provider during the 2-year period beginning on 
the date the affidavit was signed. 
(5) PRIVATE
CONTRACTS
FOR
NONCOVERED 
ITEMS AND SERVICES FOR ANY INDIVIDUAL.—An in-
stitutional or individual provider with no agreement 
in effect under section 301 may bill or enter into a 
private contract with any individual for a item or 
service that is not a benefit under this Act. 
TITLE IV—ADMINISTRATION 
Subtitle A—General 
Administration Provisions 
SEC. 401. ADMINISTRATION. 
(a) GENERAL DUTIES OF THE SECRETARY.— 
(1) IN GENERAL.—The Secretary shall develop 
policies, procedures, guidelines, and requirements to 
carry out this Act, including related to— 
(A) eligibility for benefits; 
(B) enrollment; 
(C) benefits provided; 
(D) provider participation standards and 
qualifications, as described in title III; 
(E) levels of funding; 
(F) methods for determining amounts of 
payments to providers of covered items and 
services, consistent with subtitle B; 
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(G) a process for appealing or petitioning 
for a determination of coverage or noncoverage 
of items and services under this Act; 
(H) planning for capital expenditures and 
service delivery; 
(I) planning for health professional edu-
cation funding; 
(J) encouraging States to develop regional 
planning mechanisms; and 
(K) any other regulations necessary to 
carry out the purposes of this Act. 
(2) REGULATIONS.—Regulations authorized by 
this Act shall be issued by the Secretary in accord-
ance with section 553 of title 5, United States Code. 
(3) ACCESSIBILITY.—The Secretary shall have 
the obligation to ensure the timely and accessible 
provision of items and services that all eligible indi-
viduals are entitled to under this Act. 
(b) UNIFORM REPORTING STANDARDS; ANNUAL RE-
PORT; STUDIES.— 
(1) UNIFORM REPORTING STANDARDS.— 
(A) IN GENERAL.—The Secretary shall es-
tablish uniform State reporting requirements 
and national standards to ensure an adequate 
national database containing information per-
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taining to health services practitioners, ap-
proved providers, the costs of facilities and 
practitioners providing items and services, the 
quality of such items and services, the outcomes 
of such items and services, and the equity of 
health among population groups. Such database 
shall include, to the maximum extent feasible 
without compromising patient privacy, health 
outcome measures used under this Act, and to 
the maximum extent feasible without excessively 
burdening providers, a description of the stand-
ards and qualifications, levels of finding, and 
methods 
described 
in 
subparagraphs 
(D) 
through (F) of subsection (a)(1). 
(B) REQUIRED
DATA
DISCLOSURES.—In 
establishing reporting requirements and stand-
ards under subparagraph (A), the Secretary 
shall require a provider with an agreement in 
effect under section 301 to disclose to the Sec-
retary, in a time and manner specified by the 
Secretary, the following (as applicable to the 
type of provider): 
(i) Any data the provider is required 
to report or does report to any State or 
local agency, or, as of January 1, 2019, to 
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the Secretary or any entity that is part of 
the Department of Health and Human 
Services, except data that are required 
under the programs terminated in section 
903. 
(ii) Annual financial data that in-
cludes information on employees (including 
the number of employees, hours worked, 
and wage information) by job title and by 
each patient care unit or department with-
in each facility (including outpatient units 
or departments); the number of registered 
nurses per staffed bed by each such unit or 
department; information on the dollar 
value and annual spending (including pur-
chases, upgrades, and maintenance) for 
health information technology; and risk-ad-
justed and raw patient outcome data (in-
cluding data on medical, surgical, obstet-
ric, and other procedures). 
(C) REPORTS.—The Secretary shall regu-
larly analyze information reported to the Sec-
retary and shall define rules and procedures to 
allow researchers, scholars, health care pro-
viders, and others to access and analyze data 
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for purposes consistent with quality and out-
comes research, without compromising patient 
privacy. 
(2) ANNUAL REPORT.—Beginning 2 years after 
the date of the enactment of this Act, the Secretary 
shall annually report to Congress on the following: 
(A) The status of implementation of the 
Act. 
(B) Enrollment under this Act. 
(C) Benefits under this Act. 
(D) Expenditures and financing under this 
Act. 
(E) 
Cost-containment 
measures 
and 
achievements under this Act. 
(F) Quality assurance. 
(G) Health care utilization patterns, in-
cluding any changes attributable to the pro-
gram. 
(H) Changes in the per-capita costs of 
health care. 
(I) Differences in the health status of the 
populations of the different States, including in-
come and racial characteristics, and other popu-
lation health inequities. 
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(J) Progress on quality and outcome meas-
ures, and long-range plans and goals for 
achievements in such areas. 
(K) Plans for improving service to medi-
cally underserved populations. 
(L) Transition problems as a result of im-
plementation of this Act. 
(M) Opportunities for improvements under 
this Act. 
(3) STATISTICAL ANALYSES AND OTHER STUD-
IES.—The Secretary may, either directly or by con-
tract— 
(A) make statistical and other studies, on 
a nationwide, regional, State, or local basis, of 
any aspect of the operation of this Act; 
(B) develop and test methods of delivery of 
items and services as the Secretary may con-
sider necessary or promising for the evaluation, 
or for the improvement, of the operation of this 
Act; and 
(C) develop methodological standards for 
policymaking. 
(c) AUDITS.— 
(1) IN GENERAL.—The Comptroller General of 
the United States shall conduct an audit of the De-
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partment of Health and Human Services every fifth 
fiscal year following the effective date of this Act to 
determine the effectiveness of the program in car-
rying out the duties under subsection (a). 
(2) REPORTS.—The Comptroller General of the 
United States shall submit a report to Congress con-
cerning the results of each audit conducted under 
this subsection. 
SEC. 402. CONSULTATION. 
The Secretary shall consult with Federal agencies, 
Indian tribes and urban Indian health organizations, and 
private entities, such as labor organizations representing 
health care workers, professional societies, national asso-
ciations, nationally recognized associations of health care 
experts, medical schools and academic health centers, con-
sumer groups, and business organizations in the formula-
tion of guidelines, regulations, policy initiatives, and infor-
mation gathering to ensure the broadest and most in-
formed input in the administration of this Act. Nothing 
in this Act shall prevent the Secretary from adopting 
guidelines, consistent with the provisions of section 203(c), 
developed by such a private entity if, in the Secretary’s 
judgment, such guidelines are generally accepted as rea-
sonable and prudent and consistent with this Act. 
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SEC. 403. REGIONAL ADMINISTRATION. 
(a) COORDINATION WITH REGIONAL OFFICES.—The 
Secretary shall establish and maintain regional offices for 
purposes of carrying out the duties specified in subsection 
(c) and promoting adequate access to, and efficient use 
of, tertiary care facilities, equipment, and services by indi-
viduals enrolled under this Act. Wherever possible, the 
Secretary shall incorporate regional offices of the Centers 
for Medicare & Medicaid Services for this purpose. 
(b) APPOINTMENT OF REGIONAL DIRECTORS.—In 
each such regional office there shall be— 
(1) one regional director appointed by the Sec-
retary; and 
(2) one deputy director appointed by the re-
gional director to represent the Indian and Alaska 
Native tribes in the region, if any. 
(c) REGIONAL OFFICE DUTIES.—Each regional di-
rector shall— 
(1) provide an annual health care needs assess-
ment with respect to the region under the director’s 
jurisdiction to the Secretary after a thorough exam-
ination of health needs and in consultation with pub-
lic health officials, clinicians, patients, and patient 
advocates; 
(2) recommend any changes in provider reim-
bursement or payment for delivery of health services 
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determined appropriate by the regional director, sub-
ject to the provisions of title VI; and 
(3) establish a quality assurance mechanism in 
each such region in order to minimize both under-
utilization and overutilization of health care items 
and services and to ensure that all providers meet 
quality standards established pursuant to this Act. 
SEC. 404. BENEFICIARY OMBUDSMAN. 
(a) IN GENERAL.—The Secretary shall appoint a 
Beneficiary Ombudsman who shall have expertise and ex-
perience in the fields of health care and education of, and 
assistance to, individuals enrolled under this Act. 
(b) DUTIES.—The Beneficiary Ombudsman shall— 
(1) receive complaints, grievances, and requests 
for information submitted by individuals enrolled 
under this Act or eligible to enroll under this Act 
with respect to any aspect of the Medicare for All 
Program; 
(2) provide assistance with respect to com-
plaints, grievances, and requests referred to in para-
graph (1), including assistance in collecting relevant 
information for such individuals, to seek an appeal 
of a decision or determination made by a regional of-
fice or the Secretary; and 
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(3) submit annual reports to Congress and the 
Secretary that describe the activities of the Ombuds-
man and that include such recommendations for im-
provement in the administration of this Act as the 
Ombudsman determines appropriate. The Ombuds-
man shall not serve as an advocate for any increases 
in payments or new coverage of services, but may 
identify issues and problems in payment or coverage 
policies. 
SEC. 405. CONDUCT OF RELATED HEALTH PROGRAMS. 
In performing functions with respect to health per-
sonnel education and training, health research, environ-
mental health, disability insurance, vocational rehabilita-
tion, the regulation of food and drugs, and all other mat-
ters pertaining to health, the Secretary shall direct the ac-
tivities of the Department of Health and Human Services 
toward contributions to the health of the people com-
plementary to this Act. 
Subtitle B—Control Over Fraud 
and Abuse 
SEC. 411. APPLICATION OF FEDERAL SANCTIONS TO ALL 
FRAUD AND ABUSE UNDER THE MEDICARE 
FOR ALL PROGRAM. 
The following sections of the Social Security Act shall 
apply to this Act in the same manner as they apply to 
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title XVIII or State plans under title XIX of the Social 
Security Act: 
(1) Section 1128 (relating to exclusion of indi-
viduals and entities). 
(2) Section 1128A (civil monetary penalties). 
(3) Section 1128B (criminal penalties). 
(4) Section 1124 (relating to disclosure of own-
ership and related information). 
(5) Section 1126 (relating to disclosure of cer-
tain owners). 
(6) Section 1877 (relating to physician refer-
rals). 
TITLE V—QUALITY ASSESSMENT 
SEC. 501. QUALITY STANDARDS. 
(a) IN GENERAL.—All standards and quality meas-
ures under this Act shall be implemented and evaluated 
by the Center for Clinical Standards and Quality of the 
Centers for Medicare & Medicaid Services (referred to in 
this title as the ‘‘Center’’) or such other agency deter-
mined appropriate by the Secretary, in coordination with 
the Agency for Healthcare Research and Quality and other 
offices of the Department of Health and Human Services. 
(b) DUTIES OF THE CENTER.—The Center shall per-
form the following duties: 
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(3) Adoption of methodologies for profiling the 
patterns of practice of health care professionals and 
for identifying and notifying outliers. 
(4) Development of minimum criteria for com-
petence for entities that can qualify to conduct ongo-
ing and continuous external quality reviews in the 
administrative regions. Such criteria shall require 
such an entity to be administratively independent of 
the individual or board that administers the region 
and shall ensure that such entities do not provide fi-
nancial incentives to reviewers to favor one pattern 
of practice over another. The Center shall ensure co-
ordination and reporting by such entities to ensure 
national consistency in quality standards. 
(5) Submission of a report to the Secretary an-
nually specifically on findings from outcomes re-
search and development of practice guidelines that 
may affect the Secretary’s determination of coverage 
of services under section 401(a)(1)(G). 
SEC. 502. ADDRESSING HEALTH CARE DISPARITIES. 
(a) 
EVALUATING
DATA
COLLECTION
AP-
PROACHES.—The Center shall evaluate approaches for the 
collection of data under this Act, to be performed in con-
junction with existing quality reporting requirements and 
programs under this Act, that allow for the ongoing, accu-
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rate, and timely collection of data on disparities in health 
care services and performance on the basis of race, eth-
nicity, gender, geography, disability, or socioeconomic sta-
tus. In conducting such evaluation, the Center shall con-
sider the following objectives: 
(1) Protecting patient privacy. 
(2) Minimizing the administrative burdens of 
data collection and reporting on providers under this 
Act. 
(3) Improving data on race, ethnicity, gender, 
geography, and socioeconomic status. 
(b) REPORTS TO CONGRESS.— 
(1) REPORT ON EVALUATION.—Not later than 
18 months after the date on which benefits first be-
come available as described in section 106(a), the 
Center shall submit to Congress and the Secretary 
a report on the evaluation conducted under sub-
section (a). Such report shall, taking into consider-
ation the results of such evaluation— 
(A) identify approaches (including defining 
methodologies) for identifying and collecting 
and evaluating data on health care disparities 
on the basis of race, ethnicity, gender, geog-
raphy, or socioeconomic status under the Medi-
care for All Program; and 
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(B) include recommendations on the most 
effective strategies and approaches to reporting 
quality measures, as appropriate, on the basis 
of race, ethnicity, gender, geography, or socio-
economic status. 
(2) REPORT
ON
DATA
ANALYSES.—Not later 
than 4 years after the submission of the report 
under subsection (b)(1), and every 4 years there-
after, the Center shall submit to Congress and the 
Secretary a report that includes recommendations 
for improving the identification of health care dis-
parities based on the analyses of data collected 
under subsection (c). 
(c) IMPLEMENTING EFFECTIVE APPROACHES.—Not 
later than 2 years after the date on which benefits first 
become available as described in section 106(a), the Sec-
retary shall implement the approaches identified in the re-
port submitted under subsection (b)(1) for the ongoing, 
accurate, and timely collection and evaluation of data on 
health care disparities on the basis of race, ethnicity, gen-
der, geography, or socioeconomic status. 
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TITLE 
VI—HEALTH 
BUDGET; 
PAYMENTS; COST CONTAIN-
MENT MEASURES 
Subtitle A—Budgeting 
SEC. 601. NATIONAL HEALTH BUDGET. 
(a) NATIONAL HEALTH BUDGET.— 
(1) IN GENERAL.—By not later than September 
1 of each year, beginning with the year prior to the 
date on which benefits first become available as de-
scribed in section 106(a), the Secretary shall estab-
lish a national health budget, which specifies a budg-
et for the total expenditures to be made for covered 
health care items and services under this Act. 
(2) DIVISION OF BUDGET INTO COMPONENTS.— 
The national health budget shall consist of the fol-
lowing components: 
(A) An operating budget. 
(B) A capital expenditures budget. 
(C) A special projects budget for purposes 
of allocating funds for capital expenditures and 
staffing needs of providers located in rural or 
medically underserved areas (as defined in sec-
tion 330(b)(3) of the Public Health Service Act 
(42 U.S.C. 254b(b)(3))), including areas des-
ignated as health professional shortage areas 
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(as defined in section 332(a) of the Public 
Health Service Act (42 U.S.C. 254e(a))). 
(D) Quality assessment activities under 
title V. 
(E) Health professional education expendi-
tures. 
(F) Administrative costs, including costs 
related to the operation of regional offices. 
(G) A reserve fund to respond to the costs 
of treating an epidemic, pandemic, natural dis-
aster, or other such health emergency, or mar-
ket-shift adjustments related to patient volume. 
(H) Prevention and public health activities. 
(3) ALLOCATION
AMONG
COMPONENTS.—The 
Secretary shall allocate the funds received for pur-
poses of carrying out this Act among the compo-
nents described in paragraph (2) in a manner that 
ensures— 
(A) that the operating budget allows for 
every participating provider in the Medicare for 
All Program to meet the needs of their respec-
tive patient populations; 
(B) that the special projects budget is suf-
ficient to meet the health care needs within 
areas described in paragraph (2)(C) through 
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the construction, renovation, and staffing of 
health care facilities in a reasonable timeframe; 
(C) a fair allocation for quality assessment 
activities; and 
(D) that the health professional education 
expenditure component is sufficient to provide 
for the amount of health professional education 
expenditures sufficient to meet the need for cov-
ered health care services. 
(4) REGIONAL
ALLOCATION.—The Secretary 
shall annually provide each regional office with an 
allotment the Secretary determines appropriate for 
purposes of carrying out this Act in such region, in-
cluding payments to providers in such region, capital 
expenditures in such region, special projects in such 
region, health professional education in such region, 
administrative expenses in such region, and preven-
tion and public health activities in such region. 
(5) OPERATING BUDGET.—The operating budg-
et described in paragraph (2)(A) shall be used for— 
(A) payments to institutional providers 
pursuant to section 611; and 
(B) payments to individual providers pur-
suant to section 612. 
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(6) CAPITAL
EXPENDITURES
BUDGET.—The 
capital expenditures budget described in paragraph 
(2)(B) shall be used for— 
(A) the construction or renovation of 
health care facilities, excluding congregate or 
segregated facilities for individuals with disabil-
ities who receive long-term care services and 
support; and 
(B) major equipment purchases. 
(7) SPECIAL PROJECTS BUDGET.—The special 
projects budget shall be used for the construction of 
new facilities, major equipment purchases, and staff-
ing in rural or medically underserved areas (as de-
fined in section 330(b)(3) of the Public Health Serv-
ice Act (42 U.S.C. 254b(b)(3))), including areas des-
ignated as health professional shortage areas (as de-
fined in section 332(a) of the Public Health Service 
Act (42 U.S.C. 254e(a))). 
(8) TEMPORARY WORKER ASSISTANCE.— 
(A) IN GENERAL.—For up to 5 years fol-
lowing the date on which benefits first become 
available as described in section 106(a), at least 
1 percent of the budget shall be allocated to 
programs providing assistance to workers who 
perform functions in the administration of the 
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health insurance system, or related functions 
within health care institutions or organizations 
who may be affected by the implementation of 
this Act and who may experience economic dis-
location as a result of the implementation of 
this Act. 
(B) CLARIFICATION.—Assistance described 
in subparagraph (A) shall include wage replace-
ment, retirement benefits, job training, and 
education benefits. 
(b) DEFINITIONS.—In this section: 
(1) CAPITAL EXPENDITURES.—The term ‘‘cap-
ital expenditures’’ means expenses for the purchase, 
lease, construction, or renovation of capital facilities 
and for major equipment. 
(2) HEALTH
PROFESSIONAL
EDUCATION
EX-
PENDITURES.—The term ‘‘health professional edu-
cation expenditures’’ means expenditures in hospitals 
and other health care facilities to cover costs associ-
ated with teaching and related research activities, in-
cluding the impact of workforce diversity on patient 
outcomes. 
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Subtitle B—Payments to Providers 
SEC. 
611. 
PAYMENTS 
TO 
INSTITUTIONAL 
PROVIDERS 
BASED ON GLOBAL BUDGETS. 
(a) IN GENERAL.—Not later than the beginning of 
each fiscal quarter during which an institutional provider 
of care (including hospitals, skilled nursing facilities, Fed-
erally qualified health centers, home health agencies, and 
independent dialysis facilities) is to furnish items and 
services under this Act, the Secretary shall pay to such 
institutional provider a lump sum in accordance with the 
succeeding provisions of this subsection and consistent 
with the following: 
(1) PAYMENT IN FULL.—Such payment shall be 
considered as payment in full for all operating ex-
penses for items and services furnished under this 
Act, whether inpatient or outpatient, by such pro-
vider for such quarter, including outpatient or any 
other care provided by the institutional provider or 
provided by any health care provider who provided 
items and services pursuant to an agreement paid 
through the global budget as described in paragraph 
(3). 
(2) QUARTERLY REVIEW.—The regional direc-
tor, on a quarterly basis, shall review whether re-
quirements of the institutional provider’s participa-
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tion agreement and negotiated global budget have 
been performed and shall determine whether adjust-
ments to such institutional provider’s payment are 
warranted. This review shall include consideration 
for additional funding necessary for unanticipated 
items and services for individuals with complex med-
ical needs or market-shift adjustments related to pa-
tient value. The review shall also include an assess-
ment of any adjustments made to ensure that accu-
racy and need for adjustment was appropriate. 
(3) AGREEMENTS
FOR
SALARIED
PAYMENTS 
FOR CERTAIN PROVIDERS.—Certain group practices 
and other health care providers, as determined by 
the Secretary, with agreements to provide items and 
services at a specified institutional provider paid a 
global budget under this subsection may elect to be 
paid through such institutional provider’s global 
budget in lieu of payment under section 612 of this 
title. Any— 
(A) individual health care professional of 
such group practice or other provider receiving 
payment through an institutional provider’s 
global budget shall be paid on a salaried basis 
that is equivalent to salaries or other compensa-
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tion rates negotiated for individual health care 
professionals of such institutional provider; and 
(B) any group practice or other health care 
provider that receives payment through an in-
stitutional provider global budget under this 
paragraph shall be subject to the same report-
ing and disclosure requirements of the institu-
tional provider. 
(b) PAYMENT AMOUNT.— 
(1) IN GENERAL.—The amount of each pay-
ment to a provider described in subsection (a) shall 
be determined before the start of each fiscal year 
through negotiations between the provider and the 
regional director with jurisdiction over such pro-
vider. Such amount shall be based on factors speci-
fied in paragraph (2). 
(2) PAYMENT FACTORS.—Payments negotiated 
pursuant to paragraph (1) shall take into account, 
with respect to a provider— 
(A) the historical volume of services pro-
vided for each item and services in the previous 
3-year period; 
(B) the actual expenditures of such pro-
vider in such provider’s most recent cost report 
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