(ii) efforts to decrease health care dis-
parities in rural or medically underserved 
areas; 
(iii) a response to emergent epidemic 
conditions; and 
(iv) proposed new and innovative pa-
tient care programs at the institutional 
level; and 
(H) any other factor determined appro-
priate by the Secretary. 
(3) LIMITATION.—Payment amounts negotiated 
pursuant to paragraph (1) may not— 
(A) take into account capital expenditures 
of the provider or any other expenditure not di-
rectly associated with the provision of items and 
services by the provider to an individual; 
(B) be used by a provider for capital ex-
penditures or such other expenditures; 
(C) exceed the provider’s capacity to pro-
vide care under this Act; or 
(D) be used to pay or otherwise com-
pensate any board member, executive, or ad-
ministrator of the institutional provider who 
has any interest or relationship prohibited 
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under section 301(b)(2) of this Act or disclosed 
under section 301 of this Act. 
(4) OPERATING
EXPENSES.—For purposes of 
this subsection, ‘‘operating expenses’’ of a provider 
include the following: 
(A) The cost of all items and services asso-
ciated with the provision of inpatient care and 
outpatient care, including the following: 
(i) Wages and salary costs for physi-
cians, nurses, and other health care practi-
tioners employed by an institutional pro-
vider, including mandatory minimum safe 
registered nurse-to-patient staffing ratios 
and optimal staffing levels for physicians 
and other healthcare workers. 
(ii) Wages and salary costs for all an-
cillary staff and services. 
(iii) Costs of all pharmaceutical prod-
ucts administered by health care clinicians 
at the institutional provider’s facilities or 
through services provided in accordance 
with State licensing laws or regulations 
under which the institutional provider op-
erates. 
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(iv) Purchasing and maintenance of 
medical devices, supplies, and other health 
care technologies, including diagnostic test-
ing equipment. 
(v) Costs of all incidental services nec-
essary for safe patient care and handling. 
(vi) Costs of patient care, education, 
and prevention programs, including occu-
pational health and safety programs, public 
health programs, and necessary staff to 
implement such programs, for the contin-
ued education and health and safety of cli-
nicians and other individuals employed by 
the institutional provider. 
(B) Administrative costs for the institu-
tional provider. 
(5) LIMITATION
ON
COMPENSATION.—Com-
pensation costs for any employee or any contractor 
or any subcontractor employee of an institutional 
provider receiving global budgets under this section 
shall meet the compensation cap established in sec-
tion 702 of the Bipartisan Budget Act of 2013 (41 
U.S.C. 4304(a)(16)) and implementing regulations. 
(6) REGIONAL
NEGOTIATIONS
PERMITTED.— 
Subject to section 614, a regional director may nego-
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tiate changes to an institutional provider’s global 
budget, including any adjustments to address un-
foreseen market-shifts related to patient volume. 
(c) BASELINE RATES AND ADJUSTMENTS.— 
(1) IN GENERAL.—The Secretary shall use ex-
isting prospective payment systems under title 
XVIII of the Social Security Act to serve as the 
comparative payment rate system in global budget 
negotiations described in subsection (b). The Sec-
retary shall update such comparative payment rate 
systems annually. 
(2) SPECIFICATIONS.—In developing the com-
parative payment rate system, the Secretary shall 
use only the operating base payment rates under 
each such prospective payment systems with applica-
ble adjustments. 
(3) LIMITATION.—The comparative rate system 
established under this subsection shall not include 
the value-based payment adjustments and the cap-
ital expenses base payment rates that may be in-
cluded in such a prospective payment system. 
(4) INITIAL YEAR.—In the first year that global 
budget payments under this Act are available to in-
stitutional providers and for purposes of selecting a 
comparative payment rate system used during initial 
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global budget negotiations for each institutional pro-
vider, the Secretary shall take into account the ap-
propriate prospective payment system from the most 
recent year under title XVIII of the Social Security 
Act to determine what operating base payment the 
institutional provider would have been paid for cov-
ered items and services furnished the preceding year 
with applicable adjustments, excluding value-based 
payment adjustments, based on such prospective 
payment system. 
SEC. 612. PAYMENT TO INDIVIDUAL PROVIDERS THROUGH 
FEE-FOR-SERVICE. 
(a) IN GENERAL.—In the case of a provider not de-
scribed in section 611(a) (including those in group prac-
tices who are not receiving payment on a salaried basis 
described in section 611(a)(3)), payment for items and 
services furnished under this Act for which payment is not 
otherwise made under section 611 shall be made by the 
Secretary in amounts determined under the fee schedule 
established pursuant to subsection (b). Such payment 
shall be considered to be payment in full for such items 
and services, and a provider receiving such payment may 
not charge the individual receiving such item or service 
in any amount. 
(b) FEE SCHEDULE.— 
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(1) ESTABLISHMENT.—Not later than 1 year 
after the date of the enactment of this Act, and in 
consultation with providers and regional office direc-
tors, the Secretary shall establish a national fee 
schedule for items and services payable under this 
Act. The Secretary shall evaluate the effectiveness of 
the fee-for-service structure and update such fee 
schedule annually. 
(2) 
AMOUNTS.—In 
establishing 
payment 
amounts for items and services under the fee sched-
ule established under paragraph (1), the Secretary 
shall take into account— 
(A) the amounts payable for such items 
and services under title XVIII of the Social Se-
curity Act; and 
(B) the expertise of providers and value of 
items and services furnished by such providers. 
(c) ELECTRONIC BILLING.—The Secretary shall es-
tablish a uniform national system for electronic billing for 
purposes of making payments under this subsection. 
(d) PHYSICIAN PRACTICE REVIEW BOARD.—Each di-
rector of a regional office, in consultation with representa-
tives of physicians practicing in that region, shall establish 
and appoint a physician practice review board to assure 
quality, cost effectiveness, and fair reimbursements for 
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physician-delivered items and services. The use of Quality- 
Adjusted Life Years, Disability-Adjusted Life Years, or 
other similar mechanisms that discriminate against people 
with disabilities is prohibited for use in any value or cost- 
effectiveness assessments. 
SEC. 613. ENSURING ACCURATE VALUATION OF SERVICES 
UNDER 
THE 
MEDICARE 
PHYSICIAN 
FEE 
SCHEDULE. 
(a) STANDARDIZED
AND
DOCUMENTED
REVIEW 
PROCESS.—Section 1848(c)(2) of the Social Security Act 
(42 U.S.C. 1395w–4(c)(2)) is amended by adding at the 
end the following new subparagraph: 
‘‘(P) STANDARDIZED
AND
DOCUMENTED 
REVIEW PROCESS.— 
‘‘(i) IN GENERAL.—Not later than one 
year after the date of enactment of this 
subparagraph, the Secretary shall estab-
lish, document, and make publicly avail-
able, in consultation with the Office of Pri-
mary Health Care, a standardized process 
for reviewing the relative values of physi-
cians’ services under this paragraph. 
‘‘(ii) MINIMUM REQUIREMENTS.—The 
standardized process shall include, at a 
minimum, methods and criteria for identi-
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fying services for review, prioritizing the 
review of services, reviewing stakeholder 
recommendations, and identifying addi-
tional resources to be considered during 
the review process.’’. 
(b) PLANNED AND DOCUMENTED USE OF FUNDS.— 
Section 1848(c)(2)(M) of the Social Security Act (42 
U.S.C. 1395w–4(c)(2)(M)) is amended by adding at the 
end the following new clause: 
‘‘(x) PLANNED
AND
DOCUMENTED 
USE OF FUNDS.—For each fiscal year (be-
ginning with the first fiscal year beginning 
on or after the date of enactment of this 
clause), the Secretary shall provide to Con-
gress a written plan for using the funds 
provided under clause (ix) to collect and 
use information on physicians’ services in 
the determination of relative values under 
this subparagraph.’’. 
(c) INTERNAL TRACKING OF REVIEWS.— 
(1) IN GENERAL.—Not later than 1 year after 
the date of enactment of this Act, the Secretary 
shall submit to Congress a proposed plan for system-
atically and internally tracking the Secretary’s re-
view of the relative values of physicians’ services, 
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such as by establishing an internal database, under 
section 1848(c)(2) of the Social Security Act (42 
U.S.C. 1395w–4(c)(2)), as amended by this section. 
(2) MINIMUM
REQUIREMENTS.—The proposal 
shall include, at a minimum, plans and a timeline 
for achieving the ability to systematically and inter-
nally track the following: 
(A) When, how, and by whom services are 
identified for review. 
(B) When services are reviewed or re-
viewed or when new services are added. 
(C) The resources, evidence, data, and rec-
ommendations used in reviews. 
(D) When relative values are adjusted. 
(E) The rationale for final relative value 
decisions. 
(d) FREQUENCY OF REVIEW.—Section 1848(c)(2) of 
the Social Security Act (42 U.S.C. 1395w–4(c)(2)) is 
amended— 
(1) in subparagraph (B)(i), by striking ‘‘5’’ and 
inserting ‘‘4’’; and 
(2) in subparagraph (K)(i)(I), by striking ‘‘peri-
odically’’ and inserting ‘‘annually’’. 
(e) CONSULTATION WITH MEDICARE PAYMENT AD-
VISORY COMMISSION.— 
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(1) IN
GENERAL.—Section 1848(c)(2) of the 
Social Security Act (42 U.S.C. 1395w–4(c)(2)) is 
amended— 
(A) in subparagraph (B)(i), by inserting 
‘‘in consultation with the Medicare Payment 
Advisory Commission,’’ after ‘‘The Secretary,’’; 
and 
(B) in subparagraph (K)(i)(I), as amended 
by subsection (d)(2), by inserting ‘‘, in coordi-
nation with the Medicare Payment Advisory 
Commission,’’ after ‘‘annually’’. 
(2) CONFORMING AMENDMENTS.—Section 1805 
of the Social Security Act (42 U.S.C. 1395b–6) is 
amended— 
(A) in subsection (b)(1)(A), by inserting 
the following before the semicolon at the end: 
‘‘and including coordinating with the Secretary 
in accordance with section 1848(c)(2) to sys-
tematically review the relative values established 
for physicians’ services, identify potentially 
misvalued services, and propose adjustments to 
the relative values for physicians’ services’’; and 
(B) in subsection (e)(1), in the second sen-
tence, by inserting ‘‘or the Ranking Minority 
Member’’ after ‘‘the Chairman’’. 
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(f) PERIODIC AUDIT BY THE COMPTROLLER GEN-
ERAL.—Section 1848(c)(2) of the Social Security Act (42 
U.S.C. 1395w–4(c)(2)), as amended by subsection (a), is 
amended by adding at the end the following new subpara-
graph: 
‘‘(Q) PERIODIC
AUDIT
BY
THE
COMP-
TROLLER GENERAL.— 
‘‘(i) IN
GENERAL.—The Comptroller 
General of the United States (in this sub-
section referred to as the ‘Comptroller 
General’) shall periodically audit the review 
by the Secretary of relative values estab-
lished under this paragraph for physicians’ 
services. 
‘‘(ii) ACCESS TO INFORMATION.—The 
Comptroller General shall have unre-
stricted access to all deliberations, records, 
and data related to the activities carried 
out under this paragraph, in a timely man-
ner, upon request.’’. 
SEC. 614. PAYMENT PROHIBITIONS; CAPITAL EXPENDI-
TURES; SPECIAL PROJECTS. 
(a) SENSE OF CONGRESS.—It is the sense of Con-
gress that tens of millions of people in the United States 
do not receive healthcare services while billions of dollars 
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that could be spent on providing health care are diverted 
to profit. There is a moral imperative to correct the mas-
sive deficiencies in our current health system and to elimi-
nate profit from the provision of health care. 
(b) PROHIBITIONS.—Payments to providers under 
this Act may not take into account, include any process 
for the provision of funding for, or be used by a provider 
for— 
(1) marketing of the provider; 
(2) the profit or net revenue of the provider, or 
increasing the profit or net revenue of the provider; 
(3) incentive payments, bonuses, or other com-
pensation based on patient utilization of items and 
services or any financial measure applied with re-
spect to the provider (or any group practice, inte-
grated health care delivery system, or other provider 
with which the provider contracts or has a pecuniary 
interest), including any value-based payment or em-
ployment-based compensation; 
(4) any agreement or arrangement described in 
section 203(a)(4) of the Labor-Management Report-
ing and Disclosure Act of 1959 (29 U.S.C. 
433(a)(4)); or 
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(5) political or contributions prohibited under 
section 317 of the Federal Elections Campaign Act 
of 1971 (52 U.S.C. 30119(a)(1)). 
(c) PAYMENTS FOR CAPITAL EXPENDITURES.— 
(1) IN
GENERAL.—The Secretary shall pay, 
from amounts made available for capital expendi-
tures pursuant to section 601(a)(2)(B), such sums 
determined appropriate by the Secretary to providers 
who have submitted an application to the regional 
director of the region or regions in which the pro-
vider operates or seeks to operate in a time and 
manner specified by the Secretary for purposes of 
funding capital expenditures of such providers. 
(2) PRIORITY.—The Secretary shall prioritize 
allocation of funding under paragraph (1) to 
projects that propose to use such funds to improve 
service in a medically underserved area (as defined 
in section 330(b)(3) of the Public Health Service 
Act (42 U.S.C. 254b(b)(3))) or to address health 
disparities among racial, income, or ethnic groups, 
or based on geographic regions. 
(3) LIMITATION.—The Secretary shall not 
grant funding for capital expenditures under this 
subsection for capital projects that are financed di-
rectly or indirectly through the diversion of private 
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or other non-Medicare for All Program funding that 
results in reductions in care to patients, including 
reductions in registered nursing staffing patterns 
and changes in emergency room or primary care 
services or availability. 
(4) CAPITAL
PROJECTS
FUNDED
BY
CHARI-
TABLE DONATIONS.—Operating expenses and funds 
shall not by used by an institutional provider receiv-
ing payment for capital expenditures under this sub-
section for a capital project funded by charitable do-
nations without the approval of the regional director 
or directors of the region or regions where the cap-
ital project is located. 
(d) PROHIBITION AGAINST CO-MINGLING OPER-
ATING AND CAPITAL FUNDS.—Providers that receive pay-
ment under this title shall be prohibited from using, with 
respect to funds made available under this Act— 
(1) funds designated for operating expenditures 
for capital expenditures or for profit; or 
(2) funds designated for capital expenditures 
for operating expenditures. 
(e) PAYMENTS FOR SPECIAL PROJECTS.— 
(1) IN GENERAL.—The Secretary shall allocate 
to each regional director, from amounts made avail-
able for special projects pursuant to section 
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601(a)(2)(C), such sums determined appropriate by 
the Secretary for purposes of funding projects de-
scribed in such section, including the construction, 
renovation, or staffing of health care facilities, in 
rural, underserved, or health professional or medical 
shortage areas within such region. Each regional di-
rector shall, prior to distributing such funds in ac-
cordance with paragraph (2), present a budget de-
scribing how such funds will be distributed to the 
Secretary. 
(2) DISTRIBUTION.—A regional director shall 
distribute funds to providers operating in the region 
of such director’s jurisdiction in a manner deter-
mined appropriate by the director. 
(f) 
PROHIBITION
ON
FINANCIAL
INCENTIVE 
METRICS
IN
PAYMENT
DETERMINATIONS.—The Sec-
retary may not utilize any quality metrics or standards 
for the purposes of establishing provider payment meth-
odologies, programs, modifiers, or adjustments for pro-
vider payments under this title. 
SEC. 615. OFFICE OF PRIMARY HEALTH CARE. 
(a) IN GENERAL.—There is established within the 
Agency for Healthcare Research and Quality an Office of 
Primary Health Care, responsible for coordinating with 
the Secretary, the Health Resources and Services Admin-
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istration, and other offices in the Department as nec-
essary, in order to— 
(1) coordinate health professional education 
policies and goals, in consultation with the Secretary 
to achieve the national goals specified in subsection 
(b); 
(2) develop and maintain a system to monitor 
the number and specialties of individuals through 
their health professional education, any postgraduate 
training, and professional practice; 
(3) develop, coordinate, and promote policies 
that expand the number of primary care practi-
tioners, registered nurses, midlevel practitioners, and 
dentists; 
(4) recommend the appropriate training, tech-
nical assistance, and patient protection enhance-
ments of primary care health professionals, including 
registered nurses, to achieve uniform high quality 
and patient safety; and 
(5) consult with the Secretary on the allocation 
of the special projects budget under section 
601(a)(2)(C). 
(b) NATIONAL GOALS.—Not later than 1 year after 
the date of enactment of this Act, the Office of Primary 
Health Care shall set forth national goals to increase ac-
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cess to high quality primary health care, particularly in 
underserved areas and for underserved populations. 
(c) CLARIFICATION.—Nothing in this— 
(1) section shall be construed to preempt any 
provision of State law establishing practice stand-
ards or guidelines for health care professionals, in-
cluding professional licensing or practice laws or reg-
ulations; and 
(2) Act shall be construed to require that any 
State impose additional educational standards or 
guidelines for health care professionals. 
SEC. 616. PAYMENTS FOR PRESCRIPTION DRUGS AND AP-
PROVED DEVICES AND EQUIPMENT. 
The prices to be paid for covered pharmaceuticals, 
medical supplies, medical technologies, and medically nec-
essary equipment covered under this Act shall be nego-
tiated annually by the Secretary. 
(1) IN GENERAL.—Notwithstanding any other 
provision of law, the Secretary shall, for fiscal years 
beginning on or after the date of the enactment of 
this subsection, negotiate with pharmaceutical man-
ufacturers the prices (including discounts, rebates, 
and other price concessions) that may be charged to 
the Medicare for All Program during a negotiated 
price period (as specified by the Secretary) for cov-
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ered drugs for eligible individuals under the Medi-
care for All Program. In negotiating such prices 
under this section, the Secretary shall take into ac-
count 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 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. 
(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 fiscal year in such nego-
tiated 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 
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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 
for purposes of manufacturing such drug for 
sale under Medicare for All Program. Any enti-
ty making use of a competitive license to use 
patent, 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: 
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(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 in-
vestment made by such manufacturer in 
the research and development of such 
drug. 
(iii) The impact of the price, including 
license compensation payments, on meeting 
the medical need of all patients at a rea-
sonable cost. 
(iv) The relationship between the 
price of such drug, including compensation 
payments, and the health benefits of such 
drug. 
(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.—Until 1 year after 
a drug described in subparagraph (A) is ap-
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proved under section 505(j) of the Federal 
Food, Drug, and Cosmetic Act or section 
351(k) of the Public Health Service Act and is 
provided under license issued by the Secretary 
under such subparagraph, the Medicare for All 
Program 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 nego-
tiated price period, from the manufacturer to 
any wholesaler, retailer, provider, health main-
tenance organization, nonprofit entity, or gov-
ernmental entity in the ten OECD (Organiza-
tion for Economic Cooperation and Develop-
ment) countries that have the largest gross do-
mestic product with a per capita income that is 
not less than half the per capita income of the 
United States. 
(D) AUTHORIZATION FOR SECRETARY TO 
PROCURE
DRUGS
DIRECTLY.—The Secretary 
may procure a drug manufactured pursuant to 
a competitive license under subparagraph (A) 
for purposes of this Act. 
(4) FDA REVIEW OF LICENSED DRUG APPLICA-
TIONS.—The Secretary shall prioritize review of ap-
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plications under section 505(j) of the Federal Food, 
Drug, and Cosmetic Act for drugs licensed under 
paragraph (3)(A). 
(5) PROHIBITION OF ANTICOMPETITIVE BEHAV-
IOR.—No drug manufacturer may engage in anti-
competitive behavior with another manufacturer that 
may interfere with the issuance and implementation 
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. 
TITLE VII—UNIVERSAL 
MEDICARE TRUST FUND 
SEC. 701. UNIVERSAL MEDICARE TRUST FUND. 
(a) IN GENERAL.—There is hereby created on the 
books of the Treasury of the United States a trust fund 
to be known as the Universal Medicare Trust Fund (in 
this section referred to as the ‘‘Trust Fund’’). The Trust 
Fund shall consist of such gifts and bequests as may be 
made and such amounts as may be deposited in, or appro-
priated to, such Trust Fund as provided in this Act. 
(b) APPROPRIATIONS INTO TRUST FUND.— 
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(1) TAXES.—There are appropriated to the 
Trust Fund for each fiscal year beginning with the 
fiscal year which includes the date on which benefits 
first become available as described in section 106, 
out of any moneys in the Treasury not otherwise ap-
propriated, amounts equivalent to 100 percent of the 
net increase in revenues to the Treasury which is at-
tributable to the amendments made by sections 801 
and 902. The amounts appropriated by the pre-
ceding 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 esti-
mates by the Secretary of the Treasury of the taxes 
paid to or deposited into the Treasury, and proper 
adjustments shall be made in amounts subsequently 
transferred to the extent prior estimates were in ex-
cess of or were less than the amounts that should 
have been so transferred. 
(2) CURRENT PROGRAM RECEIPTS.— 
(A) INITIAL YEAR.—Notwithstanding any 
other provision of law, there is appropriated to 
the Trust Fund for the fiscal year containing 
January 1 of the first year following the date 
of the enactment of this Act, an amount equal 
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to the aggregate amount appropriated for the 
preceding fiscal year for the following (in-
creased by the consumer price index for all 
urban consumers for the fiscal year involved): 
(i) The Medicare program under title 
XVIII of the Social Security Act (other 
than amounts attributable to any pre-
miums under such title). 
(ii) The Medicaid program under 
State plans approved under title XIX of 
such Act. 
(iii) The Federal Employees Health 
Benefits program, under chapter 89 of title 
5, United States Code. 
(iv) The TRICARE program, under 
chapter 55 of title 10, United States Code. 
(v) The maternal and child health 
program (under title V of the Social Secu-
rity Act), vocational rehabilitation pro-
grams, programs for drug abuse and men-
tal health services under the Public Health 
Service Act, programs providing general 
hospital or medical assistance, and any 
other Federal program identified by the 
Secretary, in consultation with the Sec-
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retary of the Treasury, to the extent the 
programs provide for payment for health 
services the payment of which may be 
made under this Act. 
(B) SUBSEQUENT YEARS.—Notwithstand-
ing any other provision of law, there is appro-
priated to the trust fund for the fiscal year con-
taining January 1 of the second year following 
the date of the enactment of this Act, and for 
each fiscal year thereafter, an amount equal to 
the amount appropriated to the Trust Fund for 
the previous year, adjusted for reductions in 
costs resulting from the implementation of this 
Act, changes in the consumer price index for all 
urban consumers for the fiscal year involved, 
and other factors determined appropriate by the 
Secretary. 
(3) RESTRICTIONS
SHALL
NOT
APPLY.—Any 
other provision of law in effect on the date of enact-
ment of this Act restricting the use of Federal funds 
for any reproductive health service shall not apply to 
monies in the Trust Fund. 
(c) INCORPORATION OF PROVISIONS.—The provisions 
of subsections (b) through (i) of section 1817 of the Social 
Security Act (42 U.S.C. 1395i) shall apply to the Trust 
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Fund under this section in the same manner as such pro-
visions applied to the Federal Hospital Insurance Trust 
Fund under such section 1817, except that, for purposes 
of applying such subsections to this section, the ‘‘Board 
of Trustees of the Trust Fund’’ shall mean the ‘‘Sec-
retary’’. 
(d) TRANSFER OF FUNDS.—Any amounts remaining 
in the Federal Hospital Insurance Trust Fund under sec-
tion 1817 of the Social Security Act (42 U.S.C. 1395i) 
or the Federal Supplementary Medical Insurance Trust 
Fund under section 1841 of such Act (42 U.S.C. 1395t) 
after the payment of claims for items and services fur-
nished under title XVIII of such Act have been completed, 
shall be transferred into the Universal Medicare Trust 
Fund under this section. 
TITLE 
VIII—CONFORMING 
AMENDMENTS TO THE EM-
PLOYEE 
RETIREMENT 
IN-
COME SECURITY ACT OF 1974 
SEC. 801. PROHIBITION OF EMPLOYEE BENEFITS DUPLICA-
TIVE OF BENEFITS UNDER THE MEDICARE 
FOR ALL PROGRAM; COORDINATION IN CASE 
OF WORKERS’ COMPENSATION. 
(a) IN GENERAL.—Part 5 of subtitle B of title I of 
the Employee Retirement Income Security Act of 1974 
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(29 U.S.C. 1131 et seq.) is amended by adding at the end 
the following new section: 
‘‘SEC. 522. PROHIBITION OF EMPLOYEE BENEFITS DUPLI-
CATIVE OF UNIVERSAL MEDICARE PROGRAM 
BENEFITS; 
COORDINATION 
IN 
CASE 
OF 
WORKERS’ COMPENSATION. 
‘‘(a) IN GENERAL.—Subject to subsection (b), no em-
ployee benefit plan may provide benefits that duplicate 
payment for any items or services for which payment may 
be made under the Medicare for All Act of 2019. 
‘‘(b) REIMBURSEMENT.—Each workers compensation 
carrier that is liable for payment for workers compensa-
tion services furnished in a State shall reimburse the 
Medicare for All Program for the cost of such services. 
‘‘(c) DEFINITIONS.—In this subsection— 
‘‘(1) the term ‘workers compensation carrier’ 
means an insurance company that underwrite work-
ers compensation medical benefits with respect to 
one or more employers and includes an employer or 
fund that is financially at risk for the provision of 
workers compensation medical benefits; 
‘‘(2) the term ‘workers compensation medical 
benefits’ means, with respect to an enrollee who is 
an employee subject to the workers compensation 
laws of a State, the comprehensive medical benefits 
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for work-related injuries and illnesses provided for 
under such laws with respect to such an employee; 
and 
‘‘(3) the term ‘workers compensation services’ 
means items and services included in workers com-
pensation medical benefits and includes items and 
services (including rehabilitation services and long- 
term care services) commonly used for treatment of 
work-related injuries and illnesses.’’. 
(b) CONFORMING AMENDMENT.—Section 4(b) of the 
Employee Retirement Income Security Act of 1974 (29 
U.S.C. 1003(b)) is amended by adding at the end the fol-
lowing: ‘‘Paragraph (3) shall apply subject to section 
522(b) (relating to reimbursement of the Medicare for All 
Program by workers compensation carriers).’’. 
(c) CLERICAL AMENDMENT.—The table of contents 
in section 1 of such Act is amended by inserting after the 
item relating to section 521 the following new item: 
‘‘Sec. 522. Prohibition of employee benefits duplicative of Universal Medicare 
Program benefits; coordination in case of workers’ compensa-
tion.’’. 
SEC. 802. APPLICATION OF CONTINUATION COVERAGE RE-
QUIREMENTS UNDER ERISA AND CERTAIN 
OTHER 
REQUIREMENTS 
RELATING 
TO 
GROUP HEALTH PLANS. 
(a) IN GENERAL.—Part 6 of subtitle B of title I of 
the Employee Retirement Income Security Act of 1974 
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(29 U.S.C. 1161 et seq.) shall apply only with respect to 
any employee health benefit plan that does not duplicate 
payments for any items or services for which payment may 
be made under the this Act. 
(b) CONFORMING AMENDMENT.—Section 601 of part 
6 of subtitle B of title I of the Employee Retirement In-
come Security Act of 1974 (19 U.S.C. 1161) is amended 
by adding the following subsection at the end: 
‘‘(c) Subsection (a) shall apply to any group health 
plan that does not duplicate payments for any items or 
services for which payment may be made under the Uni-
versal Health Insurance Act of 2017.’’. 
SEC. 803. EFFECTIVE DATE OF TITLE. 
The provisions of and amendments made by this title 
shall take effect on the date described in section 106(a). 
TITLE IX—ADDITIONAL 
CONFORMING AMENDMENTS 
SEC. 901. RELATIONSHIP TO EXISTING FEDERAL HEALTH 
PROGRAMS. 
(a) MEDICARE, MEDICAID, AND STATE CHILDREN’S 
HEALTH INSURANCE PROGRAM (SCHIP).— 
(1) IN GENERAL.—Notwithstanding any other 
provision of law and with respect to an individual el-
igible to enroll under this Act, subject to paragraphs 
(2) and (3)— 
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(A) no benefits shall be available under 
title XVIII of the Social Security Act for any 
item or service furnished beginning on the date 
that is 2 years after the date of the enactment 
of this Act; 
(B) no individual is entitled to medical as-
sistance under a State plan approved under 
title XIX of such Act for any item or service 
furnished on or after such date; 
(C) no individual is entitled to medical as-
sistance under a State child health plan under 
title XXI of such Act for any item or service 
furnished on or after such date; and 
(D) no payment shall be made to a State 
under section 1903(a) or 2105(a) of such Act 
with respect to medical assistance or child 
health assistance for any item or service fur-
nished on or after such date. 
(2) TRANSITION.—In the case of inpatient hos-
pital services and extended care services during a 
continuous period of stay which began before the ef-
fective date of benefits under section 106, 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, 
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or under a State child health plan under title XXI 
of such Act, the Secretary shall provide for continu-
ation of benefits under such title or plan until the 
end of the period of stay. 
(3) SCHOOL
PROGRAMS.—All school related 
health programs, centers, initiatives, services, or 
other activities or work provided under title XIX or 
title XXI of the Social Security Act as of January 
1, 2019, shall be continued and covered by the Medi-
care for All Program. 
(b) FEDERAL EMPLOYEES HEALTH BENEFITS PRO-
GRAM.—No benefits shall be made available under chapter 
89 of title 5, United States Code, with respect to items 
and services furnished to any individual eligible to enroll 
under this Act. 
(c) TRICARE.—No benefits shall be made available 
under sections 1079 and 1086 of title 10, United States 
Code, for items or services furnished to any individual eli-
gible to enroll under this Act. 
(d) TREATMENT OF BENEFITS FOR VETERANS AND 
NATIVE AMERICANS.— 
(1) IN GENERAL.—Nothing in this Act shall af-
fect the eligibility of veterans for the medical bene-
fits and services provided under title 38, United 
States Code, or of Indians for the medical benefits 
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and services provided by or through the Indian 
Health Service. 
(2) REEVALUATION.—No reevaluation of the 
Indian Health Service shall be undertaken without 
consultation with tribal leaders and stakeholders. 
SEC. 902. SUNSET OF PROVISIONS RELATED TO THE STATE 
EXCHANGES. 
Effective on the date that is 2 years after the date 
of the enactment of this Act, the Federal and State Ex-
changes established pursuant to title I of the Patient Pro-
tection 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 Ex-
change, including such provisions of the Internal Revenue 
Code of 1986, shall cease to have force or effect. 
SEC. 903. SUNSET OF PROVISIONS RELATED TO PAY FOR 
PERFORMANCE PROGRAMS. 
(a) Effective on the date described in section 106(a), 
the Federal programs related to pay for performance pro-
grams and value-based purchasing shall terminate, and 
any other provision of law that relies upon participation 
in or enrollment in such program shall cease to have force 
or effect. Programs that shall terminate include— 
(1) the Merit-based Incentive Payment System 
established pursuant to subsection (q) of section 
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1848 of the Social Security Act (42 U.S.C. 1395w– 
4(q)); 
(2) the incentives for meaningful use of cer-
tified EHR technology established pursuant to sub-
section (a)(7) of section 1848 of the Social Security 
Act (42 U.S.C. 1395w–4(a)(7)); 
(3) the incentives for adoption and meaningful 
use of certified EHR technology established pursu-
ant to subsection (o) of section 1848 of the Social 
Security Act (42 U.S.C. 1395w–4(o)); 
(4) alternative payment models established 
under section 1833(z) of the Social Security Act (42 
U.S.C. 1395(z)); and 
(5) the following programs as established pur-
suant to the following sections of the Patient Protec-
tion and Affordable Care Act: 
(A) Section 2701 (adult health quality 
measures). 
(B) Section 2702 (payment adjustments 
for health care acquired conditions). 
(C) Section 2706 (Pediatric Accountable 
Care Organization Demonstration Projects for 
the purposes of receiving incentive payments). 
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100 
(D) Section 3002(b) (42 U.S.C. 1395w– 
4(a)(8)) (incentive payments for quality report-
ing). 
(E) 
Section 
3001(a) 
(42 
U.S.C. 
1395ww(o)) (Hospital Value-Based Purchas-
ing). 
(F) Section 3006 (value-based purchasing 
program for skilled nursing facilities and home 
health agencies). 
(G) Section 3007 (42 U.S.C. 1395w–4(p)) 
(value based payment modifier under physician 
fee schedule). 
(H) Section 3008 (42 U.S.C. 1395ww(p)) 
(payment adjustments for health care-acquired 
condition). 
(I) Section 3022 (42 U.S.C. 1395jjj) 
(Medicare shared savings programs). 
(J) Section 3023 (42 U.S.C. 1395cc–4) 
(National Pilot Program on Payment Bun-
dling). 
(K) Section 3024 (42 U.S.C. 1395cc–5) 
(Independence at home demonstration pro-
gram). 
(L) Section 3025 (42 U.S.C. 1395ww(q)) 
(hospital readmissions reduction program). 
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101 
(M) Section 10301 (plans for value-based 
purchasing program for ambulatory surgical 
centers). 
TITLE X—TRANSITION 
Subtitle A—Medicare for All Tran-
sition Over 2 Years and Transi-
tional Buy-In Option 
SEC. 1001. MEDICARE FOR ALL TRANSITION OVER TWO 
YEARS. 
Title XVIII of the Social Security Act (42 U.S.C. 
1395c et seq.) is amended by adding at the end the fol-
lowing new section: 
‘‘SEC. 1899C. MEDICARE FOR ALL TRANSITION OVER 2 
YEARS. 
‘‘(a) TRANSITION.— 
‘‘(1) IN GENERAL.—Every individual who meets 
the requirements described in paragraph (3) shall be 
eligible to enroll in the Medicare for All Program 
under this section during the transition period start-
ing one year after the date of enactment of the 
Medicare for All Act of 2019. 
‘‘(2) BENEFITS.—An individual enrolled under 
this section is entitled to the benefits established 
under title II of the Medicare for All Act of 2019. 
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102 
‘‘(3) REQUIREMENTS
FOR
ELIGIBILITY.—The 
requirements described in this paragraph are the fol-
lowing: 
‘‘(A) The individual meets the eligibility re-
quirements established by the Secretary under 
title I of the Medicare for All Act of 2019. 
‘‘(B) The individual has attained the appli-
cable year of age, or is currently enrolled in 
Medicare at the time of the transition to Medi-
care for All. 
‘‘(4) APPLICABLE
YEAR
OF
AGE
DEFINED.— 
For purposes of this section, the term ‘applicable 
year of age’ means one year after the date of enact-
ment of the Medicare for All Act of 2019, the age 
of 55 or older, the age 18 or younger. 
‘‘(b) ENROLLMENT; COVERAGE.—The Secretary shall 
establish enrollment periods and coverage under this sec-
tion consistent with the principles for establishment of en-
rollment periods and coverage for individuals under other 
provisions of this title. The Secretary shall establish such 
periods so that coverage under this section shall first begin 
on January 1 of the year on which an individual first be-
comes eligible to enroll under this section. 
‘‘(c) SATISFACTION OF INDIVIDUAL MANDATE.—For 
purposes of applying section 5000A of the Internal Rev-
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103 
enue Code of 1986, the coverage provided under this sec-
tion constitutes minimum essential coverage under sub-
section (f)(1)(A)(i) of such section 5000A. 
‘‘(d) CONSULTATION.—In promulgating regulations 
to implement this section, the Secretary shall consult with 
interested parties, including groups representing bene-
ficiaries, health care providers, employers, and insurance 
companies.’’. 
SEC. 1002. ESTABLISHMENT OF THE MEDICARE TRANSI-
TION BUY-IN. 
(a) IN GENERAL.—To carry out the purpose of this 
section, for the year beginning one year after the date of 
enactment of this Act and ending with the effective date 
described in section 106(a), the Secretary, acting through 
the Administrator of the Centers for Medicare & Medicaid 
(referred to in this section as the ‘‘Administrator’’), shall 
establish, and provide for the offering through the Ex-
changes, an option to buy in to the Medicare for All Pro-
gram (in this Act referred to as the ‘‘Medicare Transition 
buy-in’’). 
(b) ADMINISTERING
THE MEDICARE TRANSITION 
BUY-IN.— 
(1) ADMINISTRATOR.—The Administrator shall 
administer the Medicare Transition buy-in in accord-
ance with this section. 
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104 
(2) APPLICATION
OF
ACA
REQUIREMENTS.— 
Consistent with this section, the Medicare Transition 
buy-in shall comply with requirements under title I 
of the Patient Protection and Affordable Care Act 
(and the amendments made by that title) and title 
XXVII of the Public Health Service Act (42 U.S.C. 
300gg et seq.) that are applicable to qualified health 
plans offered through the Exchanges, subject to the 
limitation under subsection (e)(2). 
(3) OFFERING
THROUGH
EXCHANGES.—The 
Medicare Transition buy-in shall be made available 
only through the Exchanges, and shall be available 
to individuals wishing to enroll and to qualified em-
ployers (as defined in section 1312(f)(2) of the Pa-
tient Protection and Affordable Care Act (42 U.S.C. 
18032)) who wish to make such plan available to 
their employees. 
(4) ELIGIBILITY TO PURCHASE.—Any United 
States resident may enroll in the Medicare Transi-
tion buy-in. 
(c) BENEFITS; ACTUARIAL VALUE.—In carrying out 
this section, the Administrator shall ensure that the Medi-
care Transition buy-in provides— 
(1) coverage for the benefits required to be cov-
ered under title II of this Act; and 
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105 
(2) coverage of benefits that are actuarially 
equivalent to 90 percent of the full actuarial value 
of the benefits provided under the plan. 
(d) PROVIDERS AND REIMBURSEMENT RATES.— 
(1) IN GENERAL.—With respect to the reim-
bursement provided to health care providers for cov-
ered benefits, as described in section 201, provided 
under the Medicare Transition buy-in, the Adminis-
trator shall reimburse such providers at rates deter-
mined for equivalent items and services under the 
Medicare for All fee-for-service schedule established 
in section 612(b) of this Act. 
(2) PRESCRIPTION DRUGS.—Any payment rate 
under this subsection for a prescription drug shall be 
at the prices negotiated under section 616 of this 
Act. 
(3) PARTICIPATING PROVIDERS.— 
(A) 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 (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.) on the date of enactment of this 
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106 
Act shall be a participating provider in the 
Medicare Transition buy-in. 
(B) ADDITIONAL
PROVIDERS.—The Ad-
ministrator shall establish a process to allow 
health care providers not described in subpara-
graph (A) to become participating providers in 
the Medicare Transition buy-in. Such process 
shall be similar to the process applied to new 
providers under the Medicare program. 
(e) PREMIUMS.— 
(1) DETERMINATION.—The Administrator shall 
determine the premium amount for enrolling in the 
Medicare Transition buy-in, which— 
(A) may vary according to family or indi-
vidual coverage, age, and tobacco status (con-
sistent with clauses (i), (iii), and (iv) of section 
2701(a)(1)(A) of the Public Health Service Act 
(42 U.S.C. 300gg(a)(1)(A))); and 
(B) shall take into account the cost-shar-
ing reductions and premium tax credits which 
will be available with respect to the plan under 
section 1402 of the Patient Protection and Af-
fordable Care Act (42 U.S.C. 18071) and sec-
tion 36B of the Internal Revenue Code of 1986, 
as amended by subsection (g). 
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(2) LIMITATION.—Variation in premium rates 
of the Medicare Transition buy-in by rating area, as 
described in clause (ii) of section 2701(a)(1)(A)(iii) 
of the Public Health Service Act (42 U.S.C. 
300gg(a)(1)(A)) is not permitted. 
(f) TERMINATION.—This section shall cease to have 
force or effect on the effective date described in section 
106(a). 
(g) TAX CREDITS AND COST-SHARING SUBSIDIES.— 
(1) PREMIUM ASSISTANCE TAX CREDITS.— 
(A) CREDITS
ALLOWED
TO
MEDICARE 
TRANSITION
BUY-IN
ENROLLEES
IN
NON-EX-
PANSION
STATES.—Paragraph (1) of section 
36B(c) of the Internal Revenue Code of 1986 
is amended by redesignating subparagraphs (C) 
and (D) as subparagraphs (D) and (E), respec-
tively, and by inserting after subparagraph (B) 
the following new subparagraph: 
‘‘(C) SPECIAL
RULES
FOR
MEDICARE 
TRANSITION BUY-IN ENROLLEES.— 
‘‘(i) IN GENERAL.—In the case of a 
taxpayer who is covered, or whose spouse 
or dependent (as defined in section 152) is 
covered, by the Medicare Transition buy-in 
established under section 1002(a) of the 
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108 
Medicare for All Act of 2019 for all 
months in the taxable year, subparagraph 
(A) shall be applied without regard to ‘but 
does not exceed 400 percent’. 
‘‘(ii) ENROLLEES IN MEDICAID NON-
EXPANSION STATES.—In the case of a tax-
payer residing in a State which (as of the 
date of the enactment of the Medicare for 
All Act of 2019) does not provide for eligi-
bility under clause (i)(VIII) or (ii)(XX) of 
section 1902(a)(10)(A) of the Social Secu-
rity Act for medical assistance under title 
XIX of such Act (or a waiver of the State 
plan approved under section 1115) who is 
covered, or whose spouse or dependent (as 
defined in section 152) is covered, by the 
Medicare Transition buy-in established 
under section 1002(a) of the Medicare for 
All Act of 2019 for all months in the tax-
able year, subparagraphs (A) and (B) shall 
be applied by substituting ‘0 percent’ for 
‘100 percent’ each place it appears.’’. 
(B) PREMIUM ASSISTANCE AMOUNTS FOR 
TAXPAYERS ENROLLED IN MEDICARE TRANSI-
TION BUY-IN.— 
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109 
(i) IN GENERAL.—Subparagraph (A) 
of section 36B(b)(3) of such Code is 
amended—(I) by redesignating clause (ii) 
as clause (iii), (II) by striking ‘‘clause (ii)’’ 
in clause (i) and inserting ‘‘clauses (ii) and 
(iii)’’, and (III) by inserting after clause (i) 
the following new clause: 
‘‘(ii) SPECIAL RULES FOR TAXPAYERS 
ENROLLED IN MEDICARE TRANSITION BUY- 
IN.—In the case of a taxpayer who is cov-
ered, or whose spouse or dependent (as de-
fined in section 152) is covered, by the 
Medicare Transition buy-in established 
under section 1002(a) of the Medicare for 
All Act of 2019 for all months in the tax-
able year, the applicable percentage for 
any taxable year shall be determined in the 
same manner as under clause (i), except 
that the following table shall apply in lieu 
of the table contained in such clause: 
‘‘In the case of household income 
(expressed as a percent of 
poverty line) within the 
following income tier: 
The initial 
premium 
percentage is— 
The final 
premium 
percentage is— 
Up to 100 percent ..............................
2.00 
2.00
100 percent up to 138 percent ...........
2.04 
2.04
138 percent up to 150 percent ...........
3.06 
4.08
150 percent and above ........................
4.08 
5.00.’’. 
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110 
(ii) CONFORMING AMENDMENT.—Sub-
clause (I) of clause (iii) of section 
36B(b)(3) of such Code, as redesignated 
by subparagraph (A)(i), is amended by in-
serting ‘‘, and determined after the appli-
cation of clause (ii)’’ after ‘‘after applica-
tion of this clause’’. 
(2) COST-SHARING SUBSIDIES.—Subsection (b) 
of section 1402 of the Patient Protection and Af-
fordable Care Act (42 U.S.C. 18071(b)) is amend-
ed— 
(A) by inserting ‘‘, or in the Medicare 
Transition buy-in established under section 
1002(a) of the Medicare for All Act of 2019,’’ 
after ‘‘coverage’’ in paragraph (1); 
(B) by redesignating paragraphs (1) (as so 
amended) and (2) as subparagraphs (A) and 
(B), respectively, and by moving such subpara-
graphs 2 ems to the right; 
(C) by striking ‘‘INSURED.—In this sec-
tion’’ and inserting ‘‘INSURED.— 
‘‘(1) IN GENERAL.—In this section’’; 
(D) by striking the flush language; and 
(E) by adding at the end the following new 
paragraph: 
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111 
‘‘(2) SPECIAL RULES.— 
‘‘(A) INDIVIDUALS LAWFULLY PRESENT.— 
In the case of an individual described in section 
36B(c)(1)(B) of the Internal Revenue Code of 
1986, the individual shall be treated as having 
household income equal to 100 percent of the 
poverty line for a family of the size involved for 
purposes of applying this section. 
‘‘(B) MEDICARE TRANSITION BUY-IN EN-
ROLLEES
IN
MEDICAID
NON-EXPANSION 
STATES.—In the case of an individual residing 
in a State which (as of the date of the enact-
ment of the Medicare for All Act of 2019) does 
not provide for eligibility under clause (i)(VIII) 
or (ii)(XX) of section 1902(a)(10)(A) of the So-
cial Security Act for medical assistance under 
title XIX of such Act (or a waiver of the State 
plan approved under section 1115) who enrolls 
in such Medicare Transition buy-in, the pre-
ceding sentence, paragraph (1)(B), and para-
graphs (1)(A)(i) and (2)(A) of subsection (c) 
shall each be applied by substituting ‘0 percent’ 
for ‘100 percent’ each place it appears.’’. 
(h) CONFORMING AMENDMENTS.— 
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(1) TREATMENT
AS
A
QUALIFIED
HEALTH 
PLAN.—Section 1301(a)(2) of the Patient Protection 
and Affordable Care Act (42 U.S.C. 18021(a)(2)) is 
amended— 
(A) in the paragraph heading, by inserting 
‘‘THE MEDICARE TRANSITION BUY-IN,’’ before 
‘‘AND’’; and 
(B) by inserting ‘‘The Medicare Transition 
buy-in,’’ before ‘‘and a multi-State plan’’. 
(2) LEVEL PLAYING FIELD.—Section 1324(a) 
of the Patient Protection and Affordable Care Act 
(42 U.S.C. 18044(a)) is amended by inserting ‘‘the 
Medicare Transition buy-in,’’ before ‘‘or a multi- 
State qualified health plan’’. 
Subtitle B—Transitional Medicare 
Reforms 
SEC. 1011. 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,’’; 
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(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 
(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 
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116 
ance issuers offering group or individual health in-
surance coverage shall not— 
(A) end coverage for an enrollee who has 
a disability, complex medical need, or chronic 
condition during the transition period described 
in the Act until all ages are eligible to enroll in 
the Medicare for All Program; or 
(B) impose any exclusion with respect to 
such plan or coverage on the basis of a person’s 
disability, complex medical need, or chronic con-
dition during the transition period described 
under this Act until all ages are eligible to en-
roll in the Medicare for All Program. 
(d) PUBLIC CONSULTATION DURING TRANSITION.— 
The Secretary shall consult with communities and advo-
cacy organizations of persons living with disabilities as 
well as other patient advocacy organizations to ensure that 
the transition buy-in takes into account the continuity of 
care for persons with disabilities, complex medical needs, 
or chronic conditions. 
TITLE XI—MISCELLANEOUS 
SEC. 1101. DEFINITIONS. 
In this Act— 
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(1) the term ‘‘group practice’’ has the meaning 
given such term in section 1877(h)(4) of the Social 
Security Act (42 U.S.C. 1395nn(h)(4)); 
(2) the term ‘‘individual provider’’ means a sup-
plier (as defined for purposes of paragraph (4)); 
(3) the term ‘‘institutional provider’’ means— 
(A) providers of services described in sec-
tion 1861(u) of such Act (42 U.S.C. 1395x(u)); 
(B) hospitals as defined in section 1861(e) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395x(e)), and any outpatient settings or clinics 
operating within a hospital license or any set-
ting or clinic that provides outpatient hospital 
services; 
(C) psychiatric hospitals (as defined in sec-
tion 1861(e) of the Social Security Act (42 
U.S.C. 1395x(f))); 
(D) rehabilitation hospitals (as defined by 
the Secretary of Health and Human Services 
under section 1886(d)(1)(B)(ii) of the Social 
Security Act (42 U.S.C. 1395ww(d)(1)(B)(ii))); 
(E) long-term care hospitals as defined in 
section 1861 of the Social Security Act (42 
U.S.C. 1395x(ccc)); and 
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(F) independent dialysis facilities and inde-
pendent end-stage renal disease facilities as de-
scribed in 42 CFR 413.174(b); 
(4) the term ‘‘medically necessary or appro-
priate’’ means the health care items and services or 
supplies are needed or appropriate to prevent, diag-
nose, or treat an illness, injury, condition, disease, or 
its symptoms for an individual and are determined 
to be necessary or appropriate for such individual by 
the physician or other health care professional treat-
ing such individual, after such professional performs 
an assessment of such individual’s condition, in a 
manner that meets— 
(A) the scope of practice, licensing, and 
other law of the State in which such items and 
services are to be furnished; and 
(B) appropriate standards established by 
the Secretary for purposes of carrying out this 
Act; 
(5) the term ‘‘provider’’ means an institutional 
provider or a supplier (as defined in section 1861(d) 
of such Act (42 U.S.C. 1395x(d)) if the reference to 
‘‘this title’’ were a reference to the Medicare for All 
Program); 
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(6) the term ‘‘Secretary’’ means the Secretary 
of Health and Human Services; 
(7) the term ‘‘State’’ means a State, the Dis-
trict of Columbia, or a territory of the United 
States; and 
(8) the term ‘‘United States’’ shall include the 
States, the District of Columbia, and the territories 
of the United States. 
SEC. 1102. RULES OF CONSTRUCTION. 
(a) IN GENERAL.—A State or local government may 
set additional standards or apply other State or local laws 
with respect to eligibility, benefits, and minimum provider 
standards, only if such State or local standards— 
(1) provide equal or greater eligibility than is 
available under this Act; 
(2) provide equal or greater in-person access to 
benefits under this Act; 
(3) do not reduce access to benefits under this 
Act; 
(4) allow for the effective exercise of the profes-
sional judgment of physicians or other health care 
professionals; and 
(5) are otherwise consistent with this Act. 
(b) RELATION TO STATE LICENSING LAW.—Nothing 
in this Act shall be construed to preempt State licensing, 
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practice, or educational laws or regulations with respect 
to health care professionals and health care providers, for 
such professionals and providers who practice in that 
State. 
(c) APPLICATION TO STATE AND FEDERAL LAW ON 
WORKPLACE RIGHTS.—Nothing in this Act shall be con-
strued to diminish or alter the rights, privileges, remedies, 
or obligations of any employee or employer under any Fed-
eral or State law or regulation or under any collective bar-
gaining agreement. 
(d) RESTRICTIONS ON PROVIDERS.—With respect to 
any individuals or entities certified to provide items and 
services covered under section 201(a)(7), a State may not 
prohibit an individual or entity from participating in the 
program under this Act for reasons other than the ability 
of the individual or entity to provide such services. 
Æ 
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