I 
118TH CONGRESS 
1ST SESSION H. R. 5299 
To amend title XVIII of the Social Security Act to establish a demonstration 
program for international coverage under the Medicare program. 
IN THE HOUSE OF REPRESENTATIVES 
AUGUST 29, 2023 
Mr. ESPAILLAT introduced the following bill; which was referred to the Com-
mittee on Ways and Means, and in addition to the Committee on Energy 
and Commerce, for a period to be subsequently determined by the Speak-
er, in each case for consideration of such provisions as fall within the ju-
risdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to establish 
a demonstration program for international coverage 
under the Medicare program. 
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 ‘‘Earned Benefits 
Equality and Family Reunification Act’’. 
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SEC. 2. ESTABLISHING A DEMONSTRATION PROGRAM FOR 
INTERNATIONAL 
COVERAGE 
UNDER 
THE 
MEDICARE PROGRAM. 
Title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.) is amended by inserting after section 1866F 
the following new section: 
‘‘SEC. 1866G. DEMONSTRATION PROGRAM FOR INTER-
NATIONAL COVERAGE. 
‘‘(a) IMPLEMENTATION
OF 10-YEAR DEMONSTRA-
TION PROGRAM.—Not later than 1 year after the date of 
the enactment of this section, the Secretary shall imple-
ment a 10-year demonstration program under this title (in 
this section referred to as the Program) to allow Applica-
ble Beneficiaries to apply Medicare benefits to coverage 
of items and services, premiums, and other cost-sharing 
under the health insurance systems of other countries. 
Through the Program, the Secretary shall make payments 
under subsection (e) to or on behalf of Applicable Bene-
ficiaries participating in the Program. 
‘‘(b) PROGRAM DESIGN.— 
‘‘(1) IN GENERAL.—The Secretary shall design 
the Program in such a manner to allow for the eval-
uation of the extent to which the Program accom-
plishes the following purposes: 
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‘‘(A) Increases the quality of care for Ap-
plicable Beneficiaries participating in the Pro-
gram. 
‘‘(B) Decreases the cost of care to the gov-
ernment for the Applicable Beneficiaries. 
‘‘(C) Enables Applicable Beneficiaries to 
reunify with family members. 
‘‘(D) Reduced strain on the medical infra-
structure of the United States. 
‘‘(2) CONSULTATION.—In designing the Pro-
gram, the Secretary shall use open door forums and 
other mechanisms to seek input from a consortium 
of stakeholders that may include but are not limited 
to— 
‘‘(A) the United States Department of 
State; 
‘‘(B) clinical and analytical experts with 
relevant expertise; 
‘‘(C) beneficiaries; and 
‘‘(D) foreign health insurance system ex-
perts. 
‘‘(3) PROGRAM CONSIDERATIONS.—In consulta-
tion with stakeholders as identified in subsection 
(b)(2), the Secretary shall issue guidance on— 
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‘‘(A) the guidelines to ensure the usage of 
medications and equipment that are of accept-
able quality relative to American quality stand-
ards; 
‘‘(B) ways to ensuring quality of care; and 
‘‘(C) ways to target low-income Americans 
as participants in the program. 
‘‘(c) SELECTED COUNTRIES INITIAL SELECTION.— 
In choosing Selected Countries for the Program, the Sec-
retary shall initially select at least 11 distinct nations or 
political subdivisions thereof, which shall include Canada, 
the Federal Republic of Germany, the Republic of India, 
the State of Israel, the Republic of Korea, the Republic 
of the Philippines, the Republic of Panama, the United 
Mexican States, Dominican Republic, and at least one na-
tion or political subdivision thereof in Africa. 
‘‘(d) APPLICABLE BENEFICIARY.— 
‘‘(1) VOLUNTARY
BENEFICIARY
PARTICIPA-
TION.—An Applicable Beneficiary may participate in 
the Program on a voluntary basis and may termi-
nate participation in the Program at any time. The 
election to participate in the Program or to termi-
nate participation shall constitute a Special Election 
Period under section 1852(e)(4) of this title. 
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‘‘(2) SERVICES.—In order to participate in the 
Program, an Applicable Beneficiary shall agree to 
receive coverage of health care items and services in 
a Selected Country during such time as the Applica-
ble Beneficiary is a resident of that country. 
‘‘(3) BENEFICIARY
ACCESS
TO
SERVICES.— 
Nothing in this section shall be construed as limiting 
an Applicable Beneficiary’s access to items and serv-
ices covered under this title when furnished in the 
United States, and Applicable Beneficiaries shall not 
be required to relinquish access to such benefits as 
a condition of receiving services from a participant 
in the Program. 
‘‘(4) 
NUMBER
OF
APPLICABLE
BENE-
FICIARIES.—The Secretary may cap the number of 
Applicable Beneficiaries accepted into the Program, 
but at a number no smaller than 150,000. 
‘‘(e) PHYSICIAN CERTIFICATION.—Participating phy-
sicians must be in good standing with accreditation insti-
tutions or licensing authorities in the Selected Countries. 
‘‘(f) PAYMENTS.— 
‘‘(1) IN GENERAL.—The Secretary shall make 
payments to or on behalf of Applicable Beneficiaries 
for the costs of health care items and services paid 
by Applicable Beneficiaries in Selected Countries. 
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Such payments may include payments for individual 
items or services paid by Applicable Beneficiaries, 
payments for cost sharing incurred by Applicable 
Beneficiaries, and premiums and equivalent charges 
for health insurance coverage paid by Applicable 
Beneficiaries. Payments shall not include reimburse-
ment for taxes levied on income for the purpose of 
funding health care. 
‘‘(2) PAYMENT AMOUNTS.—The Secretary shall 
limit the amounts of payment to ensure such pay-
ments and funds expended to design, implement, 
and evaluate the Program do not exceed in the ag-
gregate the amount the Secretary would pay under 
this title for equivalent services delivered in the 
United States. 
‘‘(3) NO DUPLICATE PAYMENT.—The Secretary 
shall make or permit payments under this paragraph 
only for a calendar month in which the Applicable 
Beneficiary resides in the Selected Country and does 
not incur any costs under this title other than the 
payment hereunder. 
‘‘(g) ROLE OF MEDICARE ADVANTAGE.— 
‘‘(1) In carrying out the Program, the Sec-
retary may administer the Program, either in part 
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or exclusively, through Medicare Advantage Organi-
zations. 
‘‘(2) To the extent Medicare Advantage Organi-
zations carry out functions under the Program, pay-
ments made by such organizations under subsection 
(e) shall be considered as if they were benefits under 
the original Medicare fee-for-service program option 
for purposes of sections 1852 and 1854 of this title, 
and a component of standard prescription drug cov-
erage and not supplemental prescription drug cov-
erage, under section 1860D2(a) of this title. 
‘‘(3) The Secretary may limit the number of 
Medicare Advantage Organizations participating in 
the Program, in accordance with criteria established 
by the Secretary. 
‘‘(h) REPORTING.—The Secretary shall conduct an-
nual intermediate and a final evaluation of the Program. 
Each such evaluation shall determine the extent to which 
each of the purposes described in subsection (b) have been 
accomplished under the Program. The evaluation shall 
contain recommendations to Congress with regards to the 
expansion of the Program. 
‘‘(i) ADDRESSING WASTE, FRAUD, AND ABUSE.— 
‘‘(1) Participating physicians are required to go 
through Fraud, Waste, and Abuse training within 
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90 days of implementation of the demonstration 
project and at least annually thereafter. 
‘‘(2) The Secretary must create a system to 
allow patients and physicians to report instances or 
concerns of waste, fraud, and abuse. 
‘‘(j) DEFINITIONS.—In this section: 
‘‘(1) APPLICABLE
BENEFICIARY.—The term 
‘Applicable Beneficiary’ means an individual who— 
‘‘(A) is entitled to or enrolled for benefits 
under part A, and enrolled for benefits under 
part B; 
‘‘(B) may be enrolled in a Medicare Advan-
tage plan under part C; 
‘‘(C) is either— 
‘‘(i) a resident of the United States at 
the time of application to the Program who 
intends to relocate to a Selected Country 
on or after the date of such application, or 
is a former resident of the United States 
who has relocated to a Selected Country 
within 180 days of application to the Pro-
gram; or 
‘‘(ii) a resident of a Selected Country 
for whom the Medicare program is at the 
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time of application the primary payor of 
their health care costs; and 
‘‘(D) meets such other criteria as the Sec-
retary determines appropriate. 
‘‘(2) SELECTED COUNTRY.—The term Selected 
Country means a nation or political subdivision 
thereof identified by the Secretary as having a 
health care system that provides for— 
‘‘(A) health care coverage in scope and 
quality of coverage appropriate for Medicare 
beneficiaries in accordance with criteria estab-
lished by the Secretary; and 
‘‘(B) cost of coverage, coinsurance, and 
items and services that is equivalent to or less 
than expected costs for such coverage, coinsur-
ance, and items and services in the United 
States under this title. 
‘‘(k) FUNDING.— 
‘‘(1) ADMINISTRATIVE
FUNDING.—The Sec-
retary shall allocate funds made available under sec-
tion 1115A(f)(1) to design, implement, and evaluate 
the Program. 
‘‘(2) BENEFIT FUNDING.—Payments for items 
and services under the Program shall be made in ap-
propriate part from the Federal Hospital Insurance 
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Trust Fund established by section 1817 of this title 
and the Federal Supplementary Medical Insurance 
Trust Fund established by section 1841 of this title. 
‘‘(l) WAIVERS.—The Secretary may waive any provi-
sion of this title as may be necessary to carry out the Pro-
gram under this section. 
‘‘(m) LIMITATIONS ON REVIEW.—There shall be no 
administrative or judicial review under section 1869, sec-
tion 1878, or otherwise of— 
‘‘(1) the selection of organizations, sites, or par-
ticipants to test the Program; and 
‘‘(2) the elements, parameters, scope, and dura-
tion of the Program. The preceding sentence shall 
not prevent an Applicable Beneficiary, having been 
selected as a participant, from exercising a right to 
appeal under sections 1869, 1155, 1852(g), 1860D– 
4, or otherwise. 
‘‘(n) ADMINISTRATION.— 
‘‘(1) Chapter 35 of title 44, United States 
Code, shall not apply to the activities under this sec-
tion. 
‘‘(2) The Secretary may enter into contracts for 
the administration of the Program without regard to 
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any requirement for the use of competitive proce-
dures.’’. 
Æ 
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