act to establish a Medicare for America health 
program to provide for comprehensive health coverage for all Americans. 
IN THE HOUSE OF REPRESENTATIVES 
DECEMBER 19, 2018 
Ms. DELAURO (for herself and Ms. SCHAKOWSKY) introduced the following 
bill; which was referred to the Committee on Ways and Means, and in 
addition to the Committees on Energy and Commerce, Education and the 
Workforce, Natural Resources, and the Judiciary, for a period to be sub-
sequently determined by the Speaker, in each case for consideration of 
such provisions as fall within the jurisdiction of the committee concerned 
A BILL 
To amend the Social Security Act to establish a Medicare 
for America health program to provide for comprehensive 
health coverage for all Americans. 
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 America Act of 2018’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
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TITLE I—TRANSITIONING TO AND ESTABLISHING MEDICARE FOR 
AMERICA 
Subtitle A—Transitional Public Health Option 
Sec. 101. Establishment. 
Sec. 102. Eligibility. 
Sec. 103. Benefits. 
Sec. 104. Premiums. 
Sec. 105. Providers and reimbursement rates. 
Sec. 106. Account; funding. 
Subtitle B—Medicare for America 
Sec. 111. Establishment and administration of Medicare for America. 
Sec. 112. Modifications to and coordination with existing Federal health pro-
grams. 
Subtitle C—Targeted Reforms 
Sec. 121. Limitation on removal of Medicare Advantage providers by MA orga-
nizations. 
Sec. 122. Network adequacy. 
Sec. 123. Eliminating the 24-month waiting period for Medicare coverage for 
individuals with disabilities. 
Sec. 124. Employer health plan options. 
Sec. 125. Prohibition on step therapy and prior authorization under group 
health plans. 
Sec. 126. Medicare outpatient observation services. 
Sec. 127. Abortion coverage. 
TITLE II—TAX PROVISIONS 
Sec. 201. Sunset of Public Law 115–97. 
Sec. 202. Surtax. 
Sec. 203. Basis of property acquired from a decedent. 
Sec. 204. Medicare payroll tax. 
Sec. 205. Net investment income tax. 
Sec. 206. Termination of health savings accounts. 
Sec. 207. Termination of flexible spending arrangements. 
Sec. 208. Increase in excise tax on small cigars and cigarettes and other to-
bacco products. 
Sec. 209. Excise tax on alcohol. 
Sec. 210. Tax on sugared drinks. 
TITLE III—DRUG-RELATED PROVISIONS 
Sec. 301. Establishment of the prescription drug and medical device review 
board. 
Sec. 302. Membership; staff. 
Sec. 303. Reporting requirements. 
Sec. 304. Prohibition against excessive price. 
Sec. 305. Enforcement provisions. 
Sec. 306. Authority. 
Sec. 307. Regulations. 
Sec. 308. Report to Federal agencies. 
Sec. 309. Definitions. 
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Sec. 310. Moratorium on direct-to-consumer drug advertising. 
Sec. 311. Reporting on justification for drug price increases. 
TITLE 
I—TRANSITIONING 
TO 
AND 
ESTABLISHING 
MEDI-
CARE FOR AMERICA 
Subtitle A—Transitional Public 
Health Option 
SEC. 101. ESTABLISHMENT. 
The Secretary of Health and Human Services (in this 
subtitle referred to as the ‘‘Secretary’’) shall establish a 
public health plan option that is offered in the individual 
market through the Federal and State Exchanges under 
title I of the Patient Protection and Affordable Care Act 
to eligible individuals for plan years 2020 and 2021 in 
accordance with this subtitle. 
SEC. 102. ELIGIBILITY. 
(a) IN GENERAL.—Subject to subsection (b), an indi-
vidual is eligible to enroll in such public health plan option 
if the individual is otherwise eligible to purchase individual 
health insurance coverage through an Exchange and the 
individual resides in a rating area in which the Secretary 
makes the public health plan option available. 
(b) PRIORITY.—In determining in which rating areas 
the Secretary initially will make the public health plan op-
tion available, the Secretary shall give priority to rating 
areas in which— 
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(1) not more than 1 health insurance issuer of-
fers plans on the applicable State or Federal Amer-
ican Health Benefit Exchange; or 
(2) there is a shortage of health providers or 
lack of competition that results in a high cost of 
health care services, including health professional 
shortage areas and rural areas. 
SEC. 103. BENEFITS. 
(a) IN GENERAL.—The public health plan option 
shall be a qualified health plan within the meaning of sec-
tion 1301(a) of the Patient Protection and Affordable 
Care Act (42 U.S.C. 18021(a)) that— 
(1) meets all requirements applicable to quali-
fied health plans under subtitle D of title I of the 
Patient Protection and Affordable Care Act (other 
than 
the 
requirement 
under 
section 
1301(a)(1)(C)(ii) 
of 
such 
Act 
(42 
U.S.C. 
18021(a)(1)(C)(ii))) and title XXVII of the Public 
Health Service Act; 
(2) provides coverage of the essential health 
benefits described in section 1302(b) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 
18022(b)); 
(3) provides silver and gold-level coverage de-
scribed in section 1302(d)(1)(C) of the Patient Pro-
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tection and Affordable Care Act (42 U.S.C. 
18022(d)(1)(C)); and 
(4) provides coverage of abortions and all other 
reproductive health services. 
(b) 
PREEMPTION.—Notwithstanding 
section 
1303(a)(1) of the Patient Protection and Affordable Care 
Act (42 U.S.C. 18023(a)(1))— 
(1) a State may not prohibit the public health 
plan option from offering the coverage described in 
subsection (a)(4); and 
(2) no State law that would prohibit such a 
plan from offering such coverage shall apply to such 
plan. 
SEC. 104. PREMIUMS. 
The Secretary shall establish premium rates for the 
public health plan option that— 
(1) are adjusted based on the applicable rating 
area; 
(2) are at a level sufficient to fully finance— 
(A) the costs of health benefits provided by 
such plans; and 
(B) administrative costs related to oper-
ating the plans; and 
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(3) comply with the requirements under section 
2701 of the Public Health Service Act (42 U.S.C. 
300gg). 
SEC. 105. PROVIDERS AND REIMBURSEMENT RATES. 
(a) IN GENERAL.—The Secretary shall establish a 
rate schedule for reimbursing types of health care pro-
viders furnishing items and services under the public 
health insurance plan option at rates based on rates ap-
plied for such items and services under title XVIII of the 
Social Security Act, as of the date of the enactment of 
this Act, that are necessary to maintain network ade-
quacy. The Secretary shall establish a rate schedule for 
items and services not currently covered under title XVIII 
of the Social Security Act at a level to ensure adequate 
access to providers. 
(b) PARTICIPATING PROVIDERS.— 
(1) IN GENERAL.—A health care provider that 
is a participating provider of services or supplier 
under the Medicare program under title XVIII of 
the Social Security Act or under the Medicaid pro-
gram under title XIX of such Act on the date of en-
actment of this title shall be a participating provider 
for public health insurance plan option. 
(2) ADDITIONAL
PROVIDERS.—The Secretary 
shall establish a process to allow health care pro-
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viders not described in paragraph (1) to become par-
ticipating providers for the public health insurance 
plan option. 
(c) PRESCRIPTION
DRUGS.—The Secretary shall 
apply the provisions of section 1860D–11(i) of the Social 
Security Act (42 U.S.C. 1395w–111(i)) to prescription 
drugs under the public health plan option in the same 
manner as such provisions apply with respect to applicable 
covered part D drugs under such section. 
SEC. 106. ACCOUNT; FUNDING. 
(a) ESTABLISHMENT.—There is established in the 
Treasury of the United States an account for the receipts 
and disbursements attributable to the operation of the 
public health plan option. 
(b) APPROPRIATION.—There is appropriated to the 
account established under subsection (a), out of any funds 
in the Treasury not otherwise obligated, such sums as may 
be necessary to be used by the Secretary for purposes of 
carrying out this part. 
(c) 
PROHIBITION
OF
STATE
IMPOSITION
OF 
TAXES.—Section 1854(g) of the Social Security Act (42 
U.S.C. 1395w–24(g)) shall apply to receipts and disburse-
ments described in subsection (a) in the same manner as 
such section applies to payments or premiums described 
in such section. 
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(d) CLARIFICATION.—Any provision of law restricting 
the use of Federal funds with respect to any reproductive 
health service shall not apply to funds appropriated under 
subsection (b) or with respect to the account under sub-
section (a). 
Subtitle B—Medicare for America 
SEC. 111. ESTABLISHMENT AND ADMINISTRATION OF MEDI-
CARE FOR AMERICA. 
The Social Security Act is amended by adding at the 
end the following new title: 
‘‘TITLE XXII—MEDICARE FOR 
AMERICA 
‘‘PART A—COMPREHENSIVE HEALTH COVERAGE 
‘‘SEC. 2201. ESTABLISHMENT. 
‘‘The Secretary shall establish a public health insur-
ance program, to be known as ‘Medicare for America’, 
which shall for calendar year 2022 and each subsequent 
calendar year provide comprehensive health benefits in ac-
cordance with this part to individuals enrolled for coverage 
under this title. 
‘‘SEC. 2202. ELIGIBILITY; AUTOMATIC ENROLLMENT. 
‘‘(a) ELIGIBLE INDIVIDUALS.—For purposes of this 
title, every individual who is a resident of the United 
States is entitled to benefits for health care services under 
this title. The Secretary shall promulgate a rule that pro-
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vides criteria for determining residency for eligibility pur-
poses under this title. 
‘‘(b) ENROLLMENTS.—Subject to subsection (c): 
‘‘(1) IN
GENERAL.—Beginning in 2022, the 
Secretary shall provide a mechanism for the enroll-
ment of individuals entitled to benefits under this 
title and, in conjunction with such enrollment, the 
issuance of a Medicare card which may be used for 
purposes of identification and processing of claims 
for benefits under this title. As a condition of par-
ticipation in the program, participating providers 
shall facilitate enrollment as specified by the Sec-
retary. 
‘‘(2) AUTOMATIC ENROLLMENTS.—The mecha-
nism provided under paragraph (1) shall, subject to 
paragraph (4), provide, for plan years beginning 
with plan year 2022, for the following automatic en-
rollments under Medicare for America: 
‘‘(A) ENROLLMENT AT BIRTH.—For plan 
years (beginning with plan year 2022), a proc-
ess, established by the Secretary in consultation 
with the Commissioner of Social Security, for 
the automatic enrollment of eligible individuals 
born during such plan year. 
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‘‘(B) 
CURRENT
MEDICARE
BENE-
FICIARIES.— 
‘‘(i) 
CURRENT
MEDICARE
BENE-
FICIARIES.—For plan years (beginning 
with plan year 2022), a process established 
by the Secretary for the automatic enroll-
ment of all individuals who are enrolled for 
benefits under part A or B of title XVIII 
(other than individuals who are enrolled 
for such benefits and receiving benefits 
under title XIX). 
‘‘(ii) CONTINUING POPULATION.—For 
plan years (beginning with plan year 
2022), a process established by the Sec-
retary for the automatic enrollment of eli-
gible individuals who attain the age of 65 
during such plan year. 
‘‘(iii) DUALS.—For plan years (begin-
ning with plan year 2024), a process estab-
lished by the Secretary for the automatic 
enrollment of eligible individuals who are 
enrolled for benefits under part A or B of 
title XVIII and receiving benefits under 
title XIX. 
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‘‘(C) 
OTHER
INDIVIDUALS
WITHOUT 
QUALIFIED
HEALTH
COVERAGE.—For 
plan 
years (beginning with plan year 2022), a proc-
ess established by the Secretary for the auto-
matic enrollment of eligible individuals who are 
not enrolled in other qualified health coverage 
(as defined in paragraph (4)(B)) for such plan 
year. 
‘‘(3) OTHER ENROLLMENTS.—The mechanism 
provided under paragraph (1) shall provide for the 
following: 
‘‘(A) IN
GENERAL.—Enrollment periods 
and processes for each plan year (beginning 
with plan year 2022) for enrollment under 
Medicare for America of any eligible individual 
not otherwise described in paragraph (2). 
‘‘(B) SMALL EMPLOYERS.—For plan years 
(beginning with plan year 2022), a process and 
methodology under which a small employer, as 
defined in section 124(d)(3) of the Medicare for 
America Act, may provide for the enrollment of 
the employees of such employer under Medicare 
for America. For purposes of the previous sen-
tence, the term ‘small employer’ means any em-
ployer for any calendar year if the annual pay-
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roll of such employer for the preceding calendar 
year does not exceed $2,000,000 or has fewer 
than 100 employees. 
‘‘(C) LARGE EMPLOYERS.—For plan years 
(beginning with plan year 2026), the Secretary 
shall provide for a process and methodology 
under which a large employer may provide for 
the enrollment of the employees of such em-
ployer under Medicare for America. For pur-
poses of the preceding sentence, the term ‘large 
employer’ means an employer with at least 100 
employees. 
‘‘(4) OPT
OUT
FOR
INDIVIDUALS
ENROLLED 
UNDER QUALIFIED HEALTH COVERAGE.— 
‘‘(A) IN GENERAL.—The mechanism pro-
vided under paragraph (1) shall provide, with 
respect to a plan year, for a process that en-
ables individuals who are enrolled in qualified 
health coverage for such plan year to opt out of 
coverage under Medicare for America for such 
year. 
‘‘(B) QUALIFIED HEALTH COVERAGE DE-
FINED.—For purposes of this section, the term 
‘qualified health coverage’ means coverage 
under any of the following: 
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‘‘(i) For plan years 2022 and 2023: 
‘‘(I) Qualified employer coverage, 
as defined in section 124 of the Medi-
care for America Act. 
‘‘(II) Medical coverage under 
chapter 55 of title 10, United States 
Code, including coverage under the 
TRICARE program. 
‘‘(III) A health care program 
under chapter 17 or 18 of title 38, 
United States Code, as determined by 
the Secretary of Veterans Affairs, in 
coordination with the Secretary of 
Health and Human Services and the 
Secretary. 
‘‘(IV) The health benefit program 
under chapter 89 of title 5, United 
States Code. 
‘‘(V) Medical benefits and serv-
ices provided by or through the Indian 
Health Service. 
‘‘(VI) The Medicaid program 
under title XIX of the Social Security 
Act. 
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‘‘(VII) The CHIP program under 
title XXI of the Social Security Act. 
‘‘(ii) For plan years 2024 and 2025: 
‘‘(I) Coverage described in sub-
clause (I), (II), (III), (IV), or (V) of 
clause (i). 
‘‘(II) Coverage described in sub-
clause (VI) of clause (i), but only with 
respect to coverage that is not for in-
dividuals described in subclause (VIII) 
of section 1902(a)(10)(A)(i) or who 
are also enrolled for benefits under 
title XVIII. 
‘‘(iii) For each subsequent plan year, 
coverage described in subclause (I), (II), 
(III), (IV), or (V) of clause (i). 
‘‘(c) WAIVER.—The Secretary shall establish a proc-
ess under which the Secretary may grant waivers to States 
for additional time before populations described in a pre-
vious subsection of this section of such State are automati-
cally enrolled under Medicare for America. 
‘‘SEC. 2203. BENEFITS. 
‘‘(a) IN GENERAL.—Medicare for America shall, in 
accordance with this section, provide coverage for all the 
benefits, as determined to be medically necessary and rea-
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sonable, as covered and defined under parts A and B of 
title XVIII and title XIX as of the date of the enactment 
of this title, including the following: 
‘‘(1) Ambulatory patient services. 
‘‘(2) Emergency care and urgent care services. 
‘‘(3) Hospitalization. 
‘‘(4) Maternity and newborn care. 
‘‘(5) Behavioral health, mental health and sub-
stance use disorder services, including the following: 
‘‘(A) Home-based services. 
‘‘(B) Acute services for mental health cri-
ses, including crisis stabilization services such 
as mobile crisis services, including emergency 
mobile psychiatric services. 
‘‘(C) 23-hour observation. 
‘‘(D) Outpatient services provided by hos-
pitals, freestanding clinics, and behavioral 
health providers in independent practice. 
‘‘(E) Smoking and tobacco cessation. 
‘‘(F) Case management. 
‘‘(G) Peer support services. 
‘‘(H) Counseling. 
‘‘(I) Other intensive outpatient community- 
based services, such as Assertive Community 
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Treatment and supported employment, provided 
through the LTSS benefit. 
‘‘(J) Other intensive community-based 
services provided through the Early and Peri-
odic Screening, Diagnostic, and Treatment 
(EPSDT) benefit (as defined in subpart B of 
part 441 of title 42 of the Code of Federal Reg-
ulations). 
‘‘(K) Medication assisted treatment and 
maintenance services. 
‘‘(L) Inpatient detoxification. 
‘‘(M) Ambulatory detoxification. 
‘‘(N) Psychological testing. 
‘‘(O) Home health agency services. 
‘‘(6) Prescription drugs. 
‘‘(7) Rehabilitative and habilitative services and 
devices, including the following: 
‘‘(A) Physical therapy. 
‘‘(B) Speech therapy. 
‘‘(C) Occupational therapy. 
‘‘(8) Laboratory services. 
‘‘(9) Preventive and wellness services and 
chronic disease management. 
‘‘(10) Pediatric services, including oral and vi-
sion care and all services that would otherwise be 
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covered under Early and Periodic Screening, Diag-
nostic, and Treatment under the Medicaid program 
under title XIX. 
‘‘(11) Dental. 
‘‘(12) Hearing health services including aids 
and exams. 
‘‘(13) Home and community-based long-term 
supports and services. 
‘‘(14) Chiropractic services. 
‘‘(15) Durable medical equipment, including the 
following: 
‘‘(A) Wheelchairs and accessories. 
‘‘(B) Walking aides such as walkers, canes, 
and crutches. 
‘‘(C) Bathroom equipment such as com-
modes and safety equipment. 
‘‘(D) Inhalation therapy equipment such as 
nebulizers. 
‘‘(E) Hospital beds and accessories. 
‘‘(F) Other devices such as continuous 
positive airway pressure (CPAP) machines, 
apnea monitors, and ventilators. 
‘‘(G) Insulin pumps and glucometers. 
‘‘(H) Breast pumps. 
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‘‘(I) Lymphedema compression treatment 
items. 
‘‘(J) Wigs. 
‘‘(K) Augmentative and alternative com-
munication devices, including dual-use devices. 
‘‘(16) Family planning, including the following: 
‘‘(A) Reproductive health exams. 
‘‘(B) Patient counseling and education re-
lated to family planning. 
‘‘(C) Abortion. 
‘‘(D) Screening, testing, treatment, and 
pre- and post-test counseling for sexually trans-
mitted diseases and HIV. 
‘‘(E) Contraceptives including pill, patch, 
medication, condom, implant, or other devices 
used to prevent pregnancy. 
‘‘(F) Sterilization for beneficiaries over the 
age of 21. 
‘‘(G) Infertility treatment. 
‘‘(17) Gender-confirming medical procedures 
and treatment. 
‘‘(18) Dietary and nutrition counseling. 
‘‘(19) Medically necessary food and vitamins for 
digestive and inherited metabolic disorders. 
‘‘(20) Nursing facilities. 
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‘‘(21) Orthotic and prosthetics devices. 
‘‘(22) Oxygen. 
‘‘(23) Acupuncture. 
‘‘(24) Telehealth. 
‘‘(25) Services otherwise included under the 
maternal, infant, and early childhood home visiting 
program under section 511 of the Social Security 
Act, as of the date of the enactment of this title. 
‘‘(26) Any additional benefit or service not in-
cluded in this section that is covered by any State 
plan (or waiver of such State plan) under title XIX 
on the date of the enactment of this title. 
‘‘(b) UPDATES.—Benefits covered under Medicare for 
America shall be updated in accordance with the National 
Coverage Determination process that had, as of the date 
before the date of the enactment of this title, applied with 
respect to benefits covered under title XVIII. 
‘‘(c) PROHIBITION
AGAINST
DUPLICATING
COV-
ERAGE.— 
‘‘(1) IN GENERAL.—It is unlawful for a private 
health insurer (other than an insurer with respect to 
a Medicare Advantage for America plan under part 
C of this title or qualified employer-based coverage) 
to sell health insurance coverage that duplicates the 
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benefits provided under Medicare for America under 
this part. 
‘‘(2) CONSTRUCTION.—Nothing in paragraph 
(1) shall be construed as prohibiting the sale of 
health insurance coverage for any additional benefits 
not covered by this part, insofar as the coverage sat-
isfies the conditions of paragraph (3). 
‘‘(3) APPLICATION OF PROTECTIONS.—For pur-
poses of paragraph (2), health insurance coverage 
for any additional benefits must satisfy the following 
conditions: 
‘‘(A) The provisions of section 2718 of the 
Public Health Service Act, relating to a medical 
loss ratio. 
‘‘(B) The provisions of section 2702 of the 
Public Health Service Act, relating to guaran-
teed issue. 
‘‘(C) The provisions of section 2701 of the 
Public Health Service Act, relating to commu-
nity rating. 
‘‘(D) The provisions of section 2704 of the 
Public Health Service Act, relating to the ban 
on pre-existing conditions exclusions. 
‘‘(d) STATES MAY PROVIDE ADDITIONAL BENE-
FITS.—Individual States may provide additional benefits 
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for the residents of such States at the expense of the 
State. 
‘‘(e) PROHIBITION AGAINST STEP THERAPY
AND 
PRIOR
AUTHORIZATION.—Items and services covered 
under Medicare for America shall be covered without any 
need for any prior authorization determination and with-
out any limitation applied through the use of step therapy 
protocols. 
‘‘SEC. 2204. PREMIUMS. 
‘‘(a) IN GENERAL.—(1) Subject to paragraph (2), 
each individual enrolled for benefits under this title for 
a year shall pay monthly community-rated premiums for 
such year in an amount determined by the Secretary in 
accordance with subsection (b). 
‘‘(2) 
GRANDFATHERED
MEDICARE
BENE-
FICIARIES.—In the case of an individual enrolled under 
part B of title XVIII as of the date of the enactment of 
this part, the premium applied under this section for such 
individual for benefits under this title shall be the lesser 
of— 
‘‘(A) the premium otherwise applicable to such 
individual under such title XVIII if this title had not 
been enacted; or 
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‘‘(B) the premium that would be applied to 
such individual under this title without the applica-
tion of this paragraph. 
‘‘(b) PREMIUM CONTRIBUTION BASED ON INCOME.— 
The amount of a monthly premium, with respect to a plan 
year (beginning with 2022), under this section shall be 
established by the Secretary in accordance with the fol-
lowing: 
‘‘(1) Such premium shall be determined such 
that the collective premiums for the plan year are 
with respect to the costs of health benefits provided 
under this title for such year and related administra-
tive costs. 
‘‘(2) Premiums shall vary by family composition 
only. 
‘‘(3) Federal subsidies shall be provided to en-
sure that the premium shall be— 
‘‘(A) zero in the case of an individual 
whose annual household income is below 200 
percent of the poverty line; 
‘‘(B) determined by a linear sliding scale, 
in the case of an individual whose household in-
come is at least 200 percent of the poverty line, 
but not more than 600 percent of the poverty 
line, with the premiums ranging between the 
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amount determined for individuals described in 
clause (i) and for individuals described in clause 
(iii); and 
‘‘(C) no individual or household will pay 
more than 9.69 percent of monthly income to-
ward such monthly premium. 
‘‘(4) For an individual whose employer will be 
making a firm-wide contribution under this title in 
lieu of offering employer sponsored insurance (as 
specified in section 124(b)(1)(B) of the Medicare for 
America Act), such individual shall pay a premium 
in accordance with this subsection. 
‘‘(5) For an individual who has opted out of 
their employer sponsored insurance in order to enroll 
in Medicare for America as specified in section 
124(c) of such Act, the individual shall pay the pre-
mium described in this subsection. 
‘‘(c) DEPOSITS.—Amounts paid under this section for 
coverage under this title shall be deposited in the Treasury 
to the credit of the Trust Fund established under section 
2206. 
‘‘(d) APPEALS
FOR CERTAIN MEDICARE GRAND-
FATHERED POPULATION.—In calculating premiums for 
purposes of subsection (a)(2): 
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‘‘(1) Any individual that was subject to a late 
enrollment penalty under part B of title XVIII shall 
have the right to appeal the assessment of the pen-
alty for good faith enrollment mistakes. 
‘‘(2) In any case in which the Secretary finds 
that an individual’s enrollment or nonenrollment in 
the insurance program established by this part or 
part A of title XVIII pursuant to section 1818 is un-
intentional, inadvertent, or erroneous, whether the 
result of the error, misrepresentation, or inaction of 
an officer, employee, or agent of the Federal Govern-
ment or its instrumentalities, an employer, a rep-
resentative of a group health plan, a State, or for 
any other good faith reason on the part of such indi-
vidual, the Secretary shall take such action (includ-
ing the designation for such individual of a special 
initial or subsequent enrollment period, including 
retroactive enrollment, with a coverage period deter-
mined on the basis thereof and with appropriate ad-
justments of premiums) as may be necessary to cor-
rect or eliminate the effects of such error, misrepre-
sentation, or inaction. The failure of an individual to 
enroll in the insurance program established by this 
part or part A pursuant to section 1818 due to en-
rollment under a group health plan; coverage pursu-
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ant to title XXII of the Public Health Service Act, 
section 4980B of the Internal Revenue Code of 
1986, title VI of the Employee Retirement Income 
Security Act of 1974, or title XIX; or enrollment 
under a qualified health plan offered through an Ex-
change established under title I of the Patient Pro-
tection and Affordable Care Act shall under this 
subsection absent exceptional circumstances, as de-
termined by the Secretary. 
‘‘(3) The Secretary, in consultation with the 
Commissioner of Social Security, shall develop and 
publish a formal application for requesting an action 
of the Secretary under paragraph (1) to correct or 
eliminate the effects of an error, misrepresentation, 
or inaction described in such paragraph and deter-
mine and publish specific timelines for timely resolu-
tion of such a request. 
‘‘(4) The Secretary shall also require that all 
such determinations with respect to such requests 
shall be reached within 15 business days of the sub-
mission of such application. All determinations shall 
be in writing through a standard decision notice 
which shall include an explanation of the reasons for 
the determination. 
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‘‘(5) The Commissioner of Social Security shall 
enter into contracts with independent review organi-
zations in accordance with this subsection for the 
purpose of reviewing and determining individual ap-
peals of determinations under paragraph (3) with re-
spect to an application submitted pursuant to para-
graph (2) relating to enrollment under part A or 
part B. 
‘‘(6) An individual who receives an adverse de-
termination under paragraph (3) with respect to an 
application submitted pursuant to paragraph (2) 
may appeal to an independent review organization 
designated by the Commission. Any such appeal 
must be sent to the independent review organization 
within 90 days of the date the individual received 
the determination to be eligible for review. The inde-
pendent review organization shall review and reach 
a determination of the review in writing within 45 
days of the receipt of any such appeal. 
‘‘(7) The Secretary of the Treasury may not 
enter into a contract under paragraph (5) with an 
independent review organization— 
‘‘(A) unless the organization has staff that 
has the appropriate knowledge of, and experi-
ence with, the eligibility and coordination of 
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benefits rules and regulations under this title; 
and 
‘‘(B) to the extent the organization is a fis-
cal intermediary under section 1816, a carrier 
under section 1842, or a Medicare administra-
tive contractor under section 1874A. 
‘‘(8) The Secretary of Health and Human Serv-
ices shall provide for access by independent review 
organizations 
conducting 
appeal 
determinations 
under this subsection, to the database of the Coordi-
nation of Benefits Contractor of the Centers for 
Medicare & Medicaid Services as necessary in order 
to conduct the duties of such organizations to deter-
mine appeals pursuant to this subsection. 
‘‘SEC. 2205. PAYMENT OF BENEFITS; COST-SHARING; OUT- 
OF-POCKET LIMITS. 
‘‘(a) PAYMENT
OF BENEFITS; COST-SHARING.— 
There shall be paid, in the case of each individual who 
is enrolled under Medicare for America and incurs ex-
penses for items and services with respect to which bene-
fits are payable under this part, after application of sub-
section (b) and subject to subsection (c), 80 percent of 
the reimbursement rates established pursuant to section 
2206 for such items and services, except that with respect 
to USPTF recommended preventive and chronic disease 
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services, and generic drugs, the amounts paid under this 
section shall be equal to 100 percent of the reimbursement 
rates established pursuant to section 2206 for such items 
and services. 
‘‘(b) DEDUCTIBLE.— 
‘‘(1) IN GENERAL.—There shall be a deductible 
applied under this part for each plan year that shall 
be determined on a linear sliding scale for household 
income that is at least 200 percent of the poverty 
line, but not more than 600 percent of the poverty 
line, and shall not exceed, subject to paragraphs (2) 
and (3)— 
‘‘(A) $350 for an individual; or 
‘‘(B) $500 total for all members of a 
household. 
‘‘(2) INDEXING.—In the case of plan years be-
ginning after 2021, the dollar amounts described in 
paragraph (1) shall be increased by the percentage 
increase over the previous year in the medical care 
expenditure category of the Consumer Price Index 
for All Urban Consumers (United States city aver-
age), published by the Bureau of Labor Statistics. 
‘‘(3) EXCEPTION.—There shall be no deductible 
applied under this part for months in a plan year for 
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individuals and households with annual income below 
200 percent of the federal poverty line. 
‘‘(c) MAXIMUM OUT-OF-POCKET LIMIT.— 
‘‘(1) IN GENERAL.—The coverage under Medi-
care shall provide benefits, after the eligible indi-
vidual has incurred out-of-pocket expenses for items 
and services with respect to which benefits are pay-
able under this part in a year equal to the annual 
out-of-pocket threshold specified in paragraph (2), 
with cost-sharing that is equal to $0. 
‘‘(2) ANNUAL OUT-OF-POCKET THRESHOLD.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1), subject to subparagraphs (B) and 
(C), the annual out-of-pocket threshold speci-
fied in this paragraph is a threshold that shall 
be determined on a linear sliding scale for 
household income that is at least 200 percent of 
the poverty line, but not more than 600 percent 
of the poverty line, and that shall not exceed— 
‘‘(i) with respect to an individual, 
$3,500; or 
‘‘(ii) with respect to a household, 
$5,000. 
‘‘(B) INDEXING.—In the case of plan years 
beginning after 2021, the threshold described in 
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subparagraph (A) (as in effect for the preceding 
plan year after application of this subpara-
graph) shall be increased by the percentage in-
crease over the previous year in the medical 
care expenditure category of the Consumer 
Price Index for All Urban Consumers (United 
States city average), published by the Bureau 
of Labor Statistics. 
‘‘(C) EXCEPTION.—For purposes of para-
graph (1), the annual out-of-pocket threshold 
for individuals and households with annual in-
come below 200 percent of the federal poverty 
line is $0. 
‘‘(d) NO BALANCE BILLING.—No provider may im-
pose a charge to an enrolled individual for covered services 
for which benefits are provided under this part in an 
amount higher than the reimbursement rate for such serv-
ices under section 2206 and may not impose a charge to 
such individual for such service other than with respect 
to the deductible or other cost-sharing described in this 
section. 
‘‘SEC. 2206. PROVIDERS NETWORK AND REIMBURSEMENT 
RATES. 
‘‘(a) IN GENERAL.—The Secretary shall establish a 
rate schedule for reimbursing types of health care pro-
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viders furnishing items and services under Medicare for 
America at rates that are consistent with subsection (b) 
and are necessary to maintain network adequacy. 
‘‘(b) RATES.— 
‘‘(1) IN GENERAL.—Except as provided in para-
graphs (2) and (3), the Secretary shall provide for 
rates to be provided to health care providers and 
suppliers furnishing items and services under Medi-
care for America based on rates that would be ap-
plied (including as computed, updated, and adjusted) 
under title XVIII for such type of health care pro-
viders and suppliers and item and service if such 
title remained in effect and, in the case of a type of 
provider and supplier or item or service covered 
under Medicare for America but not otherwise cov-
ered under title XVIII, shall provide for rates that 
ensure adequate access to care. 
‘‘(2) EXCEPTIONS.—For purposes of this sec-
tion, in applying paragraph (1) the Secretary shall 
ensure that rates to hospitals for inpatient services 
or outpatient services furnished under Medicare for 
America are at least 110 percent of such rates on 
average or in the aggregate for furnishing such inpa-
tient or outpatient services otherwise applied under 
title XVIII, except that for hospitals serving under-
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served areas as specified by the Secretary, such 
rates are increased as necessary to ensure adequate 
access to care. 
‘‘(3) APPLICATION.—In applying rates under 
title XVIII for purposes of this part, the following 
shall apply: 
‘‘(A) The Secretary shall provide for site- 
neutral payments for items and services fur-
nished in an outpatient hospital and physician 
office, the rate of payment for such service shall 
be the same. 
‘‘(B) The Secretary shall increase the aver-
age relative value of primary care and other 
mental and behavioral health and cognitive 
services by not less than 20 percent in order to 
ensure adequate access to inpatient and out-
patient care. 
‘‘(C) As a condition of participation in the 
program, participating providers shall accept 
Medicare for America rates paid by employer- 
sponsored insurance plans and Medicare Advan-
tage plans. 
‘‘(c) PARTICIPATING PROVIDERS.— 
‘‘(1) IN GENERAL.—A health care provider that 
is a participating provider of services or supplier 
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under the Medicare program under title XVIII on 
the date of enactment of this title shall remain a 
participating provider for Medicare for America. 
‘‘(2) ADDITIONAL PROVIDERS.—The Secretary 
shall establish a process to allow health care pro-
viders not described in paragraph (1) to become par-
ticipating providers for Medicare for America. 
‘‘(d) PRESCRIPTION DRUGS.— 
‘‘(1) IN GENERAL.—Any payment rate under 
this part for a prescription drug shall be at a rate 
negotiated by the Secretary based on value assess-
ments by one or more independent nonprofit organi-
zations certified by the National Academy of Medi-
cine and MedPAC. If the Secretary is unable to 
reach a negotiated agreement on such a reimburse-
ment rate, the Secretary shall apply prices paid by 
the Department of Veterans Affairs for such drugs 
or the average price of such drugs in nations which 
are members of the Organization for Economic Co-
operation and Development, whichever is lower. 
‘‘(2) FAILURE TO NEGOTIATE.—If a drug man-
ufacturer refuses to negotiate with the Secretary, 
then Medicare for America will not cover any of the 
manufacturer’s products. There shall be an excep-
tions process for drugs that are otherwise unavail-
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able for people with chronic conditions. Individuals 
shall continue to have access to drugs during the ap-
peals process. The Secretary shall modify such rates 
in order to accommodate payments for drugs that 
are not otherwise covered under the original Medi-
care fee-for-service program under title XVIII. 
‘‘(3) VALUE OR COST-EFFECTIVENESS ASSESS-
MENTS.—The use of Quality-Adjusted Life Years, 
Disability-Adjusted Life Years, or other similar 
mechanisms is prohibited for use in value or cost-ef-
fectiveness assessments for purposes of this sub-
section. 
‘‘SEC. 2207. TRUST FUND; FUNDING. 
‘‘(a) TRUST FUND.—There shall be established a uni-
fied Medicare Trust Fund in which funds provided under 
this title are deposited and from which expenditures under 
this title are made. The Trust Fund shall consist of such 
gifts and bequests as may be made and such amounts as 
may be deposited in, or appropriated to, such Trust Fund 
as provided in this Act. 
‘‘(b) FUNDING.— 
‘‘(1) TAXES.—There are hereby appropriated to 
the Trust Fund for each fiscal year beginning with 
fiscal year 2022, out of any moneys in the Treasury 
not otherwise appropriated, amounts equivalent to 
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100 percent of the net increase in revenues to the 
Treasury which is attributable to the amendments 
made by title II of the Medicare for America Act 
and premiums collected under this title. The 
amounts appropriated by the preceding sentence 
shall be transferred from time to time (but not less 
frequently than monthly) from the general fund in 
the Treasury to the Trust Fund, such amounts to be 
determined on the basis of estimates by the Sec-
retary of the Treasury of the taxes paid to or depos-
ited into the Treasury; and proper adjustments shall 
be made in amounts subsequently transferred to the 
extent prior estimates were in excess of or were less 
than the amounts that should have been so trans-
ferred. 
‘‘(2) CURRENT PROGRAM RECEIPTS.—Notwith-
standing any other provision of law, there are hereby 
appropriated to the Trust Fund for each fiscal year, 
beginning with fiscal year 2022, the amounts that 
would otherwise have been appropriated to carry out 
the following programs: 
‘‘(A) The Medicare program under title 
XVIII. 
‘‘(B) The Medicaid program under title 
XIX, beginning as of 2026. 
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‘‘(3) 
ADDITIONAL
APPROPRIATIONS.—Addi-
tional sums are authorized to be appropriated annu-
ally as needed to maintain maximum quality, effi-
ciency, and access under this part. 
‘‘(4) MEDICAID MAINTENANCE OF EFFORT PAY-
MENTS.—There shall be transferred to the Trust 
Fund the maintenance of effort payments made 
under section 2209. 
‘‘(c) RESTRICTIONS SHALL NOT APPLY.—Any other 
provision of law in effect on the date of enactment of this 
title restricting the use of Federal funds for any reproduc-
tive health service, including abortion, shall not apply to 
monies in the Trust Fund. 
‘‘(d) INCORPORATION OF PROVISIONS.—The provi-
sions of subsections (b) through (i) of section 1817 shall 
apply to the Trust Fund under this section in the same 
manner as such provisions applied to the Federal Hospital 
Insurance Trust Fund under such section 1817, except 
that, for purposes of applying such subsections to this sec-
tion, the ‘Board of Trustees of the Trust Fund’ shall mean 
the ‘Secretary’. 
‘‘(e) TRANSFER OF FUNDS.—Any amounts remain-
ing in the Federal Hospital Insurance Trust Fund under 
section 1817 or the Federal Supplementary Medical Insur-
ance Trust Fund under section 1841 after the payment 
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of claims for items and services furnished under title 
XVIII have been completed, shall be transferred into the 
Trust Fund under this section. 
‘‘SEC. 2208. ADMINISTRATIVE PROVISIONS. 
‘‘(a) CENTER FOR MEDICARE.—Beginning 2022, the 
Centers for Medicare & Medicaid Services shall be re-
named the Center for Medicare and all references in law 
and regulation to such Centers shall be deemed a reference 
to such Center. All powers, duties, and responsibilities of 
the Centers for Medicare & Medicaid Services shall be 
transferred to the Center for Medicare. 
‘‘(b) AUTHORITY.—The Secretary shall have the au-
thority to issue interim final rules with respect to any pro-
vision in this part. 
‘‘(c) ADMINISTRATIVE LAW JUDGES.— 
‘‘(1) IN GENERAL.—The Center for Medicare is 
not authorized to appoint administrative law judges, 
in accordance with pages 11420 through 499 of title 
70 of the Federal Register (March 8, 2005). 
‘‘(2) TIMING.—Under this title, administrative 
law judges must issue a decision within 90 days of 
receipt of a hearing request, as specified in sub-
sections (a) and (c) of section 405.1016 of title 2, 
Code of Federal Regulations. 
‘‘(d) COVERAGE DETERMINATIONS APPEALS.— 
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‘‘(1) Individuals may appeal a coverage deter-
mination under this title before the individual ob-
tains the service or item that is the subject of the 
appeal. 
‘‘(2) The Secretary shall eliminate the redeter-
mination by a Medicare administrative contractor 
from the appeals process under the Medicare pro-
gram for beneficiaries. 
‘‘(e) PRIVATE RIGHT OF ACTION.— 
‘‘(1) IN GENERAL.—An applicant or recipient 
aggrieved by any law, regulation, policy or practice 
in violation of a provision of this title may bring a 
civil action seeking any remedy available in law or 
equity to remedy that violation. In addition to any 
cause of action that may be available in a State 
court, the district courts of the United States shall 
have concurrent jurisdiction in the matters under 
the provisions of this title. 
‘‘(2) REASONABLE
ATTORNEY
FEES.—In any 
action or proceeding to enforce this title, the court 
may award reasonable attorneys’ fees and litigation 
costs (including expert fees) reasonably incurred 
against the defendant or defendants. 
‘‘(3) APPEAL.—Any civil action brought under 
this section shall be subject to appeal as provided in 
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sections 1291 and 1292 of title 28 of the United 
States Code. 
‘‘SEC. 2209. MAINTENANCE OF EFFORT REQUIREMENT. 
‘‘(a) IN GENERAL.—A State is not eligible for pay-
ment under any program specified in subsection (d) for 
a calendar quarter in a plan year beginning after 2026 
unless the State makes to the Secretary for transfer to 
the unified Medicare Trust Fund under section 2207 the 
maintenance of effort payment applicable to such State 
and plan year under subsection (b). The Secretary shall 
extend such a waiver (including the availability of Federal 
financial participation under such waiver) for such period 
as may be required for a State to meet the requirement 
of the previous sentence. 
‘‘(b) MAINTENANCE OF EFFORT PAYMENTS.—For 
purposes of this section, a maintenance of effort payment 
with respect to a State and plan year is— 
‘‘(1) for plan year 2027 and a State, a payment 
in an amount equal to the total amount of expendi-
tures of the State for medical assistance under title 
XIX and child health assistance under title XXI in-
cluding administrative costs for the plan year before 
the date of the enactment of this title; 
‘‘(2) for plan year 2028 and each subsequent 
plan year before plan year 2032— 
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‘‘(3) Maternal and child health services block 
grants under title V of the Social Security Act. 
‘‘(4) Block grants for prevention and treatment 
of substance abuse under subpart II of part B of 
title XIX of the Public Health Service Act. 
‘‘(5) State Targeted Response to Opioid Crisis 
Grant Community Services Block Grant. 
‘‘(6) Grants under section 330 of the Public 
Health Service Act. 
‘‘(7) Ryan White HIV/AIDS Program grants 
under title XXVI of the Public Health Service Act. 
‘‘SEC. 2210. APPLICATION OF TITLE XVIII PROVISIONS. 
‘‘Except as specified otherwise in this title, in imple-
menting Medicare for America, the Secretary shall to the 
greatest extent practicable apply the following provisions 
of title XVIII to the program under this title, benefits cov-
ered under this title, individuals entitled to benefits under 
this title, and providers of services and suppliers partici-
pating under the program under this title in a similar 
manner as such provisions applied to the program under 
title XVIII, benefits covered under such title, individuals 
entitled to benefits or enrolled under such title, and pro-
viders of services and suppliers participating under the 
program under such title: 
‘‘(1) Section 1801. 
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‘‘(2) Section 1805. 
‘‘(3) Section 1806. 
‘‘(4) Section 1807. 
‘‘(5) Section 1809. 
‘‘(6) Section 1812. 
‘‘(7) Section 1814. 
‘‘(8) Section 1815. 
‘‘(9) Section 1816. 
‘‘(10) Section 1818. 
‘‘(11) Section 1818A. 
‘‘(12) Section 1819. 
‘‘(13) Section 1820. 
‘‘(14) Section 1832. 
‘‘(15) Section 1834. 
‘‘(16) Section 1834A. 
‘‘(17) Section 1835. 
‘‘(18) Section 1843. 
‘‘(19) Section 1846. 
‘‘(20) Section 1847. 
‘‘(21) Section 1851. 
‘‘(22) Section 1852. 
‘‘(23) Section 1855. 
‘‘(24) Section 1856. 
‘‘(25) Section 1857. 
‘‘(26) Section 1858. 
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‘‘(27) Section 1861. 
‘‘(28) Section 1863. 
‘‘(29) Section 1864. 
‘‘(30) Section 1866B. 
‘‘(31) Section 1866C. 
‘‘(32) Section 1866E. 
‘‘(33) Section 1867. 
‘‘(34) Section 1868. 
‘‘(35) Section 1869. 
‘‘(36) Section 1871. 
‘‘(37) Section 1874A. 
‘‘(38) Section 1880. 
‘‘(39) Section 1881. 
‘‘(40) Section 1881A. 
‘‘(41) Section 1891. 
‘‘(42) Section 1894. 
‘‘(43) Section 1895. 
‘‘(44) Section 1896. 
‘‘PART B—LONG-TERM SERVICES AND SUPPORTS 
‘‘SEC. 2221. LONG-TERM SERVICES AND SUPPORTS BEN-
EFIT. 
‘‘All individuals enrolled under Medicare for America 
under this title shall have coverage for long-term services 
and supports benefits. 
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‘‘SEC. 2222. ELIGIBILITY. 
‘‘(a) ELIGIBLE INDIVIDUALS.—An individual who is 
eligible for long-term care benefits under this part is an 
individual who satisfies each of the following: 
‘‘(1) The individual is eligible for Medicare for 
America. 
‘‘(2) The individual is determined to have a 
condition, as certified by a licensed health care prac-
titioner, that results in substantially reduced func-
tional capacity in one or more of the following areas: 
‘‘(A) Communication. 
‘‘(B) Social interaction. 
‘‘(C) Learning. 
‘‘(D) Mobility. 
‘‘(E) Self-care. 
‘‘(F) Self-management. 
‘‘(G) Impairments that affect the person’s 
capacity for social or economic participation. 
‘‘(b) CLARIFICATION.—Under this part, in the case 
of an individual described in subsection (a) who, due to 
the nature of the condition of the individual, experience 
periods in which their functional capacity changes or im-
proves, such individual shall continue to have access to 
benefits under this part as needed. If such an individual’s 
functional capacity improves to a point in which the indi-
vidual no longer requires long term supports and services, 
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or requires fewer services, the individual shall be able to 
immediately and seamlessly resume receiving all needed 
services if and when their functional needs recur. Eligi-
bility for services shall be maintained if, without the serv-
ices, the individual would have reduced functional capac-
ity. The presence of supports and services or other miti-
gating measures shall not be taken into account when 
looking at functional impairment. 
‘‘(c) BENEFITS.— 
‘‘(1) DEFINITION.—For purposes of this title, 
the term ‘long-term services and supports benefit’ 
means the daily living supports needed by eligible in-
dividuals and includes all long-term services and 
supports covered, as of the date of the enactment of 
this title, under any State plan under title XIX, in-
cluding— 
‘‘(A) home and community-based services; 
and 
‘‘(B) any additional services and supports 
developed to help people with disabilities live, 
work, and participate in their communities, in-
cluding— 
‘‘(i) home health aides and home-
makers; 
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‘‘(ii) direct support professionals and 
personal attendant care services; 
‘‘(iii) hospice; 
‘‘(iv) nursing care; 
‘‘(v) medical social services; 
‘‘(vi) case management, fiscal inter-
mediary, and support brokerage services; 
‘‘(vii) short-term inpatient care, in-
cluding respite care and care for pain con-
trol; 
‘‘(viii) behavioral health long-term 
services and supports, including assertive 
community treatment, peer support serv-
ices, intensive case management, supported 
employment, and supported housing wrap-
around; and 
‘‘(ix) all additional services coverable 
in Medicaid under state plan services, sec-
tions 1115, 1915(c), 1915(k), 1915(i), and 
1915(j), for people with disabilities. 
‘‘(2) SELF-DIRECTED MODEL.—All eligible indi-
viduals shall be defaulted into a self-directed care 
option (as defined by the Secretary). 
‘‘(3) COMMUNITY
FIRST.—The benefit under 
this part shall be provided with a community-first 
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presumption and eligible individuals should be ini-
tially provided home and community-based services, 
as defined for purposes of section 1915(i). Before an 
eligible individual is admitted into a long term care 
institution, the State mental health or developmental 
disability authority or State agency that administers 
the State plan under title XIX shall conduct a man-
datory assessment to determine whether their needs 
could be met through home and community-based 
services and if so, the services would have to be ar-
ranged for by the State and the coverage would not 
be provided for the individual with respect to such 
an admission. This assessment shall be conducted at 
least annually or upon a change in condition for all 
individual already admitted to an institution. 
‘‘(d) COORDINATION WITH OTHER FEDERAL BENE-
FITS.— 
‘‘(1) RULE
OF
CONSTRUCTION.—Nothing in 
this part shall be construed as prohibiting benefits 
paid under this part from being used to compensate 
a caregiver who provides community living assistance 
services and supports to a dependent relative not 
less than 80 hours a month for providing community 
living assistance services and supports to an eligible 
individual under this part. 
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‘‘(2) DEPENDENT
RELATIVE
DEFINED.—The 
term ‘dependent relative’ means— 
‘‘(A) a child, grandchild, niece, or nephew 
(of such caregiver or such caregiver’s spouse or 
domestic partner); 
‘‘(B) a child to which the caregiver or the 
caregiver’s spouse or domestic partner is stand-
ing in loco parentis; 
‘‘(C) a parent, grandparent, sibling, aunt, 
or uncle (of such caregiver or his or her spouse 
or domestic partner); or 
‘‘(D) such caregiver’s spouse or domestic 
partner, if such child, grandchild, niece, neph-
ew, parent, grandparent, sibling, aunt, uncle, 
spouse, or domestic partner is an eligible indi-
vidual. 
‘‘(3) SUPPLEMENT
NOT
SUPPLANT.—Benefits 
received under this part by a caregiver shall supple-
ment, but not supplant, other benefits for which the 
individual is eligible under any other Federally fund-
ed program that provides benefits or assistance. 
‘‘(4) DISREGARD.—Benefits paid to a caregiver 
under this part shall be disregarded for purposes of 
determining or continuing the eligibility of the indi-
vidual or the spouse of the individual for receipt of 
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benefits under any other Federal, State, or locally 
funded assistance program, including benefits paid 
under titles II or XVI under the laws administered 
by the Secretary of Veterans Affairs, under low-in-
come housing assistance programs, under the sup-
plemental nutrition assistance program established 
under the Food and Nutrition Act of 2008, or under 
programs administered by State vocational rehabili-
tation agencies. 
‘‘PART C—MEDICARE ADVANTAGE FOR AMERICA 
‘‘SEC. 2231. ALL PRIVATE PLANS. 
‘‘(a) IN GENERAL.—For plan years beginning with 
plan year 2026, a health insurance issuer may offer health 
insurance coverage in the individual market only if such 
issuer has entered into a contract with the Secretary 
under subsection (b) to offer such coverage. 
‘‘(b) AGREEMENTS.—The Secretary shall enter into 
an agreement with an MA for America sponsor to offer 
MA for America plans under this part for the coverage 
of individuals enrolled under Medicare for America who 
elect to receive benefits under part A through such a plan. 
‘‘(c) MA FOR AMERICA PLAN; MA FOR AMERICA 
SPONSOR.—For purposes of this part— 
‘‘(1) MA FOR
AMERICA
PLAN.—An MA for 
America plan is a Medicare Advantage plan under 
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part C of title XVIII, except such plan shall provide 
coverage for individuals enrolled under Medicare for 
America under part A of this title, with respect to 
at least the benefits covered under such part A. 
‘‘(2) MA FOR AMERICA SPONSOR.—An MA for 
America sponsor is a sponsor of an MA for America 
plan. 
‘‘SEC. 2232. APPLICATION OF MEDICARE ADVANTAGE PRO-
VISIONS. 
‘‘For purposes of applying this part, except as other-
wise specified under this part, the provisions of part C 
of title XVIII, as in effect as of the date of the enactment 
of this title shall apply with respect to an MA for America 
sponsor, MA for America plan, individuals eligible for cov-
erage under this part, individuals enrolled under such 
plan, and benefits covered under part A in a similar man-
ner and to a similar extent as such provisions applied to 
an MA organization, MA plan, individuals eligible for 
under part C of such title, individuals enrolled under an 
MA plan, and benefits covered under fee-for-service Medi-
care as of such date. 
‘‘SEC. 2233. INCREASED PREMIUM FOR MEDICARE ADVAN-
TAGE FOR AMERICA PLANS. 
‘‘Nothing in this part shall preclude an individual 
from choosing a Medicare Advantage for America plan 
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which requires the individual to pay an additional amount 
because of supplemental benefits or because it is a more 
expensive plan. In such case the individual enrolled under 
such plan would be responsible for the increased monthly 
premium. 
‘‘SEC. 2234. REFERENCES. 
‘‘Beginning in 2022, all references in law and regula-
tion to Medicare Advantage shall be deemed a reference 
to Medicare Advantage for America.’’. 
SEC. 112. MODIFICATIONS TO AND COORDINATION WITH 
EXISTING FEDERAL HEALTH PROGRAMS. 
(a) MEDICARE, MEDICAID, AND STATE CHILDREN’S 
HEALTH INSURANCE PROGRAM (SCHIP).— 
(1) IN GENERAL.—Notwithstanding any other 
provision of law, subject to paragraphs (2) and (3) 
and section 2202(c) of the Social Security Act, as 
added by section 111— 
(A) no benefits shall be available under 
title XVIII of the Social Security Act for any 
item or service furnished— 
(i) beginning on or after January 1, 
2022 (except in the case of an individual 
enrolled under such title and title XIX of 
such Act); and 
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of an individual enrolled under such title 
and title XVIII of the Social Security Act 
or an individual described in subclause 
(VIII) of section 1902(a)(10)(A)(i); and 
(ii) for any item or service furnished 
on or after January 1, 2026. 
(2) TRANSITION.—In the case of inpatient hos-
pital services and extended care services during a 
continuous period of stay which began before Janu-
ary 1, 2024 for Medicare and 2026 for Medicaid or 
CHIP, and which had not ended as of such date, for 
which benefits are provided under title XVIII of the 
Social Security Act, under a State plan under title 
XIX of such Act, or under a State child health plan 
under title XXI such Act, the Secretary of Health 
and Human Services shall provide for continuation 
of benefits under such title or plan until the end of 
the period of stay. 
(b) OTHER FEDERAL HEALTH PROGRAMS.— 
(1) FEDERAL EMPLOYEES HEALTH BENEFITS 
PROGRAM.—Nothing in this Act, or the amendments 
made by this Act, shall affect benefits made avail-
able under chapter 89 of title 5, United States Code. 
(2) TRICARE.—Nothing in this Act, or the 
amendments made by this Act, shall affect benefits 
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made available under sections 1079 and 1086 of 
title 10, United States Code. 
(3) TREATMENT OF BENEFITS FOR VETERANS 
AND NATIVE AMERICANS.— 
(A) IN GENERAL.—Nothing in this Act, or 
the amendments made by this Act, shall affect 
the eligibility of veterans for the medical bene-
fits and services provided under title 38, United 
States Code, or of Indians for the medical bene-
fits and services provided by or through the In-
dian Health Service. 
(B) REEVALUATION.—No reevaluation of 
the Indian Health Service shall be undertaken 
without consultation with tribal leaders and 
stakeholders. 
(c) SUNSET OF PROVISIONS RELATED TO THE STATE 
EXCHANGES.—Effective January 1, 2022, the Federal 
and State Exchanges established pursuant to title I of the 
Patient Protection and Affordable Care Act (Public Law 
111–148) shall terminate, and any other provision of law 
that relies upon participation in or enrollment through 
such an Exchange, including such provisions of the Inter-
nal Revenue Code of 1986, shall cease to have force or 
effect. 
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(d) SEVERABILITY.—Every provision in this Act and 
every application of the provisions in this Act are severable 
from each other as a matter of Federal law. If any applica-
tion of any provision in this Act to any person or group 
of persons or circumstances is found by a court to be in-
valid, the remainder of this Act and the application of the 
Act’s provisions to all other persons and circumstances 
may not be affected. 
Subtitle C—Targeted Reforms 
SEC. 121. LIMITATION ON REMOVAL OF MEDICARE ADVAN-
TAGE PROVIDERS BY MA ORGANIZATIONS. 
(a) LIMITATION.—Section 1852(d) of the Social Se-
curity Act (42 U.S.C. 1395w–22(d)) is amended by adding 
at the end the following: 
‘‘(7) LIMITATION ON REMOVAL OF PROVIDERS 
FROM MA PLANS BY MA ORGANIZATIONS.— 
‘‘(A) REMOVAL
OF
PROVIDERS
WITH 
CAUSE.—Beginning with plan year 2019, except 
as provided in subparagraph (C), an MA orga-
nization offering an MA plan may only remove 
a provider of services or a supplier from a net-
work of such plan if the organization has cause 
to remove such provider or supplier. 
‘‘(B) CAUSE TO REMOVE PROVIDERS.— 
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‘‘(i) IN GENERAL.—An MA organiza-
tion offering an MA plan has cause to re-
move a provider of services or a supplier 
from a network of such plan if the Sec-
retary determines that the provider or sup-
plier is— 
‘‘(I) medically negligent; 
‘‘(II) in violation of any legal or 
contractual requirement applicable to 
the provider or supplier acting within 
the lawful scope of practice, including 
any participation or other requirement 
applicable to such provider or supplier 
under this title or under any contrac-
tual term for such plan; or 
‘‘(III) otherwise unfit to furnish 
items and services in accordance with 
requirements of this title. 
‘‘(ii) CONSIDERATION OF COST TO MA 
ORGANIZATIONS.—For purposes of sub-
paragraph (A), cost to an MA organization 
offering an MA plan due to the participa-
tion of a provider of services or supplier in 
a network of such plan does not constitute 
cause for the MA organization to remove 
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such provider or supplier from the network 
mid-year, and such cost may not be consid-
ered as a factor in favor of a determination 
that such organization has cause to remove 
the provider. 
‘‘(C) EXCEPTION.—With respect to each 
upcoming plan year, beginning with plan year 
2019, an MA organization offering an MA plan 
may only remove a provider of services or sup-
plier from a network of such plan for reasons 
not specified in subparagraph (B)(i) before the 
date that is 60 days before the first day of the 
annual coordinated election period for such plan 
year under section 1851(e)(3). 
‘‘(D) NOTICE AND APPEAL PROCESS.— 
‘‘(i) IN GENERAL.—Any removal of a 
provider of services or supplier from a net-
work of an MA plan may occur only after 
the completion of a fair notice and appeal 
process that the Secretary shall establish 
by regulation. Such process shall require 
the MA organization to provide to such 
provider or supplier and to the Secretary 
an explanation of the reason or reasons for 
the removal. 
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‘‘(ii) APPLICATION.— 
‘‘(I) APPLICATION OF NEW PROC-
ESS.—In the case of a removal of a 
provider of services or supplier from a 
network of an MA plan occurring on 
or after the effective date published in 
a final rule for such fair notice and 
appeal process, such process shall 
apply in lieu of the process for the 
termination or suspension of a pro-
vider 
contract 
under 
section 
422.202(a) of title 42, Code of Fed-
eral Regulations. 
‘‘(II) CONTINUATION
OF
OLD 
PROCESS.—In the case of a removal of 
a provider of services or supplier from 
a network of an MA plan occurring 
before such effective date, the process 
for the termination or suspension of a 
provider 
contract 
under 
section 
422.202(a) of title 42, Code of Fed-
eral Regulations, shall apply. 
‘‘(E) PARTICIPANT NOTICE AND PROTEC-
TION.— 
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‘‘(i) NOTICE
TO
PARTICIPANTS
OF 
PROVIDER
REMOVAL.—Not less than 60 
days before the date on which a provider 
of services or supplier is removed from a 
network of an MA plan, the MA organiza-
tion offering such plan shall provide writ-
ten notification of the removal to each in-
dividual enrolled in such plan receiving 
items or services from the provider or sup-
plier during the plan year in effect on the 
date of removal or during the previous 
plan year. Such notification shall include 
at the minimum— 
‘‘(I) the names and telephone 
numbers of available in-network pro-
viders of services and suppliers offer-
ing items and services that are the 
same or similar to the items and serv-
ices offered by the removed provider 
or supplier; 
‘‘(II) information regarding the 
options available to an individual en-
rolled in such plan to request the con-
tinuation of medical treatment or 
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therapy with the removed provider or 
supplier; and 
‘‘(III) one or more customer serv-
ice telephone numbers that an indi-
vidual enrolled in such plan may ac-
cess to obtain information regarding 
changes to the network of the plan. 
‘‘(ii) ANNUAL NOTICE OF CHANGE.— 
In addition to providing the notification of 
removal as required under clause (i), the 
MA organization offering such MA plan 
shall include such notification in the an-
nual notice of change for the MA plan for 
the upcoming plan year. 
‘‘(iii) CONTINUITY OF CARE.—In any 
case in which a provider of services or sup-
plier is removed from a network of an MA 
plan, such plan shall ensure that the re-
moval satisfies the continuity of care re-
quirements under paragraph (1)(A) with 
respect to each individual enrolled in such 
plan receiving items or services from the 
provider or supplier during the plan year 
in effect on the date of removal or during 
the previous plan year. 
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‘‘(F) RULE OF CONSTRUCTION.—Nothing 
in this paragraph shall be construed as affect-
ing the ability of a provider of services or sup-
plier to decline to participate in a network of an 
MA plan. 
‘‘(8) TRANSPARENCY IN MEASURES USED BY 
MA ORGANIZATIONS TO ESTABLISH OR MODIFY PRO-
VIDER NETWORKS.— 
‘‘(A) IN GENERAL.—Beginning with plan 
year 2019, an MA organization offering an MA 
plan shall include the information described in 
subparagraph (B)— 
‘‘(i) in the annual bid information 
submitted by the MA organization with re-
spect to the MA plan under section 1854; 
and 
‘‘(ii) on the Internet Web Site for the 
MA plan. 
‘‘(B) INFORMATION DESCRIBED.—The in-
formation described in this subparagraph is the 
following: 
‘‘(i) Information regarding the meas-
ures used by the MA organization to estab-
lish or modify the provider network of the 
MA plan, including measures of the quality 
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and efficiency of providers. Such informa-
tion shall include the specifications, meth-
odology, and sample size of such measures. 
‘‘(ii) Other information related to the 
establishment or modification of such pro-
vider network that the Secretary deter-
mines appropriate. 
‘‘(C) LIMITATION.—The information de-
scribed in subparagraph (B) shall not include 
any individually identifiable information of any 
provider or supplier of services.’’. 
(b) ENFORCEMENT.— 
(1) SANCTIONS FOR NONCOMPLIANCE.—Section 
1857(g)(1) of the Social Security Act (42 U.S.C. 
1395w–27(g)(1)) is amended— 
(A) in subparagraph (J), by striking ‘‘or’’; 
(B) by redesignating subparagraph (K) as 
subparagraph (L); 
(C) by inserting after subparagraph (J) 
the following new subparagraph: 
‘‘(K) 
fails 
to 
comply 
with 
section 
1852(d)(7) or 1852(d)(8); or’’; and 
(D) in subparagraph (L) (as so redesig-
nated), by striking ‘‘through (J)’’ and inserting 
‘‘through (K)’’. 
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(2) SANCTIONS NOT APPLICABLE TO PART D.— 
Title XVIII of the Social Security Act is amended— 
(A) in section 1860D–12(b)(3)(E) (42 
U.S.C. 
1395w–112(b)(3)(E)), 
by 
striking 
‘‘paragraph (1)(F)’’ and inserting ‘‘paragraphs 
(1)(F) and (1)(K)’’; and 
(B) in section 1894(e)(6)(B) (42 U.S.C. 
1395eee(e)(6)(B)), by inserting ‘‘(other than 
paragraph (1)(K) of such section)’’ after 
‘‘1857(g)(1)’’. 
(c) MEDICARE ADVANTAGE PLAN COMPARE TOOL.— 
Not later than one year after the date of enactment of 
this Act, the Secretary of Health and Human Services 
shall take such measures as are necessary to ensure that 
the Medicare Advantage Compare Tool takes into account 
the preferences and utilization needs of such individuals. 
SEC. 122. NETWORK ADEQUACY. 
(a) IN GENERAL.—Section 1852(d) of the Social Se-
curity Act (42 U.S.C. 1395w–22(d)) is amended by adding 
at the end the following: 
‘‘(9) NETWORK
ADEQUACY
REQUIREMENTS.— 
Beginning in plan year 2019, notwithstanding any 
other provision of law, the following shall apply: 
‘‘(A) PROVIDER AVAILABILITY.—When es-
tablishing a plan network, a Medicare Advan-
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tage organization offering an MA plan shall, 
among other factors determined by the Sec-
retary, consider the following: 
‘‘(i) The anticipated enrollment in the 
plan. 
‘‘(ii) The expected types of services 
provided and utilization of services by en-
rollees under the plan. 
‘‘(iii) The number and types of pro-
viders needed to provide such services. 
‘‘(iv) The number of network pro-
viders who are not accepting new patients. 
‘‘(v) The location of providers and en-
rollees. 
‘‘(vi) The full-time equivalent avail-
ability of a provider to provide such serv-
ices. 
‘‘(B) PROVISION
OF
CARE
IN
A
TIMELY 
MANNER.—A Medicare Advantage organization 
offering an MA plan shall ensure that providers 
are able to provide services in a timely manner, 
as defined by the Secretary, under the plan. 
‘‘(C) APPLICATION OF NETWORK ACCESS 
ADEQUACY STANDARDS.—In applying the net-
work access adequacy standards pursuant to 
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‘‘(ii) UTILIZATION
OF
OUT-OF-NET-
WORK PROVIDERS.—The utilization of out- 
of-network providers under the plan. 
‘‘(iii) AVERAGE COST PER PATIENT.— 
The average annual spending per patient 
for primary and specialty care for enrollees 
under the plan. 
‘‘(F) CERTIFICATION.—In advance of the 
annual, coordinated election period under sec-
tion 1851(e)(3), a Medicare Advantage organi-
zation shall certify to the Secretary the accu-
racy of provider directories for each plan of-
fered by the organization. 
‘‘(G) NETWORK
REVIEW.—The Secretary 
shall ensure that the network of each MA plan 
offered by a Medicare Advantage organization 
meets the network adequacy guidelines estab-
lished under this paragraph and under section 
422.112(a)(4) of title 42, Code of Federal Reg-
ulations (or any successor regulation to such 
section), at least once every 3 years or when a 
material change in network occurs.’’. 
(b) ENFORCEMENT.—Section 1857(g)(1)(K) of the 
Social Security Act (42 U.S.C. 1395w–27(g)(1)(K)), as 
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added by section 2(b), is amended by striking ‘‘or 
1852(d)(8)’’ and inserting ‘‘, 1852(d)(8), or 1852(d)(9)’’. 
SEC. 123. ELIMINATING THE 24-MONTH WAITING PERIOD 
FOR MEDICARE COVERAGE FOR INDIVID-
UALS WITH DISABILITIES. 
(a) IN GENERAL.—Section 226(b) of the Social Secu-
rity Act (42 U.S.C. 426(b)) is amended— 
(1) in paragraph (2)(A), by striking ‘‘, and has 
for 24 calendar months been entitled to,’’; 
(2) in paragraph (2)(B), by striking ‘‘, and has 
been for not less than 24 months,’’; 
(3) in paragraph (2)(C)(ii), by striking ‘‘, in-
cluding the requirement that he has been entitled to 
the specified benefits for 24 months,’’; 
(4) in the first sentence, by striking ‘‘for each 
month beginning with the later of (I) July 1973 or 
(II) the twenty-fifth month of his entitlement or sta-
tus as a qualified railroad retirement beneficiary de-
scribed in paragraph (2), and’’ and inserting ‘‘for 
each month for which the individual meets the re-
quirements of paragraph (2), beginning with the 
month following the month in which the individual 
meets the requirements of such paragraph, and’’; 
and 
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(5) in the second sentence, by striking ‘‘the 
‘twenty-fifth month of his entitlement’ ’’ and all that 
follows through ‘‘paragraph (2)(C) and’’. 
(b) CONFORMING AMENDMENTS.— 
(1) SECTION 226.—Section 226 of the Social 
Security Act (42 U.S.C. 426) is amended by— 
(A) striking subsections (e)(1)(B), (f), and 
(h); and 
(B) redesignating subsections (g) and (i) 
as subsections (f) and (g), respectively. 
(2) MEDICARE DESCRIPTION.—Section 1811(2) 
of the Social Security Act (42 U.S.C. 1395c(2)) is 
amended by striking ‘‘have been entitled for not less 
than 24 months’’ and inserting ‘‘are entitled’’. 
(3) MEDICARE COVERAGE.—Section 1837(g)(1) 
of the Social Security Act (42 U.S.C. 1395p(g)(1)) 
is amended by striking ‘‘25th month of’’ and insert-
ing ‘‘month following the first month of’’. 
(4) RAILROAD RETIREMENT SYSTEM.—Section 
7(d)(2)(ii) of the Railroad Retirement Act of 1974 
(45 U.S.C. 231f(d)(2)(ii)) is amended— 
(A) by striking ‘‘has been entitled to an 
annuity’’ and inserting ‘‘is entitled to an annu-
ity’’; 
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(B) by striking ‘‘, for not less than 24 
months’’; and 
(C) by striking ‘‘could have been entitled 
for 24 calendar months, and’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to insurance benefits under title 
XVIII of the Social Security Act with respect to items and 
services furnished in months beginning after the date of 
enactment of this Act. 
SEC. 124. EMPLOYER HEALTH PLAN OPTIONS. 
(a) DEFINITION.—A qualifying employer sponsored 
plan is— 
(1) a governmental plan (within the meaning of 
section 2791(d)(8) of the Public Health Service 
Act); or 
(2) any other plan or coverage that meets the 
benefits criteria of title XXII of the Social Security 
Act, as added by section 111, and the criteria under 
subsection (b), 
that provides health coverage that is equivalent to an actu-
arial value of at least 80 percent and makes a premium 
contribution of at least 70 percent. 
(b) OBLIGATION.—Large employers shall, with re-
spect to any full-time employee of such employer— 
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(1) offer a qualifying employer sponsored plan 
to such employee, in accordance with subsection (c); 
or 
(2) make a contribution of 8 percent of their 
annual payroll to the Medicare Trust Fund under 
title XXII of the Social Security Act. 
(c) EMPLOYEE CHOICE.—An employee may opt out 
of a qualifying employer sponsored plan as satisfied by 
subsection (b)(1) in order to enroll in Medicare for Amer-
ica. The employer shall be exempt from the contribution 
specified in subsection (b)(2). The Secretary of Health 
and Human Services shall have authority to set standards 
for determining whether employers or insurers are under-
taking any actions to affect the risk pool within Medicare 
for America by inducing individuals to decline coverage 
under a qualifying employer sponsored plan and instead 
to enroll in Medicare for America. An employer violating 
such standards shall be treated as not meeting the require-
ments of subsection (a). 
(d) SPECIAL RULES.— 
(1) ANNUAL PAYROLL.—For purposes of this 
paragraph, the term ‘‘annual payroll’’ means, with 
respect to any employer for any calendar year, the 
aggregate wages paid by the employer during such 
calendar year. 
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(2) AGGREGATION RULES.—Related employers 
and predecessors shall be treated as a single em-
ployer for purposes of this subsection. 
(3) REDUCTION FOR PART-TIME EMPLOYEES.— 
In the case of a part-time employee, the employer 
contribution requirements of paragraph (1) shall be 
treated as satisfied if the employer contribution with 
respect to such employee is not less than the part- 
time employment ratio of the contribution required 
under paragraph (1). 
(4) RULES RELATED TO PART-TIME EMPLOY-
MENT.—For purposes of this subsection— 
(A) PART-TIME
EMPLOYEE.—The term 
‘‘part-time employee’’ means, with respect to 
any month, an employee who works on average 
fewer than 30 hours per week. 
(B) PART-TIME
EMPLOYMENT
RATIO.— 
The term ‘‘part-time employment ratio’’ means, 
with respect to a part-time employee of an em-
ployer in a month, a fraction— 
(i) the numerator of which is the 
number of hours in the employee’s normal 
work week, and 
(ii) the denominator of which is 30 
hours. 
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(C) SPECIAL
RULES.—Under rules pre-
scribed by the Secretary of Health and Human 
Services, in consultation with the Secretary of 
the Treasury, in the case of an employee for an 
employer whose defined work week for full-time 
employees is less than 30 hours, any reference 
in this subsection to 30 hours is deemed a ref-
erence to the number of hours in the work week 
so defined. 
(D) CONVERSION TO HOURS OF EMPLOY-
MENT.—The Secretary of Health and Human 
Services, in consultation with the Secretary of 
the Treasury, shall establish rules for the con-
version of compensation to hours of employ-
ment, for purposes of this subsection in the 
case of employees that receive compensation on 
a salaried basis, or on the basis of a commis-
sion, or other contingent or bonus basis, rather 
than based on an hourly wage. 
(e) TIMING
AND MANNER.—Each employer that 
makes a financial contribution under subsection (b)(2) 
under this section (other than with respect to coverage 
under a group health plan) shall pay such contribution in 
a form and manner, specified by the Secretary of the 
Treasury, based upon the form and manner in which em-
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ployer excise taxes are required to be paid under section 
3111 of the Internal Revenue Code of 1986. 
(f) NON-DISCRIMINATION.— 
(1) IN
GENERAL.—Except as otherwise pro-
vided for in this title (or an amendment made by 
this title), an individual shall not, on the ground 
prohibited under title VI of the Civil Rights Act of 
1964 (42 U.S.C. 2000d et seq.), title IX of the Edu-
cation Amendments of 1972 (20 U.S.C. 1681 et 
seq.), the Age Discrimination Act of 1975 (42 
U.S.C. 6101 et seq.), or section 504 of the Rehabili-
tation Act of 1973 (29 U.S.C. 794), be excluded 
from participation in, be denied the benefits of, or 
be subjected to discrimination under, any health pro-
gram or activity, any part of which is receiving Fed-
eral financial assistance, including credits, subsidies, 
or contracts of insurance, or under any program or 
activity that is administered by an Executive Agency 
or any entity established under this title (or amend-
ments) or any employer-sponsored insurance. 
(2) CONTINUED APPLICATION OF LAWS.—Noth-
ing in this title (or an amendment made by this 
title) shall be construed to invalidate or limit the 
rights, remedies, procedures, or legal standards 
available to individuals aggrieved under title VI of 
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the Civil Rights Act of 1964 (42 U.S.C. 2000d et 
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.), sec-
tion 504 of the Rehabilitation Act of 1973 (29 
U.S.C. 794), or the Age Discrimination Act of 1975 
(42 U.S.C. 611 et seq.), or to supersede State laws 
that provide additional protections against discrimi-
nation on any basis described in paragraph (1). 
(3) REGULATIONS.—The Secretary of Health 
and Human Services may promulgate regulations to 
implement this subsection. 
SEC. 125. PROHIBITION ON STEP THERAPY AND PRIOR AU-
THORIZATION 
UNDER 
GROUP 
HEALTH 
PLANS. 
Section 2719A of the Public Health Service Act (42 
U.S.C. 300gg–19a) is amended by adding at the end the 
following new subsection: 
‘‘(e) PROHIBITION AGAINST STEP THERAPY
AND 
PRIOR AUTHORIZATION.—Beginning with the first plan 
year following the date of the enactment of this subsection, 
a group health plan may not require a prior authorization 
determination for coverage of any benefit under such plan 
and may not apply treatment limitations through the use 
of step therapy protocols.’’. 
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SEC. 126. MEDICARE OUTPATIENT OBSERVATION SERV-
ICES. 
Section 1861(i) of the Social Security Act (42 U.S.C. 
1395x(i)) is amended by adding at the end the following: 
‘‘For purposes of this subsection, an individual receiving 
outpatient observation services shall be deemed to be an 
inpatient during such period, and the date such individual 
ceases receiving such services shall be deemed the hospital 
discharge date (unless such individual is admitted as a 
hospital inpatient at the end of such period).’’. 
SEC. 127. ABORTION COVERAGE. 
Notwithstanding any other provision of law, Federal 
funds may be used to provide for abortion services under 
any health program under any of the following: 
(1) Indian Health Service. 
(2) Benefits provided to women veterans. 
(3) Benefits provided through the United States 
Immigration and Customs Enforcement to women in 
detention centers under the jurisdiction of such 
agency. 
TITLE II—TAX PROVISIONS 
SEC. 201. SUNSET OF PUBLIC LAW 115–97. 
(a) IN GENERAL.—All provisions of, and amend-
ments made by, Public Law 115–97 shall not apply to cal-
endar, taxable, plan, or limitation years beginning after 
December 22, 2017. 
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(b) APPLICATION OF CERTAIN LAWS.—The Internal 
Revenue Code of 1986 shall be applied and administered 
to years described in subsection (a) as if the provisions 
and amendments described in subsection (a) had never 
been enacted. 
SEC. 202. SURTAX. 
There is hereby imposed a tax of 5 percent on the 
adjusted gross income of each taxpayer to the extent such 
income exceeds $500,000. 
SEC. 203. BASIS OF PROPERTY ACQUIRED FROM A DECE-
DENT. 
(a) IN GENERAL.—Section 1014 of the Internal Rev-
enue Code of 1986 is amended by striking ‘‘person, be’’ 
and all that follows through the period at the end and 
inserting the following: ‘‘person, be the basis in the hands 
of the decedent.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section to property acquired or passed after the date 
of enactment of this Act. 
SEC. 204. MEDICARE PAYROLL TAX. 
(a) IN GENERAL.—Section 3101(b)(2) of the Internal 
Revenue Code of 1986 is amended by striking ‘‘0.9 per-
cent’’ and inserting ‘‘4 percent’’. 
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(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to taxable years begin-
ning after the date of the enactment of this Act. 
SEC. 205. NET INVESTMENT INCOME TAX. 
(a) IN GENERAL.—Section 1411(a) of the Internal 
Revenue Code of 1986 is amended by striking ‘‘3.8 per-
cent’’ each place such term appears and inserting ‘‘6.9 
percent’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to taxable years begin-
ning after the date of the enactment of this Act. 
SEC. 206. TERMINATION OF HEALTH SAVINGS ACCOUNTS. 
Section 223(a) of the Internal Revenue Code of 1986 
is amended by inserting after ‘‘during such taxable year’’ 
the following: ‘‘and before December 31, 2019’’. 
SEC. 207. TERMINATION OF FLEXIBLE SPENDING AR-
RANGEMENTS. 
Section 125(i)(1) of the Internal Revenue Code of 
1986 is amended by striking ‘‘may not elect for any tax-
able year to have salary reduction contributions in excess 
of $2,500 made to such arrangement’’ and inserting the 
following: ‘‘may not elect to have salary reduction con-
tributions made to such arrangement— 
‘‘(A) for taxable years beginning before 
January 1, 2020, in excess of $2,500, and 
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tionate tax at the like rate on all fractional parts of a 
pound) but not less than 5.033 cents per cigar.’’. 
(f) SMOKELESS TOBACCO.— 
(1) IN GENERAL.—Section 5701(e) of the Inter-
nal Revenue Code of 1986 is amended— 
(A) in paragraph (1), by striking ‘‘$1.51’’ 
and inserting ‘‘$28.04’’, 
(B) in paragraph (2), by striking ‘‘50.33 
cents’’ and inserting ‘‘$12.42’’, and 
(C) by adding at the end the following: 
‘‘(3) SMOKELESS TOBACCO SOLD IN DISCRETE 
SINGLE-USE
UNITS.—On discrete single-use units, 
$107.65 per each 1,000 single-use units.’’. 
(2) 
DISCRETE
SINGLE-USE
UNIT.—Section 
5702(m) of such Code is amended— 
(A) in paragraph (1), by striking ‘‘or chew-
ing tobacco’’ and inserting ‘‘chewing tobacco, 
discrete single-use unit’’; 
(B) in paragraphs (2) and (3), by inserting 
‘‘that is not a discrete single-use unit’’ before 
the period in each such paragraph; and 
(C) by adding at the end the following: 
‘‘(4) DISCRETE SINGLE-USE UNIT.—The term 
‘discrete single-use unit’ means any product con-
taining tobacco that— 
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(5) Section 5041(b)(5) of the Internal Revenue 
Code of 1986 is amended by striking ‘‘$3.30 per 
wine gallon’’ and inserting ‘‘$16.00 per proof gal-
lon’’. 
(6) Section 5041(b)(3) of the Internal Revenue 
Code of 1986 is amended by striking ‘‘$22.6 cents 
per wine gallon’’ and inserting ‘‘$16.00 per proof 
gallon’’. 
(c) BEER.—Section 5051(B) of the Internal Revenue 
Code of 1986 is amended by striking ‘‘$18 for per barrel’’ 
and inserting ‘‘$16 per proof gallon’’. 
SEC. 210. TAX ON SUGARED DRINKS. 
(a) IN GENERAL.—Subchapter D of chapter 32 of the 
Internal Revenue Code of 1986 is amended by inserting 
after part I the following new part: 
‘‘PART II—SUGAR-SWEETENED BEVERAGES 
‘‘Sec. 4171. Imposition of tax. 
‘‘Sec. 4172. Definitions. 
‘‘Sec. 4173. Special rules. 
‘‘SEC. 4171. IMPOSITION OF TAX. 
‘‘(a) IN GENERAL.—There is hereby imposed a tax 
on the sale or transfer of any specified sugar-sweetened 
beverage product by the manufacturer, producer, or im-
porter thereof. 
‘‘(b) RATE OF TAX.—The rate of tax imposed under 
subsection (a) shall be equal to one cent per 4.2 grams 
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of caloric sweetener contained in such specified sugar- 
sweetened beverage product. 
‘‘(c) PERSONS LIABLE
FOR TAX.—The manufac-
turer, producer, or importer referred to in subsection (a) 
shall be liable for the tax imposed by such subsection. 
‘‘SEC. 4172. DEFINITIONS. 
‘‘(a) SPECIFIED
SUGAR-SWEETENED
BEVERAGE 
PRODUCT.—For purposes of this part— 
‘‘(1) IN GENERAL.—For purposes of this part, 
the term ‘specified sugar-sweetened beverage prod-
uct’ means— 
‘‘(A) any liquid intended for human con-
sumption which contains a caloric sweetener, 
and 
‘‘(B) any liquid, or solid mixture of ingre-
dients, which— 
‘‘(i) contains a caloric sweetener, and 
‘‘(ii) is intended for use as an ingre-
dient in a liquid described in subparagraph 
(A). 
‘‘(2) EXCEPTIONS.—The following shall not be 
treated as liquids described in paragraph (1)(A): 
‘‘(A) Any liquid the primary ingredients of 
which are milk or soy, rice, or similar plant- 
based milk substitute. 
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‘‘(B) Any liquid composed entirely of one 
or more of the following: 
‘‘(i) The original liquid resulting from 
the pressing of fruit or vegetables. 
‘‘(ii) The liquid resulting from the re-
constitution of fruit or vegetable juice con-
centrate. 
‘‘(iii) The liquid resulting from the 
restoration of water to dehydrated fruit or 
vegetable juice. 
‘‘(C) Infant formula. 
‘‘(D) Any liquid products manufactured for 
use as— 
‘‘(i) an oral nutritional therapy for 
persons who cannot absorb or metabolize 
dietary nutrients from food or beverages, 
‘‘(ii) a source of necessary nutrition 
used due to a medical condition, or 
‘‘(iii) an oral electrolyte solution for 
infants and children formulated to prevent 
dehydration due to illness. 
‘‘(E) Any liquid with respect to which tax 
is imposed under chapter 51 (relating to dis-
tilled spirits, wines, and beer) or under section 
7652 by reason of the tax imposed under chap-
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ter 51 being imposed on like articles of domes-
tic manufacture. 
‘‘(b) CALORIC SWEETENER.—For purposes of this 
part, the term ‘caloric sweetener’ means monosaccharides, 
disaccharides, and high-fructose corn syrup. 
‘‘SEC. 4173. SPECIAL RULES. 
‘‘(a) SWEETENER TAXED ONLY ONCE.—In the case 
of any specified sugar-sweetened beverage product which 
is manufactured or produced by including one or more 
other specified sugar-sweetened beverage products, no tax 
shall be imposed under this section on any caloric sweet-
ener contained in the resulting specified sugar-sweetened 
beverage product if tax was previously imposed under this 
section on such caloric sweetener when contained in the 
specified sugar-sweetened beverage product so included. 
‘‘(b) INFLATION ADJUSTMENT.—In the case of any 
sale after December 31, 2015, the one cent amount in sec-
tion 4171(b) shall be increased by an amount equal to— 
‘‘(1) such amount, multiplied by 
‘‘(2) the cost-of-living adjustment determined 
under section 1(f)(3) for the calendar year in which 
such sale occurs, determined by substituting ‘cal-
endar year 2014’ for ‘calendar year 1992’ in sub-
paragraph (B) thereof. 
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Any increase determined under this subsection shall be 
rounded to the nearest multiple of one-tenth of a cent.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Section 4221(a) is amended by adding at 
the end the following: ‘‘Paragraphs (1), (4), (5), and 
(6) shall not apply to the tax imposed under section 
4171.’’. 
(2) The table of parts for subchapter D of 
chapter 32 of such Code is amended by inserting 
after the item relating to part I the following new 
item: 
‘‘PART II—SUGAR-SWEETENED BEVERAGES’’. 
(c) REVENUES USED
FOR PREVENTION, TREAT-
MENT, AND RESEARCH OF DIET-RELATED HEALTH CON-
DITIONS IN PRIORITY POPULATIONS.— 
(1) TRANSFER
TO
PREVENTION
AND
PUBLIC 
HEALTH FUND.—There are hereby appropriated to 
the Prevention and Public Health Fund created 
under section 4002 of the Patient Protection and 
Affordable Care Act (in addition to any other 
amounts appropriated to such Fund) amounts equiv-
alent to taxes received in the Treasury under part 
II of subchapter D of chapter 32. Rules similar to 
the rules of section 9601 of the Internal Revenue 
Code of 1986 shall apply with respect to amounts 
appropriated under this paragraph. 
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(2) RESTRICTION
ON
USE
OF
FUNDS.—Not-
withstanding subsections (c) and (d) of section 4002 
of the Patient Protection and Affordable Care Act, 
amounts appropriated to the Prevention and Public 
Health Fund under paragraph (1) may be trans-
ferred to accounts in the Department of Health and 
Human Services only for the purpose of making ex-
penditures for programs and research designed to 
reduce the human and economic costs of diabetes, 
obesity, dental caries, and other diet-related health 
conditions in priority populations (within the mean-
ing of section 901(c) of the Public Health Service 
Act). 
(d) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided in para-
graph (2), the amendments made by this section 
shall take effect on the date of the enactment of this 
Act. 
(2) EXCISE TAX.—The amendments made by 
subsections (a) and (b) shall apply to sales after the 
date of the enactment of this Act. 
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TITLE III—DRUG-RELATED 
PROVISIONS 
SEC. 301. ESTABLISHMENT OF THE PRESCRIPTION DRUG 
AND MEDICAL DEVICE REVIEW BOARD. 
There is established in the Department of Health and 
Human Services a board to be known as the Prescription 
Drug and Medical Device Price Review Board (in this Act 
referred to as the ‘‘Board’’). 
SEC. 302. MEMBERSHIP; STAFF. 
(a) MEMBERS.—The Board shall be composed of the 
members as follows: 
(1) The Assistant Secretary for Planning and 
Evaluation of the Department of Health and Human 
Services (or the Assistant Secretary’s designee). 
(2) The Administrator of the Centers for Medi-
care & Medicaid Services or, beginning with 2022, 
the Administrator of the Center for Medicare (or the 
Administrator’s designee). 
(3) The Assistant Director for the Health Serv-
ices Division of the Federal Bureau of Prisons (or 
the Assistant Director’s designee). 
(4) The Secretary of Defense (or the Sec-
retary’s designee). 
(5) The Secretary of Veterans Affairs (or the 
Secretary’s designee). 
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(6) The Commissioner of Food and Drugs (or 
the Commissioner’s designee). 
(7) The Director of the National Institutes of 
Health. 
(b) CHAIRPERSON.—The Board shall designate 1 
member of the Board to serve as the chairperson. 
(c) DIRECTOR AND STAFF.— 
(1) DIRECTOR.—The Board shall have a direc-
tor who shall be appointed by the chairperson of the 
Board, subject to rules prescribed by the Board. 
(2) STAFF.—The director may appoint and fix 
the pay of such additional personnel as the chair-
person considers appropriate, subject to rules pre-
scribed by the Board. 
(3) APPLICABILITY OF CERTAIN CIVIL SERVICE 
LAWS.—The director and staff of the Board shall be 
appointed subject to the provisions of title 5, United 
States Code, governing appointments in the competi-
tive service, and shall be paid in accordance with the 
requirements of chapter 51 and subchapter III of 
chapter 53 of such title relating to classification and 
General Schedule pay rates; except that an indi-
vidual so appointed may not receive pay in excess of 
the maximum annual rate of basic pay payable for 
grade GS–15 of the General Schedule. 
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(d) ASSISTANCE FOR THE BOARD.—Subject to sec-
tion 306(g), in carrying out this title, the Board— 
(1) may seek assistance from outside experts in 
the fields of consumer advocacy, medicine, pharma-
cology, pharmacy, and prescription drug reimburse-
ment; and 
(2) shall establish and maintain an advisory 
group and a stakeholder group for purposes of seek-
ing such assistance. 
(e) INITIAL MEETING.—The Board shall hold its ini-
tial meeting not later than 90 days after the date of the 
enactment of this Act. 
SEC. 303. REPORTING REQUIREMENTS. 
(a) REPORTING BY MANUFACTURERS.—The Board 
shall require each manufacturer of a prescription drug or 
medical device that is sold in the United States to submit 
to the Board on a periodic basis, at a level of specificity 
determined by the Board to be necessary to make a deter-
mination under section 304, the following information 
with respect to the reporting period: 
(1) Each type of prescription drug and medical 
device that is sold by the manufacturer or an affil-
iate of the manufacturer— 
(A) in the United States; or 
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(B) in a country that is a member of the 
Organization for Economic Co-operation and 
Development. 
(2) The price charged by the manufacturer and 
the affiliate for the prescription drug or medical de-
vice in the United States and in any such country, 
as applicable. 
(3) The costs of the manufacturer and the affil-
iate to produce and market the prescription drug or 
medical device for sale in the United States and in 
any such country, as applicable. 
(b) REPORTING BY CBO.—The Director of the Con-
gressional Budget Office shall submit an annual report to 
the Board on trends in the prices charged for prescription 
drugs and medical devices. 
SEC. 304. PROHIBITION AGAINST EXCESSIVE PRICE. 
(a) PROHIBITION.—Beginning on the effective date 
of the regulation required by subsection (b), the manufac-
turer of a prescription drug or medical device shall not 
charge an excessive price, as determined pursuant to such 
regulation, for such drug or device. 
(b) FORMULA.—The Board shall by regulation pre-
scribe a formula for determining whether the average 
manufacturer price of such drug or device over an annual 
quarter is an excessive price. 
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(c) DETERMINATION OF EXCESSIVE PRICE.—If the 
Board determines, on its own initiative or in response to 
a petition submitted under subsection (d), that the manu-
facturer of a prescription drug or medical device charges 
an excessive price for such drug or device in violation of 
subsection (a)— 
(1) the Board shall give the manufacturer— 
(A) notice of such violation; and 
(B) subject to subsection (d), a period to 
correct such violation; and 
(2) if the manufacturer fails to correct the vio-
lation by the end of such period, the manufacturer 
shall 
be 
subject 
to 
section 
305, 
section 
1927(c)(2)(E) of the Social Security Act (as added 
by subsection (c) of section 305), and section 4192 
of the Internal Revenue Code of 1986, as added by 
subsection (d) of section 305. 
(d) PETITIONS.—Any person may petition the Board 
to make a determination under subsection (c) regarding 
the pricing of a prescription drug or medical device. Not 
later than 90 days after the date of receipt of such a peti-
tion, the Board shall— 
(1) make a determination under subsection (c) 
regarding such pricing; or 
(2) decline to make such a determination. 
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(e) CONTINUING VIOLATION.—The Board shall not 
be required to give a manufacturer an opportunity to cor-
rect a violation, as described in subsection (c)(1)(B), be-
fore the manufacturer becomes subject to the provisions 
described in subsection (c)(2) for such violation, if— 
(1) the Board has already provided such an op-
portunity to correct to the manufacturer; and 
(2) the Board finds that the violation of sub-
section (a) is a continuation of an earlier violation 
with respect to which such an opportunity was pro-
vided. 
(f) CONSIDERATIONS.—The formula required by sub-
section (a) shall at a minimum take into consideration— 
(1) the average manufacturer price of the pre-
scription drug or medical device over the respective 
annual quarter or quarters; 
(2) the average manufacturer price of other 
prescription drugs or medical devices in the same 
therapeutic class over the same quarter or quarters; 
(3) the average price at which the prescription 
drug or medical device and other prescription drugs 
and medical devices in the same therapeutic class 
have been sold by manufacturers in countries other 
than the United States; 
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(4) the costs associated with producing and 
marketing the prescription drug or medical device, 
the value of the drug or device to patients where suf-
ficient data is available to determine such value, the 
total Federal investment in the development of the 
drug or device, the size of the patient population re-
ceiving the drug or device, and other factors deter-
minative as to the true cost of production; and 
(5) whether the price of the prescription drug 
or medical device increased during any annual quar-
ter by a percentage that is more than 2 percent 
greater than the CPI increase percentage (as defined 
in section 215(i) of the Social Security Act (42 
U.S.C. 415)) for the respective annual quarter. 
SEC. 305. ENFORCEMENT PROVISIONS. 
(a) REDUCED PATENT TERM.—If the Board finds 
that the manufacturer of a prescription drug or medical 
device, who is also an owner of a patent for such drug 
or device, charged an excessive price for such drug or de-
vice in violation of section 304(a), the Board may— 
(1) reduce the term, by not more than 5 years, 
of any patent issued under title 35, United States 
Code, relating to such drug or device; or 
(2) if the term of each patent for such drug or 
device has expired, reduce the term, by not more 
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than 5 years, of another patent owned by the patent 
owner relating to a prescription drug or medical de-
vice. 
(b) CIVIL PENALTIES.—If the Board determines 
under section 304(c) that a manufacturer of a prescription 
drug or medical device charged an excessive price for a 
prescription drug or medical device in violation of section 
304(a), the Board may impose a civil penalty on the man-
ufacturer of not more than 10 percent of the manufactur-
er’s gross sales of the drug or device during the period 
beginning on the date on which an excessive price is first 
charged and ending on the date on which the manufac-
turer ceases to charge an excessive price. 
(c) ENFORCEMENT THROUGH INCREASED MEDICAID 
REBATES.— 
(1) IN
GENERAL.—Section 1927(c)(2) of the 
Social Security Act (42 U.S.C. 1396r–8(c)(2)) is 
amended— 
(A) in subparagraph (A), by inserting ‘‘, 
subject to subparagraph (E),’’ after ‘‘increased 
by’’; and 
(B) by adding at the end the following new 
subparagraph: 
‘‘(E) DISCOURAGING EXCESSIVE PRICES.— 
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‘‘(i) IN GENERAL.—In the case of a 
manufacturer of a single source drug or an 
innovator multiple source drug with a re-
bate agreement under this section, if the 
Prescription Drug and Medical Device 
Price Review Board established under sec-
tion 301 of the Medicare for America Act 
determines under section 304(a) of such 
Act that such manufacturer charged, with 
respect to a 30-day period, an excessive 
price for such drug, and the Board deter-
mines under clause (ii) to apply an in-
creased amount described in such clause 
with respect to such manufacturer and 
drug, the amount of the rebate determined 
under subparagraph (A) for such manufac-
turer and drug shall be, subject to sub-
paragraph (D), increased by such amount 
for the 4 rebate periods following such 30- 
day period. 
‘‘(ii) INCREASED
AMOUNT
DETER-
MINATION.—For purposes of clause (i), if 
the Board described in such clause makes 
such a determination under such section 
304(a), with respect to a manufacturer 
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and drug described in such clause, the 
Board may determine an increased amount 
to apply with respect to such manufacturer 
and drug and rebate period described in 
such clause. Such increased amount may 
not exceed the rebate amount that would 
otherwise be applied to such manufacturer 
and drug under this section for such rebate 
period, without regard to this subpara-
graph.’’. 
(2) EFFECTIVE DATE.—This subsection and the 
amendments made by this subsection shall apply 
with respect to rebate agreements entered into after 
the date that is 60 days after the date of the enact-
ment of this Act. 
(d) TAX ON EXCESS PRESCRIPTION DRUG AND MED-
ICAL DEVICE PROFITS.— 
(1) DETERMINATION
OF
AMOUNT.—If the 
Board determines under section 304(a) that a man-
ufacturer, producer, or importer of a prescription 
drug or medical device charged an excessive price for 
such prescription drug or medical device during a 
taxable year, the Board may determine under this 
paragraph a reasonable price for such drug or device 
for such taxable year. 
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(2) IMPOSITION OF TAX.— 
(A) IN GENERAL.—The Internal Revenue 
Code of 1986 is amended by inserting after sec-
tion 4191 the following new section: 
‘‘SEC. 4192. EXCESSIVE PRESCRIPTION DRUG AND MEDICAL 
DEVICE PRICE. 
‘‘(a) IN GENERAL.—There is hereby imposed on the 
sale of any prescription drug or medical device by the 
manufacturer, producer, or importer a tax equal to the 
difference between the price at which such drug or device 
is so sold and the reasonable price determined by the Pre-
scription Drug and Medical Device Price Review Board 
under section 305(d)(1) of the Medicare for America Act 
for such drug or device for the taxable year for sales after 
the determination. 
‘‘(b) PRESCRIPTION DRUG OR MEDICAL DEVICE.— 
For purposes of this section, the term ‘prescription drug 
or medical device’ means any prescription drug (as defined 
in section 9008 of the Patient Protection and Affordable 
Care Act) or device (as defined in section 201(h) of the 
Federal Food, Drug, and Cosmetic Act) intended for hu-
mans.’’. 
(B) CLERICAL AMENDMENT.—The table of 
parts for chapter 32 of such Code is amended— 
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(i) in the item relating to subchapter 
E, by striking ‘‘Medical’’ and inserting 
‘‘Drugs and medical’’, and 
(ii) by inserting after the item relating 
to section 4191 the following new item: 
‘‘SEC. 4192. EXCESSIVE PRESCRIPTION DRUG AND MEDICAL 
DEVICE PRICE.’’. 
(3) EFFECTIVE DATE.—This subsection and the 
amendments made by this subsection shall apply 
with respect to sales after December 31, 2018. 
SEC. 306. AUTHORITY. 
(a) OBTAINING OFFICIAL DATA.—The chairperson of 
the Board may secure directly from any Federal agency 
information necessary to enable the Board to carry out 
its duties. Upon request of the chairperson, the head of 
the agency shall furnish such information to the Board 
to the extent such information is not prohibited from dis-
closure by law. 
(b) MAILS.—The Board may use the United States 
mails in the same manner and under the same conditions 
as other Federal agencies. 
(c) ADMINISTRATIVE SUPPORT SERVICES.—Upon the 
request of the chairperson of the Board, the Administrator 
of General Services shall provide to the Board, on a reim-
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bursable basis, the administrative support services nec-
essary for the Board to carry out its duties. 
(d) CONTRACT AUTHORITY.—The Board may con-
tract with and compensate government and private agen-
cies or persons for the purpose of conducting research, 
surveys, and other services necessary to enable the Board 
to carry out its duties. 
(e) INVESTIGATIONS.—The Board may make such in-
vestigations as it considers necessary to determine whether 
there is or may be a violation of any regulation promul-
gated under this Act and may require or permit any per-
son to file with it a statement in writing, under oath or 
otherwise as the Board shall determine, as to all the facts 
and circumstances concerning the matter to be inves-
tigated. 
(f) SUBPOENA POWER.— 
(1) IN GENERAL.—The Board may issue sub-
poenas requiring the attendance and testimony of 
witnesses and the production of any evidence relat-
ing to any matter under investigation by the Board. 
The attendance of witnesses and the production of 
evidence may be required from any place within the 
United States at any designated place of hearing 
within the United States. 
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100 
(2) FAILURE TO OBEY A SUBPOENA.—If a per-
son refuses to obey a subpoena issued under para-
graph (1), the Board may apply to a United States 
district court for an order requiring that person to 
appear before the Board to give testimony, produce 
evidence, or both, relating to the matter under inves-
tigation. The application may be made within the ju-
dicial district where the hearing is conducted or 
where that person is found, resides, or transacts 
business. Any failure to obey the order of the court 
may be punished by the court as civil contempt. 
(3) SERVICE OF SUBPOENAS.—The subpoenas 
of the Board shall be served in the manner provided 
for subpoenas issued by a United States district 
court under the Federal Rules of Civil Procedure for 
the United States district courts. 
(4) SERVICE OF PROCESS.—All process of any 
court to which application is made under paragraph 
(2) may be served in the judicial district in which 
the person required to be served resides or may be 
found. 
(5) NOTICE.—Upon issuing any subpoena 
under this subsection, the Board shall give notice of 
such issuance to the appropriate committees of Con-
gress, including the Committee on Appropriations of 
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101 
the House of Representatives and the Committee on 
Appropriations of the Senate. 
(g) CONFIDENTIALITY.—Nothing in this title shall be 
construed as authorizing the Board to disclose any infor-
mation that is a trade secret or confidential information 
subject to section 552(b)(4) of title 5, United States Code, 
or section 1905 of title 18, United States Code. 
SEC. 307. REGULATIONS. 
(a) IN GENERAL.—Not later than 1 year after the 
date of the initial meeting held under section 302(e), the 
Board shall issue final regulations to carry out this Act. 
(b) NOTICE
AND COMMENT REQUIREMENT.—The 
regulations developed under subsection (a) shall be issued 
in accordance with the notice and comment procedures es-
tablished under section 553 of title 5, United States Code. 
SEC. 308. REPORT TO FEDERAL AGENCIES. 
Not later than 1 year after the effective date of the 
regulations under section 307 and annually thereafter, the 
Board shall submit to each Federal agency that dispenses 
or makes payments for the dispensing of prescription 
drugs or medical devices a report containing— 
(1) a list of each prescription drug and medical 
device for which an excessive price was charged dur-
ing the preceding calendar year, as determined by 
the Board under section 304; 
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102 
(2) recommendations to the Federal agency 
against dispensing or making payments for the dis-
pensing of the prescription drug or medical device; 
and 
(3) recommendations to the Federal agency to 
substitute, in place of any drug or device listed pur-
suant to paragraph (1), a similar prescription drug 
or medical device that is not sold at an excessive 
price. 
SEC. 309. DEFINITIONS. 
In this title: 
(1) The term ‘‘affiliate’’ means, with respect to 
a manufacturer, any entity that controls, is con-
trolled by, or is under common control with such 
manufacturer. 
(2) The term ‘‘average manufacturer price’’ 
means the average price charged by the manufac-
turer of a prescription drug or medical device, as ap-
plicable, for sales of the drug or device by the manu-
facturer in the United States over the respective an-
nual quarter. 
(3) The term ‘‘medical device’’ means a device 
(as defined in section 201 of the Federal Food, 
Drug, and Cosmetic Act (21 U.S.C. 321)). 
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103 
(4) The term ‘‘prescription drug’’ means a drug 
(as defined in section 201 of the Federal Food, 
Drug, and Cosmetic Act (21 U.S.C. 321)) that is 
subject to section 503(b)(1) of such Act (21 U.S.C. 
353(b)(1)). 
SEC. 310. MORATORIUM ON DIRECT-TO-CONSUMER DRUG 
ADVERTISING. 
The Federal Food, Drug, and Cosmetic Act (21 
U.S.C. 301 et seq.) is amended— 
(1) in section 301 (21 U.S.C. 331), by adding 
at the end the following: 
‘‘(eee) The conduct of direct-to-consumer advertising 
of a drug in violation of section 506J.’’; and 
(2) in chapter V, by inserting after section 506I 
(21 U.S.C. 356f) the following: 
‘‘SEC. 506J. DIRECT-TO-CONSUMER DRUG ADVERTISING. 
‘‘(a) PROHIBITIONS.— 
‘‘(1) FIRST THREE YEARS.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), no person shall conduct direct-to- 
consumer advertising of a drug for which an 
application is submitted under section 505(b) 
before the end of the 3-year period beginning 
on the date of the approval of such application. 
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104 
‘‘(B) WAIVER.—The Secretary may waive 
the application of subparagraph (A) to a drug 
during the third year of the 3-year period de-
scribed in such subparagraph if— 
‘‘(i) the sponsor of the drug submits 
an application to the Secretary pursuant to 
subparagraph (C); and 
‘‘(ii) the Secretary, after considering 
the application and any accompanying ma-
terials, determines that direct-to-consumer 
advertising of the drug would have an af-
firmative value to public health. 
‘‘(C) APPLICATION FOR WAIVER.—To seek 
a waiver under subparagraph (B), the sponsor 
of a drug shall submit an application to the 
Secretary at such time, in such manner, and 
containing such information as the Secretary 
may require. 
‘‘(2) SUBSEQUENT YEARS.—The Secretary may 
prohibit direct-to-consumer advertising of a drug 
during the period beginning at the end of the 3-year 
period described in paragraph (1)(A) if the Sec-
retary determines that the drug has significant ad-
verse health effects based on post-approval studies, 
risk-benefit analyses, adverse event reports, the sci-
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105 
entific literature, any clinical or observational stud-
ies, or any other appropriate resource. 
‘‘(b) REGULATIONS.—Not later than 1 year after the 
date of the enactment of this section, the Secretary shall 
revise the regulations promulgated under this Act gov-
erning drug advertisements to the extent necessary to im-
plement this section. 
‘‘(c) RULE OF CONSTRUCTION.—This section shall 
not be construed to diminish the authority of the Secretary 
to prohibit or regulate direct-to-consumer advertising of 
drugs under other provisions of law.’’. 
SEC. 311. REPORTING ON JUSTIFICATION FOR DRUG PRICE 
INCREASES. 
Title III of the Public Health Service Act (42 U.S.C. 
241 et seq.) is amended by adding at the end the fol-
lowing: 
‘‘PART W—DRUG PRICE REPORTING; DRUG 
VALUE FUND 
‘‘SEC. 399OO. REPORTING ON JUSTIFICATION FOR DRUG 
PRICE INCREASES. 
‘‘(a) DEFINITIONS.—In this section: 
‘‘(1) MANUFACTURER.—The term ‘manufac-
turer’ means the person— 
‘‘(A) that holds the application for a drug 
approved under section 505 of the Federal 
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106 
Food, Drug, and Cosmetic Act or the license 
issued under section 351 of the Public Health 
Service Act; or 
‘‘(B) who is responsible for setting the 
price for the drug. 
‘‘(2) QUALIFYING DRUG.—The term ‘qualifying 
drug’ means any drug that is approved under sub-
section (c) or (j) of section 505 of the Federal Food, 
Drug, and Cosmetic Act or licensed under subsection 
(a) or (k) of section 351 of this Act— 
‘‘(A) that has a wholesale acquisition cost 
of $100 or more per month supply or per a 
course of treatment that lasts less than a 
month and is— 
‘‘(i)(I) subject to section 503(b)(1) of 
the Federal Food, Drug, and Cosmetic 
Act; or 
‘‘(II) commonly administered by hos-
pitals (as determined by the Secretary); 
‘‘(ii) not designated as a drug for a 
rare disease or condition under section 526 
of the Federal Food, Drug, and Cosmetic 
Act; and 
‘‘(iii) not designated by the Secretary 
as a vaccine; and 
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107 
‘‘(B) for which, during the previous cal-
endar year, at least 1 dollar of the total amount 
of sales were for individuals enrolled under the 
Medicare program under title XVIII of the So-
cial Security Act (42 U.S.C. 1395 et seq.) or 
under a State Medicaid plan under title XIX of 
such Act (42 U.S.C. 1396 et seq.) or under a 
waiver of such plan. 
‘‘(3) WHOLESALE
ACQUISITION
COST.—The 
term ‘wholesale acquisition cost’ has the meaning 
given that term in section 1847A(c)(6)(B) of the So-
cial Security Act (42 U.S.C. 1395w–3a(c)(6)(B)). 
‘‘(b) REPORT.— 
‘‘(1) REPORT REQUIRED.—The manufacturer of 
a qualifying drug shall submit a report to the Sec-
retary for each price increase of a qualifying drug 
that will result in an increase in the wholesale acqui-
sition cost of that drug that is equal to— 
‘‘(A) 10 percent or more over a 12-month 
period; or 
‘‘(B) 25 percent or more over a 36-month 
period. 
‘‘(2) REPORT
DEADLINE.—Each report de-
scribed in paragraph (1) shall be submitted to the 
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108 
Secretary not later than 30 days prior to the 
planned effective date of such price increase. 
‘‘(c) CONTENTS.—A report under subsection (b) 
shall, at a minimum, include— 
‘‘(1) with respect to the qualifying drug— 
‘‘(A) the percentage by which the manufac-
turer will raise the wholesale acquisition cost of 
the drug on the planned effective date of such 
price increase; 
‘‘(B) a justification for, and description of, 
each manufacturer’s price increase that oc-
curred during the 12-month period described in 
subsection (b)(1)(A) or the 36-month period de-
scribed in subsection (b)(1)(B), as applicable; 
‘‘(C) the identity of the initial developer of 
the drug; 
‘‘(D) a description of the history of the 
manufacturer’s price increases for the drug 
since the approval of the application for the 
drug under section 505 of the Federal Food, 
Drug, and Cosmetic Act or the issuance of the 
license for the drug under section 351, or since 
the manufacturer acquired such approved appli-
cation or license; 
‘‘(E) the current list price of the drug; 
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109 
‘‘(F) the total expenditures of the manu-
facturer on— 
‘‘(i) materials and manufacturing for 
such drug; and 
‘‘(ii) acquiring patents and licensing 
for such drug; 
‘‘(G) the percentage of total expenditures 
of the manufacturer on research and develop-
ment for such drug that was derived from Fed-
eral funds; 
‘‘(H) the total expenditures of the manu-
facturer on research and development for such 
drug that is used for— 
‘‘(i) basic and preclinical research; 
‘‘(ii) clinical research; 
‘‘(iii) new drug development; 
‘‘(iv) pursuing new or expanded indi-
cations for such drug through supple-
mental applications under section 505 of 
the Federal Food, Drug, and Cosmetic 
Act; and 
‘‘(v) carrying out postmarket require-
ments related to such drug, including those 
under section 505(o)(3) of such Act; 
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110 
‘‘(I) the total revenue and the net profit 
generated from the qualifying drug for each cal-
endar year since the approval of the application 
for the drug under section 505 of the Federal 
Food, Drug, and Cosmetic Act or the issuance 
of the license for the drug under section 351, 
or since the manufacturer acquired such ap-
proved application or license; and 
‘‘(J) the total costs associated with mar-
keting and advertising for the qualifying drug; 
‘‘(2) with respect to the manufacturer— 
‘‘(A) the total revenue and the net profit 
of the manufacturer for the 12-month period 
described in subsection (b)(1)(A) or the 36- 
month period described in subsection (b)(1)(B), 
as applicable; 
‘‘(B) all stock-based performance metrics 
used by the manufacturer to determine execu-
tive compensation for the 12-month period de-
scribed in subsection (b)(1)(A) or the 36-month 
period described in subsection (b)(1)(B), as ap-
plicable; and 
‘‘(C) any additional information the manu-
facturer chooses to provide related to drug pric-
ing decisions, such as total expenditures on— 
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‘‘(i) drug research and development; 
or 
‘‘(ii) clinical trials on drugs that failed 
to receive approval by the Food and Drug 
Administration; and 
‘‘(3) such other related information as the Sec-
retary considers appropriate. 
‘‘(d) CIVIL PENALTY.—Any manufacturer of a quali-
fying drug that fails to submit a report for the drug as 
required by this section shall be subject to a civil penalty 
of $100,000 for each day on which the violation continues. 
‘‘(e) PUBLIC POSTING.— 
‘‘(1) IN GENERAL.—Subject to paragraph (3), 
not later than 30 days after the submission of a re-
port under subsection (b), the Secretary shall post 
the report on the public website of the Department 
of Health and Human Services. 
‘‘(2) FORMAT.—In developing the format of 
such report for public posting, the Secretary shall 
consult stakeholders, including beneficiary groups, 
and shall seek feedback on the content and format 
from consumer advocates and readability experts to 
ensure such public reports are user-friendly to the 
public and are written in plain language that con-
sumers can readily understand. 
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‘‘(3) TRADE SECRETS AND CONFIDENTIAL IN-
FORMATION.—In carrying out this section, the Sec-
retary shall enforce applicable law concerning the 
protection of confidential commercial information 
and trade secrets. 
‘‘SEC. 399OO–1. USE OF CIVIL PENALTY AMOUNTS. 
‘‘The Secretary shall collect the civil penalties under 
section 399OO, in addition to any other amounts avail-
able, and without further appropriation, and shall use 
such funds to carry out activities described in this part 
and to improve consumer and provider information about 
drug value and drug price transparency. 
‘‘SEC. 399OO–2. ANNUAL REPORT TO CONGRESS. 
‘‘(a) IN GENERAL.—Subject to subsection (b), the 
Secretary shall submit to Congress, and post on the public 
website of the Department of Health and Human Services 
in a way that is easy to use and understand, an annual 
report— 
‘‘(1) summarizing the information reported pur-
suant to section 399OO; and 
‘‘(2) including copies of the reports and sup-
porting detailed economic analyses submitted pursu-
ant to such section. 
‘‘(b) TRADE SECRETS AND CONFIDENTIAL INFORMA-
TION.—In carrying out this section, the Secretary shall 
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enforce applicable law concerning the protection of con-
fidential commercial information and trade secrets.’’. 
Æ 
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