I 
115TH CONGRESS 
2D SESSION 
H. R. 6117 
To provide for the establishment of Medicare part E public health plans, 
and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JUNE 14, 2018 
Mr. RICHMOND (for himself, Mr. HUFFMAN, Mr. LOWENTHAL, Mr. JEFFRIES, 
Ms. EDDIE BERNICE JOHNSON of Texas, and Mr. DESAULNIER) intro-
duced the following bill; which was referred to the Committee on Energy 
and Commerce, and in addition to the Committees on Ways and Means, 
and Education and the Workforce, for a period to be subsequently deter-
mined by the Speaker, in each case for consideration of such provisions 
as fall within the jurisdiction of the committee concerned 
A BILL 
To provide for the establishment of Medicare part E public 
health plans, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Choose Medicare Act’’. 
SEC. 2. PUBLIC HEALTH PLAN. 
The Social Security Act is amended by adding at the 
end the following: 
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‘‘TITLE XXII—MEDICARE PART E PUBLIC HEALTH PLANS 
‘‘SEC. 2201. PUBLIC HEALTH PLANS.— 
‘‘(a) ESTABLISHMENT.—The Secretary shall estab-
lish public health plans (to be known as ‘Medicare part 
E plans’) that are available in the individual market, small 
group market, and large group market. 
‘‘(b) BENEFITS.— 
‘‘(1) IN
GENERAL.—Each Medicare part E 
plan, regardless of whether the plan is offered in the 
individual market, small group market, or large 
group market, shall be a qualified health plan within 
the meaning of section 1301(a) of the Patient Pro-
tection and Affordable Care Act (42 U.S.C. 
18021(a)) that— 
‘‘(A) meets all requirements applicable to 
qualified health plans under subtitle D of title 
I of the Patient Protection and Affordable Care 
Act (42 U.S.C. 18021 et seq.) (other than the 
requirement under section 1301(a)(1)(C)(ii) of 
such Act) and title XXVII of the Public Health 
Service Act (42 U.S.C. 300gg et seq.); 
‘‘(B) provides coverage of— 
‘‘(i) the essential health benefits de-
scribed in section 1302(b) of the Patient 
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Protection and Affordable Care Act (42 
U.S.C. 18022(b)); and 
‘‘(ii) all items and services for which 
benefits are available under title XVIII; 
‘‘(C) provides gold-level coverage described 
in section 1302(d)(1)(C) of the Patient Protec-
tion and Affordable Care Act (42 U.S.C. 
18022(d)(1)(C)); and 
‘‘(D) provides coverage of abortions and all 
other reproductive services. 
‘‘(2) PREEMPTION.—Notwithstanding section 
1303(a)(1) of the Patient Protection and Affordable 
Care Act (42 U.S.C. 18023(a)(1))— 
‘‘(A) a State may not prohibit a Medicare 
part E plan from offering the coverage de-
scribed in paragraph (1)(D); and 
‘‘(B) no State law that would prohibit such 
a plan from offering such coverage shall apply 
to such plan. 
‘‘(c) ELIGIBILITY; ENROLLMENT.— 
‘‘(1) AVAILABILITY ON THE EXCHANGES.—The 
Medicare part E plans offered in the individual and 
small group markets shall be offered through the 
Federal and State Exchanges, including the Small 
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Business Health Options Program Exchanges (com-
monly referred to as the ‘SHOP Exchanges’). 
‘‘(2) ELIGIBILITY.— 
‘‘(A) IN GENERAL.—Any individual who is 
a resident of the United States, as determined 
by the Secretary under subparagraph (C), and 
who is not an individual described in subpara-
graph (B), is eligible to enroll in a Medicare 
part E plan. 
‘‘(B) EXCLUSIONS.—An individual de-
scribed in this subparagraph is any individual 
who is— 
‘‘(i) entitled to, or enrolled for, bene-
fits under title XVIII; 
‘‘(ii) eligible for medical assistance 
under a State plan under title XIX; or 
‘‘(iii) enrolled for child health assist-
ance or pregnancy-related assistance under 
a State plan under title XXI. 
‘‘(C) REGULATIONS.—The Secretary shall 
promulgate a rule for determining residency for 
purposes of subparagraph (A). 
‘‘(3) EMPLOYER-SPONSORED PLANS.— 
‘‘(A) EMPLOYER ENROLLMENT.—Effective 
with respect to the first plan year that begins 
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1 year after the date of enactment of the 
Choose Medicare Act and each plan year there-
after, the Secretary shall provide options for 
Medicare part E plans in the small group mar-
ket and large group market that are voluntary, 
and available to all employers. 
‘‘(B) GROUP
HEALTH
PLANS.—The Sec-
retary, acting through the Administrator for the 
Centers for Medicare & Medicaid Services, at 
the request of a plan sponsor, shall serve as a 
third party administrator of a group health 
plan that is a Medicare part E plan offered by 
such sponsor. 
‘‘(C) PORTABILITY FOR EMPLOYER-SPON-
SORED PLANS.—The Secretary shall develop a 
process for allowing individuals enrolled in a 
Medicare part E plan offered in the small group 
market or large group market to maintain 
health insurance coverage through a Medicare 
part E plan if the individual subsequently loses 
eligibility for enrollment in such a plan based 
on termination of the employment relationship. 
The ability to maintain such coverage shall 
exist regardless of whether the individual has 
the option to enroll in other health insurance 
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coverage, including coverage offered in the indi-
vidual market or through a subsequent em-
ployer. 
‘‘(d) PREMIUMS.—The Secretary shall establish pre-
mium rates for the Medicare part E plans that— 
‘‘(1) are adjusted based on— 
‘‘(A) whether the plan is offered in the in-
dividual market, small group market, or large 
group market; and 
‘‘(B) the applicable rating area; 
‘‘(2) are at a level sufficient to fully finance— 
‘‘(A) the costs of health benefits provided 
by such plans; and 
‘‘(B) administrative costs related to oper-
ating the plans; and 
‘‘(3) comply with the requirements under sec-
tion 2701 of the Public Health Service Act, includ-
ing for such plans that are offered in the large 
group market. 
‘‘(e) PROVIDERS AND REIMBURSEMENT RATES.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish a rate schedule for reimbursing types of health 
care providers furnishing items and services under 
the Medicare part E plans at rates that are con-
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sistent with the negotiations described in paragraph 
(2) and are necessary to maintain network adequacy. 
‘‘(2) MANNER
OF
NEGOTIATION.—The Sec-
retary shall negotiate the rates described in para-
graph (1) in a manner that results in payment rates 
that are not lower, in the aggregate, than rates 
under title XVIII, and not higher, in the aggregate, 
than the average rates paid by other health insur-
ance issuers offering health insurance coverage 
through an Exchange. 
‘‘(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 on the date of enactment of Choose 
Medicare Act shall be a participating provider 
for Medicare part E plans. 
‘‘(B) ADDITIONAL PROVIDERS.—The Sec-
retary shall establish a process to allow health 
care providers not described in subparagraph 
(A) to become participating providers for Medi-
care part E plans. 
‘‘(f) ENCOURAGING USE OF ALTERNATIVE PAYMENT 
MODELS.—The Secretary shall, as applicable, utilize alter-
native payment models, including those described in sec-
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tion 1833(z)(3)(C), as added by section 101(e)(2) of the 
Medicare Access and CHIP Reauthorization Act of 2015 
(Public Law 114–10), in making payments for items and 
services (including prescription drugs) furnished under 
Medicare part E plans. The payment rates under such al-
ternative payment models shall comply with the require-
ment for negotiated rates under subsection (e)(2). 
‘‘(g) PRESCRIPTION DRUGS.—The Secretary shall 
apply the provisions of section 1860D–11(i) to prescrip-
tion drugs under Medicare part E plans in the same man-
ner as such provisions apply with respect to applicable cov-
ered part D drugs under such section. 
‘‘(h) APPROPRIATIONS.— 
‘‘(1) START-UP FUNDING.—For purposes of es-
tablishing the Medicare part E plans, there is appro-
priated to the Secretary, out of any funds in the 
Treasury not otherwise obligated, $2,000,000,000, 
for fiscal year 2019. 
‘‘(2) INITIAL
RESERVES.—There is appro-
priated to the Secretary, out of any funds in the 
Treasury not otherwise obligated, such sums as may 
be necessary, based on projected enrollment in the 
Medicare part E plans in the first plan year in 
which such plans are offered, to provide reserves for 
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the purpose of paying claims filed during the initial 
90-day period of such plan year. 
‘‘(3) CLARIFICATION.—Any provision of law re-
stricting the use of Federal funds with respect to 
any reproductive health service shall not apply to 
funds appropriated under paragraph (1) or (2). 
‘‘(i) HEALTH INSURANCE ISSUER.—With respect to 
any Medicare part E plan, the Secretary shall be consid-
ered a health insurance issuer, within the meaning of sec-
tion 2791(b) of the Public Health Service Act.’’. 
SEC. 3. NOTICE AND NAVIGATOR REFERRAL FOR EMPLOY-
EES UNDER THE FAIR LABOR STANDARDS 
ACT OF 1938. 
(a) IN GENERAL.—Section 18B of the Fair Labor 
Standards Act of 1938 (29 U.S.C. 218b) is amended— 
(1) in the heading, by striking ‘‘TO’’ and insert-
ing ‘‘AND NAVIGATOR REFERRAL FOR’’; 
(2) by redesignating subsection (b) as sub-
section (c); 
(3) by inserting after subsection (a) the fol-
lowing: 
‘‘(b) NAVIGATOR REFERRAL.— 
‘‘(1) IN GENERAL.—An employer described in 
paragraph (3) shall refer each full-time employee (as 
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defined in section 4980H of the Internal Revenue 
Code of 1986) to— 
‘‘(A) an entity that serves as a navigator 
under section 1311(i) of the Patient Protection 
and Affordable Care Act (42 U.S.C. 18031(i)) 
for the Exchange operating in the State of the 
employer; or 
‘‘(B) if the Exchange operating in the 
State of the employer does not have an entity 
serving as such a navigator, another entity that 
shall carry out equivalent activities as such a 
navigator. 
‘‘(2) REFERRAL.—The referral described in 
paragraph (1) shall occur— 
‘‘(A) at the time the employer hires the 
employee; or 
‘‘(B) on the effective date described in sub-
section (c)(2) with respect to an employee who 
is currently employed by the employer on such 
date. 
‘‘(3) EMPLOYER.—An employer described in 
this paragraph is any employer that— 
‘‘(A) does not provide an eligible employer- 
sponsored 
plan 
as 
defined 
in 
section 
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5000A(f)(2) of the Internal Revenue Code of 
1986; or 
‘‘(B) provides such an eligible employer- 
sponsored plan, but the plan is determined 
under section 36B(c)(2)(C) of such Code— 
‘‘(i) to be unaffordable to the em-
ployee; or 
‘‘(ii) to not provide the required min-
imum actuarial value.’’; and 
(4) in subsection (c), as so redesignated— 
(A) in the heading, by striking ‘‘EFFEC-
TIVE
DATE’’ 
and 
inserting 
‘‘EFFECTIVE 
DATES’’; 
(B) by striking ‘‘Subsection (a)’’ and in-
serting the following: 
‘‘(1) NOTICE.—Subsection (a);’’; and 
(C) by adding at the end the following: 
‘‘(2) NAVIGATOR
REFERRAL.—Subsection (b) 
shall take effect with respect to employers in a State 
beginning on the date that is 2 years after the date 
of enactment of the Choose Medicare Act.’’. 
(b) STUDY.—Not later than January 1, 2023, the 
Comptroller General of the United States shall conduct 
a study on the impact of the requirements under section 
18B of the Fair Labor Standards Act of 1938 (29 U.S.C. 
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218b), including the amendments made by subsection (a), 
on the rate of individuals without minimum essential cov-
erage as defined in section 5000A of the Internal Revenue 
Code of 1986 in the United States and in each State. 
(c) FUNDING FOR NAVIGATOR PROGRAM.—Section 
1311(i)(6) of the Patient Protection and Affordable Care 
Act (42 U.S.C. 18031(i)(6)) is amended— 
(1) by striking ‘‘Grants’’ and inserting the fol-
lowing: 
‘‘(A) IN GENERAL.—Grants’’; and 
(2) by adding at the end the following: 
‘‘(B) 
AUTHORIZATION
OF
APPROPRIA-
TIONS.—There is authorized to be appropriated 
such sums as may be necessary to address ca-
pacity limitations of entities serving as naviga-
tors through a grant under this subsection.’’. 
SEC. 4. PROTECTING AGAINST HIGH OUT-OF-POCKET EX-
PENDITURES FOR MEDICARE FEE-FOR-SERV-
ICE BENEFITS. 
Title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.) is amended by adding at the end the fol-
lowing new section: 
‘‘PROTECTION AGAINST HIGH OUT-OF-POCKET 
EXPENDITURES 
‘‘SEC. 1899D. (a) IN GENERAL.—Notwithstanding 
any other provision of this title, in the case of an indi-
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vidual entitled to, or enrolled for, benefits under part A 
or enrolled in part B, if the amount of the out-of-pocket 
cost-sharing of such individual for a year (beginning with 
2020) equals or exceeds the annual out-of-pocket limit 
under subsection (b) for that year, the individual shall not 
be responsible for additional out-of-pocket cost-sharing in-
curred during that year. 
‘‘(b) ANNUAL OUT-OF-POCKET LIMIT.— 
‘‘(1) IN GENERAL.—The amount of the annual 
out-of-pocket limit under this subsection shall be— 
‘‘(A) for 2020, $6,700; or 
‘‘(B) for a subsequent year, the amount 
specified in this subsection for the preceding 
year increased or decreased by the percentage 
change in the medical care component of the 
Consumer Price Index for All Urban Con-
sumers for the 12-month period ending with 
June of such preceding year. 
‘‘(2) ROUNDING.—If any amount determined 
under paragraph (1)(B) is not a multiple of $5, such 
amount shall be rounded to the nearest multiple of 
$5. 
‘‘(c) OUT-OF-POCKET COST-SHARING DEFINED.— 
‘‘(1) IN GENERAL.—Subject to paragraphs (2) 
and (3), in this section, the term ‘out-of-pocket cost- 
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sharing’ means, with respect to an individual, the 
amount of the expenses incurred by the individual 
that are attributable to— 
‘‘(A) deductibles, coinsurance, and copay-
ments applicable under part A or B; or 
‘‘(B) for items and services that would 
have otherwise been covered under part A or B 
but for the exhaustion of those benefits. 
‘‘(2) CERTAIN COSTS NOT INCLUDED.— 
‘‘(A) NON-COVERED
ITEMS
AND
SERV-
ICES.—Expenses incurred for items and serv-
ices which are not covered under part A or B 
shall not be considered incurred expenses for 
purposes of determining out-of-pocket cost- 
sharing under paragraph (1). 
‘‘(B) ITEMS
AND
SERVICES
NOT
FUR-
NISHED ON AN ASSIGNMENT-RELATED BASIS.— 
If an item or service is furnished to an indi-
vidual under this title and is not furnished on 
an assignment-related basis, any additional ex-
penses the individual incurs above the amount 
the individual would have incurred if the item 
or service was furnished on an assignment-re-
lated basis shall not be considered incurred ex-
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penses for purposes of determining out-of-pock-
et cost-sharing under paragraph (1). 
‘‘(3) SOURCE OF PAYMENT.—For purposes of 
paragraph (1), the Secretary shall consider expenses 
to be incurred by the individual without regard to 
whether the individual or another person, including 
a State program, an employer, a medicare supple-
mental policy, or other third-party coverage, has 
paid for such expenses. 
‘‘(d) ANNOUNCEMENT
OF
THE ANNUAL OUT-OF- 
POCKET LIMIT.—The Secretary shall (beginning in 2019) 
announce (in a manner intended to provide notice to all 
interested parties) the annual out-of-pocket limit under 
this section that will be applicable for the succeeding 
year.’’. 
SEC. 5. NEGOTIATING FAIR PRICES FOR MEDICARE PRE-
SCRIPTION DRUGS. 
(a) IN GENERAL.—Section 1860D–11 of the Social 
Security Act (42 U.S.C. 1395w–111) is amended by strik-
ing subsection (i) (relating to noninterference) and by in-
serting the following: 
‘‘(i) NEGOTIATING FAIR PRICES WITH DRUG MANU-
FACTURERS.— 
‘‘(1) IN GENERAL.—Notwithstanding any other 
provision of law, in furtherance of the goals of pro-
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viding quality care and containing costs under this 
part, the Secretary shall, with respect to applicable 
covered part D drugs, and may, with respect to 
other covered part D drugs, negotiate, using the ne-
gotiation technique or techniques that the Secretary 
determines will maximize savings and value to the 
government for prescription drug plans and MA–PD 
plans and for plan enrollees (in a manner that may 
be similar to Federal entities and that may include, 
but is not limited to, formularies, reference pricing, 
discounts, rebates, other price concessions, and cov-
erage determinations), with drug manufacturers the 
prices that may be charged to PDP sponsors and 
MA organizations for such drugs for part D eligible 
individuals who are enrolled in a prescription drug 
plan or in an MA–PD plan. In conducting such ne-
gotiations, the Secretary shall consider the drug’s 
current price, initial launch price, prevalence of dis-
ease and usage, and approved indications, the num-
ber of similarly effective alternative treatments for 
each approved use of the drug, the budgetary impact 
of providing coverage under this part for such drug 
for all individuals who would likely benefit from the 
drug, evidence on the drug’s effectiveness and safety 
compared to similar drugs, and the quality and 
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quantity of clinical data and rigor of the applicable 
process of approval of a drug under section 505 of 
the Federal Food, Drug, and Cosmetic Act or a bio-
logical product under section 351 of the Public 
Health Service Act. 
‘‘(2) USE OF LOWER OF VA OR BIG FOUR PRICE 
IF NEGOTIATIONS FAIL.—If, after attempting to ne-
gotiate for a price with respect to a covered part D 
drug under paragraph (1) for a period of 1 year, the 
Secretary is not successful in obtaining an appro-
priate price for the drug (as determined by the Sec-
retary), the Secretary shall establish the price that 
may be charged to PDP sponsors and MA organiza-
tions for such drug for part D eligible individuals 
who are enrolled in a prescription drug plan or in 
an MA–PD plan at an amount equal to the lesser 
of— 
‘‘(A) the price paid by the Secretary of 
Veterans Affairs to procure the drug under the 
laws administered by the Secretary of Veterans 
Affairs; or 
‘‘(B) the price paid to procure the drug 
under section 8126 of title 38, United States 
Code. 
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