517 
payments otherwise made with respect to 
such individual under such part. 
‘‘(2) OTHER INNOVATIVE ALTERNATIVES.— 
‘‘(A) IN GENERAL.—The State submits to 
the Secretary, and has approved by the Sec-
retary, an innovative alternative proposal relat-
ing to coordinating coverage of such individuals 
under Medicare and the State plan under title 
XIX. 
‘‘(B) PROCESS
FOR
REVIEW.—With re-
spect to proposals submitted to the Secretary 
under subparagraph (A), the Secretary shall ap-
prove such a proposal if the State demonstrates 
with respect to the proposal that— 
‘‘(i) there would be no increased cost 
to the Federal Government if it were ap-
proved; and 
‘‘(ii) there would be no reduction in 
the quality of care provided to such indi-
viduals if the proposal were approved.’’. 
(d) CONFORMING AMENDMENTS.— 
(1) SECTION 226.—Section 226 of the Social 
Security Act (42 U.S.C. 426) is amended— 
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(A) in subsection (a), in the matter pre-
ceding paragraph (1), by inserting ‘‘, subject to 
section 1860E–11(a)’’ after ‘‘individual who’’; 
(B) in subsection (b), in the matter pre-
ceding paragraph (1), by inserting ‘‘, subject to 
section 1860E–11(a)’’ after ‘‘individual who’’; 
and 
(C) in subsection (c), in the matter pre-
ceding paragraph (1), by inserting ‘‘, subject to 
section 1860E–11(a)’’ after ‘‘subsection (a)’’. 
(2) SECTION 226A.—Section 226A(a) of such 
Act (42 U.S.C. 426–1(a)) is amended, in the matter 
preceding paragraph (1), by inserting ‘‘and subject 
to section 1860E–11(a)’’ after ‘‘or title XVIII’’. 
(3) SECTION 1932.—Section 1932(a)(2)(B) of 
the Social Security Act (42 U.S.C. 1396u– 
2(a)(2)(B)) is amended by striking ‘‘A State’’ and 
inserting ‘‘Except in the case of a State that has 
elected the maintenance of effort option described in 
section 1944(b)(2), a State’’. 
SEC. 423. NEW BENEFIT STRUCTURE UNDER UNIFIED 
MEDICARE. 
(a) IN GENERAL.—Part E of title XVIII of the Social 
Security Act, as added by section 251, is amended by add-
ing at the end the following: 
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‘‘Subpart 2—Out-of-Pocket Limit 
‘‘SEC. 1860E–21. OUT-OF-POCKET LIMIT. 
‘‘(a) IN GENERAL.—Beginning with 2021, in the case 
of a Medicare enrollee, if the amount of the out-of-pocket 
cost-sharing of such enrollee for a calendar year equals 
or exceeds the catastrophic limit under subsection (b) for 
that year— 
‘‘(1) the enrollee shall not be responsible for ad-
ditional out-of-pocket cost-sharing incurred during 
that year; and 
‘‘(2) the Secretary shall establish procedures 
under which the Secretary shall, in appropriate part 
from the Part A Medicare FFS Account under sec-
tion 1817 and the Part B Medicare FFS Account 
under section 1841— 
‘‘(A) pay on behalf of the enrollee the 
amount of the additional out-of-pocket cost- 
sharing described in paragraph (1) attributable 
to deductibles and coinsurance described in sub-
section (c)(1); and 
‘‘(B) reimburse the enrollee the amount of 
the additional out-of-pocket cost-sharing de-
scribed in paragraph (1) attributable to 
deductibles and coinsurance described in sub-
section (c)(2). 
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‘‘(b) CATASTROPHIC LIMIT.—The amount of the cat-
astrophic limit under this subsection for a year shall be 
the dollar amount in effect under section 223(c)(2)(A)(ii) 
of the Internal Revenue Code of 1986 for self-only cov-
erage for taxable years beginning in such year. 
‘‘(c) OUT-OF-POCKET COST-SHARING DEFINED.—In 
this section, the term ‘out-of-pocket cost-sharing’ means, 
with respect to an individual, the amount of costs incurred 
by the individual that are attributable to— 
‘‘(1) deductibles and coinsurance imposed under 
part A or part B; and 
‘‘(2) deductibles and coinsurance imposed under 
standard prescription drug coverage pursuant to sec-
tion 1860D–2(b) or alternative prescription drug 
coverage pursuant to section 1860D–2(c) offered by 
a prescription drug plan.’’. 
(b) APPLICATION OF OUT-OF-POCKET LIMIT TO MA– 
PD PLANS.— 
(1) IN GENERAL.—Section 1852(a)(1)(B) of the 
Social Security Act (42 U.S.C. 1395w–22(a)(1)(B)) 
is amended— 
(A) in clause (i), by striking ‘‘clause (iii)’’ 
and inserting ‘‘clauses (iii) and (vi)’’; and 
(B) by adding at the end the following new 
clause: 
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‘‘(vi) OUT-OF-POCKET
LIMIT.—The 
provisions of section 1860E–21— 
‘‘(I) shall apply to individuals en-
rolled under an MA–PD plan in the 
same manner as such provisions apply 
to Medicare enrollees under such sec-
tion, except that in lieu of the applica-
tion of subsection (a)(2) of such sec-
tion the MA–PD plan shall establish 
procedures to provide for payment of 
any additional out-of-pocket cost-shar-
ing described in subsection (a)(1) of 
such section incurred by individuals 
enrolled under the MA–PD plan; and 
‘‘(II) as applied under subclause 
(I), may not be waived by application 
of this subparagraph. 
In applying subsection (b) of section 
1860E–21 pursuant to the previous sen-
tence, an MA–PD plan may substitute a 
dollar amount that is less than the dollar 
amount specified under such subsection.’’. 
(2) EXEMPTING MA–PD PLANS OFFERING AL-
TERNATIVE PRESCRIPTION DRUG COVERAGE FROM 
PART
D
DEDUCTIBLE
AND
OUT-OF-POCKET
LIMIT 
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REQUIREMENTS.—Section 1860D–2(c) of the Social 
Security Act (42 U.S.C. 1395w–102(c)) is amend-
ed— 
(A) in paragraph (2), by striking ‘‘The de-
ductible’’ and inserting ‘‘In the case of a pre-
scription drug plan, the deductible’’; and 
(B) in paragraph (3), by striking ‘‘The 
coverage provides’’ and inserting ‘‘In the case 
of a prescription drug plan, the coverage pro-
vides’’. 
(c) PRESCRIPTION DRUG PLANS REQUIRED TO RE-
PORT ENROLLEES’ OUT-OF-POCKET COST-SHARING.— 
Section 1860D–12(b) of the Social Security Act (42 
U.S.C. 1395w–112(b)) is amended by adding at the end 
the following new paragraph: 
‘‘(7) 
OUT-OF-POCKET
COST-SHARING
RE-
PORTS.—Each contract entered into with a PDP 
sponsor under this part with respect to a prescrip-
tion drug plan offered by such sponsor shall require 
that, with respect to each claim submitted for items 
or services furnished to an individual enrolled under 
the plan pursuant to the contract, the sponsor sub-
mits to the Secretary information on the amount of 
out-of-pocket cost-sharing (as defined in section 
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(D) in subsection (f), by striking ‘‘In es-
tablishing’’ and inserting ‘‘Subject to subpart 2 
of part E, in establishing’’; and 
(E) in subsection (g)(1), by inserting ‘‘and 
subpart 2 of part E’’ and ‘‘paragraphs (4) and 
(5)’’. 
(3) Section 1882(a)(2) of such Act is amended 
by striking ‘‘No medicare’’ and inserting ‘‘Subject to 
section 1860E–24(c), no medicare’’. 
SEC. 424. LATE ENROLLMENT PENALTY NOT TO APPLY FOR 
MONTHS OF ANY HEALTH COVERAGE. 
(a) IN GENERAL.—Section 1839(b) of the Social Se-
curity Act (42 U.S.C. 1395r) is amended in the second 
sentence, by inserting before the period at the end the fol-
lowing: ‘‘or months during which the individual has any 
other health coverage’’. 
(b) EFFECTIVE DATE.—The amendment made by 
paragraph (1) shall apply for months of coverage begin-
ning after the date of the enactment of this Act. 
SEC. 425. MEDIGAP REFORM. 
Notwithstanding any provision of section 1882 of the 
Social Security Act (42 U.S.C. 1395ss), as of the date 
of the enactment of this Act, no policy may be offered 
under such section that does not provide guaranteed cov-
erage (without regard to an individual’s preexisting condi-
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tions, if any) to all individuals eligible to enroll under such 
policy. 
SEC. 426. ACO REVISION. 
(a) ENROLLMENT.—Enrollment in such an ACO 
under such title shall be based on the method established 
under part E of such title. Such a network shall bear full 
risk in the event payments under such title do not equal 
or exceed liabilities under such network. 
(b) DIRECTION OF PAYMENT.—An ACO may direct 
that any payments under such title be made to a central-
ized entity rather than to an individual provider or sup-
plier. 
(c) BIDS.—The Secretary of Health and Human 
Services shall establish a process whereby such networks 
compete using a bidding process similar to that described 
in part E of such title for Medicare Advantage plans. 
SEC. 427. PRIMARY CARE OPTIONS. 
(a) SELECTION OF PRIMARY CARE PHYSICIAN.—The 
Secretary shall establish a mechanism under which an in-
dividual enrolled under part B of title XVIII of the Social 
Security Act may select such individual’s primary care 
physician. Such an individual shall not be liable for more 
than $5 for each visit to such selected physician. 
(b) PAYMENT TO PHYSICIAN.—A physician selected 
under subsection (a) shall receive a monthly fee in lieu 
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of any other payment under such part B for evaluation 
and monitoring of such individual. The Secretary shall 
provide a list of standardized benefits that are included 
in such payment, including telephone and email commu-
nications, office visits, preventive care, and vaccinations. 
SEC. 428. GENERAL PROVISIONS; EFFECTIVE DATE. 
Part E of title XVIII of the Social Security Act, as 
inserted by section 101(a)(2) and as previously amended, 
is further amended by adding at the end the following new 
subpart: 
‘‘Subpart 5.—General Provisions 
‘‘SEC. 1860E–51. APPLICABILITY; DEFINITIONS. 
‘‘(a) IN GENERAL.—The provisions of this Act are 
superseded to the extent inconsistent with the provisions 
of this part. 
‘‘(b) TERMINOLOGY.—For purposes of this part: 
‘‘(1) MEDICARE ENROLLEE.— 
‘‘(A) IN
GENERAL.—The term ‘Medicare 
enrollee’ means— 
‘‘(i) an individual entitled to (or en-
rolled for benefits) under part A and en-
rolled under part B; and 
‘‘(ii) except as otherwise specified, an 
individual described in section 1860E– 
11(a)(3). 
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‘‘(B) TREATMENT.—Any reference in this 
Act (or any other Act) in effect before the date 
of the enactment of this part, to an individual 
entitled to benefits under part A or enrolled 
under part B shall be deemed a reference to a 
Medicare enrollee. 
‘‘(2) MEDICARE FEE-FOR-SERVICE.—The term 
‘Medicare fee-for-service’ means the original Medi-
care fee-for-service program under parts A and B, 
as modified by this part, and does not include part 
C or part D. 
‘‘(3) 
MEDICARE
FEE-FOR-SERVICE
EN-
ROLLEE.—The term ‘Medicare fee-for-service en-
rollee’ means a Medicare enrollee who is not enrolled 
under a Medicare Advantage plan under part C. 
‘‘SEC. 1860E–61. GENERAL EFFECTIVE DATE. 
‘‘Except as otherwise specified, the provisions of this 
part shall apply to items and services furnished on or after 
January 1, 2021, and to plan years beginning on or after 
such date (referred to in this title as the ‘general effective 
date’).’’. 
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Subtitle D—Telehealth 
Improvements and Expansion 
SEC. 431. EXPANSION OF COVERAGE OF TELEHEALTH 
SERVICES. 
(a) COVERED SERVICES.—Section 1834(m)(4)(F)(i) 
of the Social Security Act (42 U.S.C. 1395m(m)(4)(F)(i)) 
is amended— 
(1) by striking ‘‘and office’’ and inserting ‘‘of-
fice’’; and 
(2) by inserting: ‘‘respiratory services, audiology 
services (as defined in section 1861(ll)), outpatient 
therapy services (including physical therapy, occupa-
tional therapy, and speech-language pathology serv-
ices)’’ after ‘‘the Secretary)),’’. 
(b) PROVIDERS.—Subsection (m) of section 1834 of 
such Act (42 U.S.C. 1395m) is amended— 
(1) in paragraph (1), by striking ‘‘or a practi-
tioner (described in section 1842(b)(18)(C))’’ and 
inserting ‘‘, a practitioner (described in section 
1842(b)(18)(C)), or an applicable professional (as 
defined in paragraph (4)(G))’’; 
(2) by striking ‘‘physician or practitioner’’ each 
time it appears in such subsection and inserting 
‘‘physician, practitioner, or applicable professional’’; 
(3) in paragraph (3)(A)— 
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