(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. 
(a) IN GENERAL.—The Secretary shall establish pre-
mium 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; 
(3) comply with the requirements under section 
2701 of the Public Health Service Act (42 U.S.C. 
300gg); and 
(4) ensure that no individual or household will 
pay more than 8 percent of adjusted gross monthly 
income toward the monthly premium. 
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(b) FEDERAL SUBSIDIES.—Federal subsidies shall be 
provided to ensure that the premium shall be— 
(1) zero in the case of an individual whose an-
nual household income is below 200 percent of the 
poverty line; 
(2) determined by a linear sliding scale, in the 
case of an individual whose household income is at 
least 200 percent of the poverty line, but not more 
than 600 percent of the poverty line; and 
(3) no individual or household above 600 per-
cent of poverty level will pay more than 8 percent 
of adjusted gross monthly income toward such 
monthly premium. 
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, such as dental, vision, and 
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hearing benefits, well child visits, and reproductive health 
services, 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 the public health insurance plan option. 
(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 the public health insurance 
plan option. 
(3) 
CLARIFICATION.—Notwithstanding 
any 
other provision of law, health care providers may not 
be prohibited from participating in the public health 
insurance option for reasons other than their ability 
to provide covered services. Health care providers 
and institutions are prohibited from denying covered 
individuals access to any covered benefits and serv-
ices because of their religious objections. 
(c) PRESCRIPTION
DRUGS.—The Secretary shall 
apply the provisions of section 1860D–11(i) of the Social 
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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. 
(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). 
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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 2026 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— 
‘‘(1) a resident of the United States or a terri-
tory of the United States; 
‘‘(2) an individual who is lawfully present, as 
defined in section 152.2 of title 45 of the Code of 
Federal Regulations; or 
‘‘(3) an individual who would be eligible for cov-
erage under a State Medicaid plan pursuant to sec-
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tion 1903(v) (as such section was in effect as of the 
date of the enactment of this title), 
is entitled to benefits for health care services under this 
title. The Secretary shall promulgate a rule that provides 
criteria for applying this subsection, including determining 
residency for eligibility purposes under this title. Nothing 
in this title shall preclude a State from using State funds 
to provide for an individual’s health coverage who is not 
eligible under this subsection. 
‘‘(b) ENROLLMENTS.—Subject to subsection (c): 
‘‘(1) IN
GENERAL.—Beginning in 2026, 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 for America card which may 
be used for purposes of identification and processing 
of claims for benefits under this title. The card shall 
not use the individual’s social security number as an 
identifier. As a condition of participation in the pro-
gram, participating providers shall facilitate enroll-
ment as specified by the Secretary. The State enti-
ties responsible for enrolling individuals in the Med-
icaid program under title XIX and the Children’s 
Health Insurance Program under title XXI shall 
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cilitating enrollment into Medicare for 
America will not be subject to a mandatory 
employer contribution. 
‘‘(iii) 
AUTHORITY.—The 
Secretary 
may set standards for determining whether 
employers are undertaking any actions to 
affect the risk pool within Medicare for 
America by inducing individuals to decline 
coverage under a qualifying employer-spon-
sored plan and instead to enroll in Medi-
care for America. An employer violating 
such standards shall be treated as not 
meeting the requirements of qualified 
health coverage. 
‘‘(C) LARGE EMPLOYERS.—For plan years 
(beginning with plan year 2030), 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 or whose annual payroll exceeds 
$2,000,000. 
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‘‘(D) MEMBERS OF CONGRESS AND THEIR 
STAFF.—Beginning for plan year 2026, Mem-
bers of Congress and their staff, subject to 
paragraph (4), shall be enrolled in Medicare for 
America. 
‘‘(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: 
‘‘(i) For plan years 2026 and 2027: 
‘‘(I) Qualified employer coverage, 
as defined in section 126 of the Medi-
care for America Act. 
‘‘(II) Medical coverage under 
chapter 55 of title 10, United States 
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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. 
‘‘(VII) The CHIP program under 
title XXI of the Social Security Act. 
‘‘(ii) For plan years 2028 and 2029: 
‘‘(I) Coverage described in sub-
clause (I), (II), (III), (IV), or (V) of 
clause (i). 
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‘‘(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 so long as the 
State can demonstrate substantial progress has been made 
in transitioning these populations. 
‘‘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, as cov-
ered 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. 
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‘‘(2) Emergency care and urgent care services. 
‘‘(3) Hospitalization. 
‘‘(4) Maternity and newborn care. 
‘‘(5) Behavioral health services, including men-
tal health, substance use disorder services, and in-
tensive home and community based services. 
‘‘(6) Prescription drugs approved by the Food 
and Drug Administration. 
‘‘(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, all services that would 
otherwise be coverable under early and periodic 
screening, diagnostic, and treatment under the Med-
icaid program under title XIX and services otherwise 
included under the maternal, infant, and early child-
hood home visiting program under section 511, as of 
the date of the enactment of this title. 
‘‘(11) Dental care, at a minimum the services 
necessary to prevent disease and promote oral 
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health, restore oral structures to health and func-
tion, and treat emergency conditions, nightguards, 
mouthguards, and dentures. 
‘‘(12) Hearing health services including aids 
and exams. 
‘‘(13) Vision services. 
‘‘(14) Home and community based long-term 
services and supports. 
‘‘(15) Chiropractic services. 
‘‘(16) Durable medical equipment (as defined 
for purposes of title XIX), 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 for medical conditions. 
‘‘(K) Augmentative and alternative com-
munication devices, including dual-use devices. 
‘‘(L) Oxygen. 
‘‘(M) Orthotic and prosthetic devices. 
‘‘(N) Disposable medical supplies. 
‘‘(17) 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) Voluntary sterilization for bene-
ficiaries over the age of 21. 
‘‘(G) Infertility treatment. 
‘‘(18) Gender-confirming medical procedures 
and treatment. 
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‘‘(19) Screening, testing, treatment, and pre- 
and post-test counseling for sexually transmitted dis-
eases and HIV. 
‘‘(20) Dietary and nutrition counseling. 
‘‘(21) Medically necessary food and vitamins for 
digestive and inherited metabolic disorders. 
‘‘(22) Nursing facilities. 
‘‘(23) Acupuncture. 
‘‘(24) Digital health therapeutics, as approved 
by the Center for Healthcare and the Center for 
Medicare and Medicaid Innovation. 
‘‘(25) Telehealth. 
‘‘(26) Non-emergency medical transportation. 
‘‘(27) Care coordination, including services de-
fined in section 440.169 of title 42, Code of Federal 
Regulations. 
‘‘(28) Palliative care. 
‘‘(29) Any additional benefit or service not in-
cluded in this section that is coverable 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 coverable under Medicare 
for America shall be updated in accordance with the Na-
tional Coverage Determination process that had, as of the 
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date before the date of the enactment of this title, applied 
with respect to benefits covered under title XVIII. 
‘‘(c) IMPLEMENTING POLICIES.—The Secretary shall 
establish payment models, quality measures, and other im-
plementing policies that provide further access to the cov-
erage under this title. For purposes of the previous sen-
tence, the Secretary shall consult with stakeholders, in-
cluding those covering pediatrics, disabilities, and seniors. 
‘‘(d) 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 
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 paragraphs (3) and (4). 
Nothing shall preclude employers meeting the re-
quirements under section 126 of the Medicare for 
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America Act from providing supplemental coverage 
under this section to their employees. 
‘‘(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. 
‘‘(4) NO FEES TO BROKERS.—For purposes of 
paragraph (2), the condition described in this para-
graph is that health insurance coverage described in 
such paragraph does not pay fees to insurance bro-
kers. 
‘‘(e) 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. 
‘‘(f) 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) IN GENERAL.—Subject to paragraph (2), 
each individual enrolled for benefits under this title 
for a year shall pay monthly community-rated pre-
miums 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 en-
actment 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 ap-
plication of this paragraph. 
‘‘(b) PREMIUM CONTRIBUTION BASED ON INCOME.— 
The amount of a monthly premium, with respect to a plan 
year (beginning with 2026), 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; and 
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‘‘(C) no individual or household will pay 
more than 8 percent of adjusted gross monthly 
income toward such 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 126(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 
126(c) of such Act, the individual shall pay the less-
er of— 
‘‘(A) the premium described in this sub-
section; or 
‘‘(B) the amount owed after the amount of 
employer contribution (as specified in section 
126(b)(1)(B) of the Medicare for America Act) 
is subtracted from the premium established by 
the Secretary of Health and Human Services as 
described in paragraph (1), whichever is less. 
‘‘(c) DEPOSITS.—Amounts paid under this section for 
coverage under this title shall be deposited in the Treasury 
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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): 
‘‘(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) 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. 
‘‘(3) 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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‘‘(4) 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 relating to enrollment under 
part A or part B. 
‘‘(5) An individual who receives an adverse de-
termination under paragraph (3) 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 independent review orga-
nization shall review and reach a determination of 
the review in writing within 45 days of the receipt 
of any such appeal. 
‘‘(6) The Secretary of the Treasury may not 
enter into a contract under paragraph (4) 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 
benefits rules and regulations under this title; 
and 
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‘‘(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. 
‘‘(7) The Secretary shall provide for access by 
independent review organizations conducting appeal 
determinations under this subsection, to the data-
base of the Coordination of Benefits Contractor of 
the Centers for Medicare & Medicaid Services as 
necessary in order to conduct the duties of such or-
ganizations to determine 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, subject to subsection (c), 
80 percent of the reimbursement rates established pursu-
ant to section 2206 for such items and services, except 
that for the following services, the amounts paid under 
this section shall be equal to 100 percent of the reimburse-
ment rates established pursuant to section 2206 for such 
items and services: 
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‘‘(1) USPTF recommended preventive and 
chronic disease services. 
‘‘(2) Long-term services and supports. 
‘‘(3) Generic drugs, and prescription drugs if 
medically necessary. 
‘‘(4) All services for individuals who are medi-
cally frail or otherwise have special medical needs, 
(including children with serious emotional disturb-
ance and adults with serious mental illness), individ-
uals with chronic substance use disorders, or individ-
uals with serious and complex medical conditions 
(such as epilepsy and HIV), individuals with a phys-
ical, intellectual or developmental disability that sig-
nificantly impairs their ability to perform one or 
more activities of daily living. 
‘‘(5) Pregnancy related services. 
‘‘(6) Emergency services. 
‘‘(7) Services for children under age 21. 
The Secretary shall establish a default monthly payment 
plan under the Medicare for America benefits package to 
ensure the payment owed by the individual enrolled under 
Medicare for America is spread-out evenly throughout the 
year. 
‘‘(b) DEDUCTIBLE.—There shall be no deductible 
under Medicare for America. 
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‘‘(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. 
Individuals or households with income above 
600 percent of the Federal poverty line shall 
have 
their 
annual 
out-of-pocket 
threshold 
capped at $3,500 and $5,000 respectively. 
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‘‘(B) INDEXING.—In the case of plan years 
beginning after 2021, the threshold described in 
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 LIFETIME OR ANNUAL LIMITS.—There shall 
be no lifetime or annual limits for any services or benefits 
coverable under Medicare for America. 
‘‘(e) NO BALANCE BILLING.—No provider may im-
pose a charge to an enrolled individual for coverable serv-
ices 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 other cost-sharing described in this section. 
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‘‘(f) NO PRIVATE CONTRACTING.—A health care pro-
vider or health care institution are prohibited from enter-
ing into a private contract with an individual enrolled 
under Medicare for America for any item or service 
coverable under Medicare for America. 
‘‘(g) LIMITATIONS ON THE USE OF FLEXIBLE SAV-
INGS ACCOUNTS.—Flexible Savings Accounts shall only be 
used for benefits and services not covered by Medicare for 
America. 
‘‘SEC. 2206. PROVIDERS NETWORK 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 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 establish 
rates for benefits and services to be provided to 
health care providers and suppliers furnishing under 
Medicare for America based on rates that would be 
applied (including as computed, updated, and ad-
justed) under title XVIII or title XIX, whichever is 
higher, for such type of health care providers and 
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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 coverable under Medicare 
for America but not otherwise coverable under title 
XVIII or title XIX, shall provide for rates that en-
sure 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 or title XIX, whichever is higher, except 
that for hospitals serving underserved areas as speci-
fied by the Secretary, such rates are increased as 
necessary to ensure adequate access to care. 
‘‘(3) APPLICATION.—In applying rates under 
title XVIII and title XIX, as applicable, 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. 
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‘‘(B) The Secretary shall provide for a 
mechanism to provide payments for direct and 
indirect costs of graduate medical education 
programs without any cap on the number of 
residency positions for which payment may be 
made, including payments to hospitals for such 
programs and to eligible facilities for programs 
for population health-based residencies and for 
nurse practitioner post-licensure clinical train-
ing, residency, and fellowship programs. 
‘‘(C) 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 30 percent in order to 
ensure adequate access to inpatient and out-
patient care. 
‘‘(D) 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 for America plans. 
‘‘(E) The Secretary shall semiannually re-
view if the rates paid by Medicare for America 
are creating barriers to care. The Secretary 
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shall have the authority to raise rates as nec-
essary to ensure adequate access to care. 
‘‘(4) INCREASED FEDERAL MATCH FOR MED-
ICAID
AND
THE
CHILDREN’S
HEALTH
INSURANCE 
PROGRAM
FOR
YEARS
2026
THROUGH
2030.—The 
Secretary of Health and Human Services shall pay 
the difference between the Medicare for America 
rates and the Medicaid and CHIP rates during the 
period beginning on January 1, 2026, and ending on 
December 31, 2030. 
‘‘(c) 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 or 
the Medicaid program under title XIX on the date 
of enactment of this title shall remain a partici-
pating 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.—Notwithstanding any other 
provision of law, the Secretary shall, for plan years 
beginning on or after the date of the enactment of 
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this title, negotiate with pharmaceutical manufactur-
ers the prices (including discounts, rebates, and 
other price concessions) that may be charged to 
Medicare for America and MA for America organiza-
tions during a negotiated price period (as specified 
by the Secretary) for covered drugs for Medicare for 
America enrollees. In negotiating such prices under 
this section, the Secretary shall take into account 
the following factors: 
‘‘(A) The comparative clinical effectiveness 
and cost effectiveness, when available from an 
impartial source, of such drug. 
‘‘(B) The budgetary impact of providing 
coverage of such drug. 
‘‘(C) The number of similarly effective 
drugs or alternative treatment regimens for 
each approved use of such drug. 
‘‘(D) The associated financial burden on 
patients that utilize such drug. 
‘‘(E) The associated unmet patient need 
for such drug. 
‘‘(F) The total revenues from global sales 
obtained by the manufacturer for such drug 
and the associated investment in research and 
development of such drug by the manufacturer. 
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‘‘(2) FINALIZATION OF NEGOTIATED PRICE.— 
The negotiated price of each covered drug for a ne-
gotiated price period shall be finalized not later than 
30 days before the first plan year in such negotiated 
price period. 
‘‘(3) COMPETITIVE LICENSING AUTHORITY.— 
‘‘(A) IN GENERAL.—Notwithstanding any 
exclusivity under clause (iii) or (iv) of section 
505(j)(5)(F) of the Federal Food, Drug, and 
Cosmetic Act, clause (iii) or (iv) of section 
505(c)(3)(E) of such Act, section 351(k)(7)(A) 
of the Public Health Service Act, or section 
527(a) of the Federal Food, Drug, and Cos-
metic Act, or by an extension of such exclusivity 
under section 505A of such Act or section 505E 
of such Act, and any other provision of law that 
provides for market exclusivity (or extension of 
market exclusivity) with respect to a drug, in 
the case that the Secretary is unable to success-
fully negotiate an appropriate price for a cov-
ered drug for a negotiated price period, the Sec-
retary shall authorize the use of any patent, 
clinical trial data, or other exclusivity granted 
by the Federal Government with respect to such 
drug as the Secretary determines appropriate 
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for purposes of manufacturing such drug for 
sale under Medicare for America. Any entity 
making use of a competitive license to use pat-
ent, clinical trial data, or other exclusivity 
under this section shall provide to the manufac-
turer holding such exclusivity reasonable com-
pensation, as determined by the Secretary 
based on the following factors: 
‘‘(i) The risk-adjusted value of any 
Federal Government subsidies and invest-
ments in research and development used to 
support the development of such drug. 
‘‘(ii) The risk-adjusted value of any 
investment made by such manufacturer in 
the research and development of such 
drug. 
‘‘(iii) The impact of the price, includ-
ing license compensation payments, on 
meeting the medical need of all patients. 
‘‘(iv) The relationship between the 
price of such drug, including compensation 
payments, and the health benefits of such 
drug. 
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‘‘(v) Other relevant factors determined 
appropriate by the Secretary to provide 
reasonable compensation. 
‘‘(B) REASONABLE
COMPENSATION.—The 
manufacturer described in subparagraph (A) 
may seek recovery against the United States in 
the United States Court of Federal Claims. 
‘‘(C) INTERIM PERIOD.— 
‘‘(i) IN GENERAL.—Until 1 year after 
a drug described in subparagraph (A) is 
approved under section 505(j) of the Fed-
eral Food, Drug, and Cosmetic Act or sec-
tion 351(k) of the Public Health Service 
Act and is provided under license issued by 
the Secretary under such subparagraph, 
Medicare for America shall not pay more 
for such drug than the average of the 
prices available, during the most recent 12- 
month period for which data is available 
prior to the beginning of such negotiated 
price period, from the manufacturer to any 
wholesaler, retailer, provider, health main-
tenance organization, nonprofit entity, or 
governmental entity in the ten OECD (Or-
ganization for Economic Cooperation and 
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Development) countries that have the larg-
est gross domestic product with a per cap-
ita income that is not less than half the 
per capita income of the United States or 
the price established by the Prescription 
Drug and Medical Device Review Board 
established under title III of the Medicare 
for America Act of 2019. 
‘‘(ii) FEDERAL
PROGRAM
LICENS-
ING.—If such drug is not made available 
at the price determined, the Secretary shall 
authorize such entities to use any patent, 
clinical trial data, or other exclusivity 
granted by the Federal Government with 
respect to such drug as the Secretary de-
termines appropriate for purposes of man-
ufacturing such drug for sale under any 
Federal program, including those provided 
by Medicare for America, Veterans Affairs, 
the Department of Defense, and the Coast 
Guard. 
‘‘(D) AUTHORIZATION FOR SECRETARY TO 
PROCURE DRUGS DIRECTLY.— 
‘‘(i) IN
GENERAL.—The Secretary 
may procure a drug manufactured pursu-
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ant to a competitive license under subpara-
graph (A) for purposes of this part or pur-
suant to a Federal program license under 
subparagraph (C)(ii) for purposes of a 
Federal program directly from the entity 
manufacturing the drug pursuant to such 
a license. 
‘‘(ii) CLARIFICATION REGARDING AP-
PLICATION
OF
BUY
AMERICAN
ACT.—In 
the case where the Secretary procures a 
drug under this subparagraph, the provi-
sions of chapter 83 of title 41, United 
States Code (commonly referred to as the 
‘Buy American Act’), shall apply. 
‘‘(E) PRIORITY FOR U.S. MANUFACTURERS 
IN AUTHORIZING COMPETITIVE LICENSES.—In 
authorizing a competitive license under this 
paragraph, the Secretary— 
‘‘(i) shall give preference to entities 
that the Secretary determines have the 
highest safety and security standards; and 
‘‘(ii) may give priority to entities that 
will manufacture such drug in the United 
States. 
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‘‘(4) FDA REVIEW OF LICENSED DRUG APPLI-
CATIONS.—The Secretary shall prioritize review of 
applications under section 505(j) of the Federal 
Food, Drug, and Cosmetic Act for drugs licensed 
under paragraph (3)(A). 
‘‘(5) PROHIBITION
OF
ANTICOMPETITIVE
BE-
HAVIOR.—No drug manufacturer may engage in 
anticompetitive behavior with another manufacturer 
that may interfere with the issuance and implemen-
tation of a competitive license or run contrary to 
public policy. 
‘‘(6) REQUIRED
REPORTING.—The Secretary 
may require pharmaceutical manufacturers to dis-
close to the Secretary such information that the Sec-
retary determines necessary for purposes of carrying 
out this subsection. 
‘‘(7) CLARIFICATION.—Nothing in this sub-
section shall be construed as preventing Medicare for 
America obtaining a discount or reduction of the 
price for a covered drug below the price negotiated 
by the Secretary. 
‘‘(8) 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-
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fectiveness assessments for purposes of this sub-
section. 
‘‘(9) CLARIFICATION.—There shall be no for-
mulary under Medicare for America. 
‘‘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 2026, out of any moneys in the Treasury 
not otherwise appropriated, amounts equivalent to 
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 
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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 2026, 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 2030. 
‘‘(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. 
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‘‘(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 
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 HEALTH CARE.—Beginning 2026, 
the Centers for Medicare & Medicaid Services shall be re-
named the Center for Health Care and all references in 
law and regulation to such Centers shall be deemed a ref-
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erence to such Center. All powers, duties, and responsibil-
ities of the Centers for Medicare & Medicaid Services shall 
be transferred to the Center for Health Care. 
‘‘(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 Health 
Care is not authorized to appoint administrative law 
judges, in accordance with pages 11420 through 
11499 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.— 
‘‘(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. Individuals shall continue to receive the serv-
ice or item if an appeal is filed before the provision 
of the service or item is terminated. 
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‘‘(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 
denied a right conferred by this title may bring a 
civil action seeking any remedy available in law or 
equity to remedy that violation. State courts and 
district courts of the United States shall have con-
current jurisdiction of such actions. 
‘‘(2) RIGHT DEFINED.—Rights are created by 
any provision of this title that— 
‘‘(A) prescribes, establishes, or confers a 
benefit or protection in favor of the individual 
or individuals seeking to enforce the provision; 
or 
‘‘(B) prescribes, establishes, or imposes a 
duty or obligation on a person or entity to act 
or conduct operations in a manner that benefits 
the individual or individuals seeking to enforce 
the provision. 
‘‘(3) REASONABLE
ATTORNEY
FEES.—In any 
action or proceeding to enforce this title, the court 
may award reasonable attorneys’ fees and litigation 
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costs (including expert fees) reasonably incurred 
against the defendant or defendants. 
‘‘(4) APPEAL.—Any civil action brought under 
this section shall be subject to appeal as provided in 
sections 1291 and 1292 of title 28 of the United 
States Code. 
‘‘(5) CONTINUED
APPLICATION
OF
OTHER 
LAWS.—Nothing 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 
section 1979 of the Revised Statutes (42 U.S.C. 
1983), or to supersede State laws causes of action. 
‘‘(f) NON-DISCRIMINATION.— 
‘‘(1) IN GENERAL.—Except as otherwise pro-
vided for in 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 Education Amendments of 1972 (20 U.S.C. 
1681 et seq.), the Age Discrimination Act of 1975 
(42 U.S.C. 6101 et seq.), section 504 of the Reha-
bilitation Act of 1973 (29 U.S.C. 794), or section 
1557 of the Affordable Care Act (42 U.S.C. 18116), 
be excluded from participation in, be denied the ben-
efits of, or be subjected to discrimination under, any 
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health program or activity, any part of which is re-
ceiving Federal financial assistance, including cred-
its, 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 amendments) or any employer-spon-
sored insurance. The enforcement mechanisms pro-
vided for and available under such title VI, title IX, 
section 794, Age Discrimination Act, or such section 
1557 shall apply for purposes of violations of this 
subsection. 
‘‘(2) CONTINUED
APPLICATION
OF
LAWS.— 
Nothing 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 
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), the Age Discrimination Act of 1975 
(42 U.S.C. 611 et seq.), or section 1557 of the Af-
fordable Care Act (42 U.S.C. 18116) or to super-
sede State laws that provide additional protections 
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against discrimination on any basis described in 
paragraph (1). 
‘‘(3) HEALTH CARE PROVIDERS.—Health care 
providers may not be prohibited from participating 
in the Medicare for America for reasons other than 
their ability to provide covered services. Health care 
providers and institutions are prohibited from deny-
ing covered individuals access to covered benefits 
and services because of their religious objections. 
This subsection supercedes any provision of law that 
allows for conscience protection. 
‘‘(4) REGULATIONS.—The Secretary may pro-
mulgate regulations to implement this subsection. 
‘‘SEC. 2209. MAINTENANCE OF EFFORT REQUIREMENT. 
‘‘(a) IN GENERAL.—A State is not eligible for pay-
ment under any program specified in subsection (c) for 
a calendar quarter in a plan year beginning after 2035 
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. 
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‘‘(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 2036 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 2037 and each subsequent 
plan year before plan year 2041— 
‘‘(A) in the case of a State that is a 
PPACA expansion State, the payment amount 
applied under this subsection for the previous 
plan year, increased by growth in GDP per cap-
ita plus 0.4 percent; and 
‘‘(B) in the case of a State that is not a 
PPACA expansion State, the payment amount 
applied under this subsection for the previous 
plan year, increased by growth in GDP per cap-
ita plus 0.7 percent; and 
‘‘(3) beginning in 2041, for each subsequent 
plan year, with respect to any State, the payment 
amount applied under this subsection for the pre-
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‘‘(1) DEFINITION.—For purposes of this title, 
the term ‘home and community based long-term 
services and supports benefit’ means the daily living 
supports needed by eligible individuals in order to 
live, work, and participate in their communities, and 
includes all home and community based services and 
supports coverable as of the date of the enactment 
of this title, under any State plan or waiver under 
title XIX, including— 
‘‘(A) home health aides and homemakers; 
‘‘(B) direct support professionals and per-
sonal attendant care services; 
‘‘(C) hospice; 
‘‘(D) nursing care; 
‘‘(E) medical social services; 
‘‘(F) care coordination, including case 
management, fiscal intermediary, and support 
brokerage services; 
‘‘(G) short-term inpatient care, including 
respite care and care for pain control; 
‘‘(H) behavioral health home and commu-
nity based long-term services and supports, in-
cluding assertive community treatment; peer 
support services; intensive care coordination, in-
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(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. 
(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. 
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